MORNING REPORT

IDENTITY

Name : Mr. Muh Rival

Age : 16 years old
Address : Watu-watu Village, Bombana
Admission : January, 6 2020
Doctor in Charge : dr. Syamsul Rijal Sp. B
PRIMARY SURVEY
A
Clear, Cervical Spine Control

RR = 22x/min, symmetric, spontaneous, B

thoracoabdominal type.

C
BP = 100/60mmHg, HR = 75 x/min, regular, strong, CRT
< 2 minutes

D
GCS 7 (E2M5V1), pupil : Isokor : 2 mm/ 2mm,

E
T = 37,00C (axillary)
 HISTORY TAKING
(ALLOANAMNESIS)
Chief complain :
• Patient with traffic accident
•Anamnesis :
the patient was admitted to the hospital with facial and head injuries. The incident
occurred at 00.00 p.m. shortly after the accident the patient was unconscious then the
patient regained consciousness. The patient also complained of headache and one of his
incisors was pulled out.
Mechanism of trauma : The patient rides his own motorcycle without using helmet at an unknown
speed. The accident occurred at 00.00 p.m. while driving, the patient crashed into a speed limiting
device and then fell. The left side of the patient body and face is exposed to a pile of stones.
History of trauma :

There was history of unconsciousness is exist

There was history of bleeding from mouth is exist

There was no history of alcoholic

History of previous treatment: at Konawe hospital and was given IVFD, analgesic, proton pump inhibitor,
diuretic,antibiotic, neuroprotector.
 GENERAL STATE (AT 04:00 PM)

General State : Somnolen, severe illnes, good

nourish

Head : Localized state Chest : Normal

Face : Localized state Thorax : Normal
Eyes : Normal Abdomen : Normal
Nose : Normal Upper limb : Normal
Mouth : Normal Lower limb : Normal
Ears : Normal
Neck : Localized state
 LOCALIZE STATE
Head and Face region

Inspection :
Frontal Region : Wound (exist) Vulnus Ekskoriatum (exist)
Orbita Region : Swelling (exist), haematome (exist) wound (exist) vulnus
ekskoriatum (exist)
Zygomatica Region : Swelling (exist), wound (exist) vulnus ekskoriatum(exisit)
Buccal Region : Swelling (exist), wound (exist) vulnus ekskoriatum (exist)
Mentalis region : Swelling (exist), wound (exist) vulnus ekskoriatum (exist)
Neck Region
Inspection
Trigonum Caroticum Region : Wound (exist) vulnus ekskoriatum (exist)
Cervicalis Posterior Region : Wound(exist) vulnus ekskoriatum (exist)
 LOCALIZE STATE
Palpation :
• Tenderness (+)
• Step Off :
Rima orbitalis superior (normal)
Rima orbitalis inferior (normal)
Frontonasalis (normal)
Frontozygoma (normal)
Zygomaticum (normal)
Maxilla (normal)
Mandible (normal)
Unstable maxilla (normal)
Unstable mandible (normal)
Intra oral : malocclusion (not exist), avulsion (exist), active bleeding (not
exist)
CLINICAL FINDING
Plan of Diagnostic

CT-SCAN SKULL
X-RAY SOULDER
CT-SCAN SKULL
X-RAY SHOULDER
 DIAGNOSIS

Severe Capitis Trauma + Multiple Vulnus

Excoriatum
 MANAGEMENT

Non-Pharmacology Pharmacology
IVFD
Rest
O2
Immobilisation
Antipiretic Injection
Wound Care Analgetic Injection
Education Antibiotic Injection
Antifibrinolitic Injection
Vitamin
Consult Surgeon
 THANK YOU

GENERAL SURGERY
DEPARTMENT