Morning report 3rd Aprl 2014

Konsulen dr. Jean Pello, SpB

DM Desendio KTPDM Isni Ardhia

1ST CASE

BIODATA

• Name : Ms. As• Age : 18 years old• Sex : FeMale• Address : Naikoten• Job: College

Anamnesis

• Chief Complaint : pain and laceration on ankle

• MOIpatient come to ER because of pain and laceration on angkle. Laceration caused by dog bite 4 hour before admitted to the ER. She was bitten by her neighbor dog which it in maternal phase. The dog bit on behind foot and make some laceration wounds, pain, and bleeding. Nause-vomit, fever, dizziness, malaise doesn’t present. patient poured the wound with coffee in order to stop the bleeding.

Primary Survey

• A: Patent, clear• B : RR: 20 times/min, spontan• C : Blood pressure : 120/70 mmHg , Pulse: 92

times/minute, reguler. • D : GCS E4V5M6• E :Multiple V. Laceration on region maleolus

lateralis and medialis (0,2x1 cm), bleeding (-)

Secondary Survey

• GCS : E4 V5 M6• Head : Normal• eyes : anemic (-/-), light reflex (+/+), icteric (-/-)

, isokhor +/+• Ear : normal• Nose : normal• Neck: Normal

Thorax

• Inspection : chest expansion simetrics, reguler, abdominothoracal, Bruish (-)

• Palpation : vocal fremitus R=D, krepitasi (-), Pain (-)

• Percusion: sonor (+/+)• Auscultation : vesicular (+/+), ronchi (-/-),

wheezing (-/-)

Abdomen

• Inspection : look flat, follow the chest expansion

• Palpation : pain (-), mass (-), tenderness (-)• Percusion : timpany (+)• Auscultation : peristaltics (+), normal

Extremity

– Look

Multiple V. Laceration on region maleolus lateralis and medialis (0,2x1 cm), bleeding (-)

– Feelpain (+)

– Move• ROM : normal

Assessment

• Vulnus Morsum e.c Dog bite

Planning therapy

• Wound toilet• Anti tetanus serum• Mefenamat Acid 3x1 tab• Amoxicillin 3x1 tab

• Picture

2ND CASES

BIODATA

• Name : Mr. RF• Age : 68 years old• Sex : Male• Address : Rote Ndao• Job: Farmer

Anamnesis

• Chief Complaint : Difficult urinate

• MOIpatient has difficult to urinate for the last 3 month,he also complain that he must strain his abdominal muscle when getting the urinate. But he felt his urine still left behind on the abdomen so make him doesn’t satisfy, his other complain: not adecuat in urinate flow, pain after urinate, increase the urinate frequency, 5 time/days especially in the night. In this patient doesn’t present fever, nausea- vommit, dyspnea, abdominal pain and he has normal in urinate consistency

Secondary Survey

• GCS : E4 V5 M6• Head : Normal• eyes : anemic (-/-), light reflex (+/+), icteric (-/-)

, isokhor +/+• Ear : normal• Nose : normal• Neck: Normal

Thorax

• Inspection : chest expansion simetrics, reguler, abdominothoracal, Bruish (-)

• Palpation : vocal fremitus R=D, krepitasi (-), Pain (-)

• Percusion: sonor (+/+)• Auscultation : vesicular (+/+), ronchi (-/-),

wheezing (-/-)

Abdomen

• Inspection : look flat, follow the chest expansion

• Palpation : pain (-), mass (-), tenderness (-)• Percusion : timpany (+)• Auscultation : peristaltics (+), normal

Extremity

warm, CRT<2”, Edema (-/-,-/-)

STATUS UROLOGIS• Regio Flank D / S– Inspection: Skin color normal, inflammation sign (-),

hematoma (-), vertebra alignment normal, gibbus (-), mass (-).

– Palpation: Ballottement (-/-)– Percusion: CVA pain(-/-)

• Regio Suprapubic– Inspection: Skin color normal, inflammation sign (-),

hematoma (-)– Palpation: Bladder full, pain (+),

• Regio Genitalia Exsterna

– Penis• Inspection: Skin color normal,

inflammation sign (-), hematoma (-), oedema (-)

– Scrotum• Inspection: Skin color normal,

inflammation sign (-), hematoma (-), oedema (-)

• Palpation: Testis 2 pairs, size normal, pain (-)

Rectal Toucher:• Anus and perineum normal• Tonus spincter ani eksterna normal•Ampula recti: dilatation, mucosa slippery, flat, surface flat, consistency rubbery, pain (-), nodul (-),•Sulcus medianus flat, can’t reach upper lobe•Handscone : mucous (-), blood (-), stool (+)

Assessment

• RETENSIO Urine e.c BPH dd Stone in urinary tract

Planning therapy

• DC• Drink 1600 cc/days

• Picture