MORNING REPORT

MORNING REPORT22-09-20131BIODATAName : Mr. NMAge : 65 years oldSex : MaleAddress : BaunJob : Farmer

2AnamnesisChief Complaint : bleeding mouth after falling from treeMOIThe patient came to ER with bleeding mouth after falling from tree about a hour ago. Patient feel hurt in his mouth, left wrist joint and left knee. Vomit (-), nausea (-), dizzy (-), dyspnea (-) and the patient can not turn head to the left because he feel hurt in his lower jaw.

3Primary SurveyA: clearB : RR: 20 times in a minuteC : Blood preasure : 130/90 mmHg , Pulse: 80 times/minute, reguler. D : AlertE : -blunt trauma region atriculatio genu sinistra, Vulnus ekskoriasi in region in manus sinistra, blunt trauma in mandibula 4

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Secondary SurveyGCS : E4V5 M6Eye : anemic (-/-), light reflex (+/+), icteric (-/-)Ear : In normal limitNose : In normal limitThroat : Normal8ThoraxInspection : chest movement simetrics, reguler, abdominothoracalPalpation : vocal fremitus R=DPercusion: sonor (+/+)Auscultation : vesicular (+/+), ronchie (-/-), wheezing (-/-)

9AbdomenInspection : distended (-)Auscultation : peristaltics + normalPalpation : tenderness pain (-) , mass (-) Percusion : timpany sound (+)

10Extremity Lookbruise (+), swelling (+) on the jaw, left knee and left wristFeelpain (+)MoveROM : limit

11AssessmentVulnus ekskoriasi regio cubiti posterior sinistraSusp. fracture os mandibularSusp. Fracture os patella sinistraPlanning diagnosisfoto kranial AP/LateralWrist sinistraFemur/patella sinistra

Planning therapyIVFD RL 20 tpmKetorolac Inj. 3% .ivPiracetam inj. 3 gr .ivTetagam inj. 1 amp .imObserve vital sign