MORNING REPORT

29TH Oct 2015

PATIENT IDENTITY

• Name : A.R• Gender : Male• Age : 17 th• Occupation : Student • Address : Lamongan • Ethnic : Javanesse• Religion : Moeslem

SUMMARY OF DATABASE

• Chief of complaint:– Loss of consciousness post traffic accident

SUMMARY OF DATABASE• MOI:– Loss of consciousness post road traffic accidents since 2 hours before admission

to hospital with high-speed motor vehicle collision. According of witness, patient rode his motorcycle on the broadway, then patient hitted by motorcycle on the right side. Patient fell down to the left side with head hit the ground first , then he fainted. After 1.5 hours patient unconsciousness, then he woke up in the car with agitated conditions. Sometimes he could communicate with other person, and he complain that his stomach really painful.

– Amnesia for events before or after the injury– Patient admission to hospital with head injuries.– Persistant headache since the injury– Vomiting 1x since the injury, it contains foods and blood in the emergency room– Seizure since the injury denied– Clear fluid from the aers and nose denied, but there was bloody nose.

• History of past illness:– Trauma history denied– Deficit neurologies before denied

• History of family illness:-• History of social ilness: -

PRIMARY SURVEY

• A : gargling (-), snoring (-), speak fluently (+), potential ostruction (-)

• B : spontan, RR 22x/mnt, ves/ves, rh-/-, wh-/-, SaO2 100% with nasal canul 3lpm

• C : Acral WDR, CRT < 2 sec, Pulse 73x/mnt, BP 122/59 mmHg

• D : GCS 336, lateralitation (-), LR +/+, isocor pupil 3mm/3mm

• E : temp 36.2C

SECONDARY SURVEY• GCS 336• H/N :

– a-/ i-/ c-/ d-. Enlargement lymph node (-), vulnus ekskoriasi (+) et regio facial, vulnus app (-)

• Tho : – sim, ret-, vulnus ekskoriasi (-)

• P : – ves/ves, rh -/-, wh -/-, fr costae (-)

• C : – S1S2, murmur (-), gallop (-)

• Abd : – flat, soepl, H/L not palpable, pressure pain (-)

• Ekstremity: – acral WDR, CRT < 2 sec

LABORATORIUM

• Hb : 14.4• Lekosit : 19.8• Platelets : 238• BT : 2.00• CT : 8.30

IMAGING (CT SCAN)

CLUE AND CUE

• Men, 17th

• Head injuries post KLL• GCS 336

PROBLEM LIST

• Moderate Brain Injury

ASSESSMENT

• Moderate Brain Injury • Epidural haemorrhage

PLANNING DIAGNOSIS

• LFT• RFT

TREATMENT

• Ivfd RL 1500cc/24 jam• O2 nasal canul 3-4 lpm• Inj. Ketorolac 2x1 amp• Inj. Ondancetron 3x8 mg• Inj. Mersitopril 4x3 g• Inj. Manitol 200 cc 6x100 cc• Attached FC• Attached NGT• Pro consult Sp. BS and Sp. An