surgery morning report

8/12/2019 SURGERY MORNING REPORT

1/21

Emergency Unit

Night Shift ReportMarch, 18th2014

Assistant:

Dr. Hendy Sibuea

Co-assistant:

Renol (chief)

DeboraTiur

Metiel

Septa Tio

Hizkia


2/21

1. Ms. S (36Years Old)09400500

Mechanism of the Trauma

Unknown

Injury of target organ

Head

Symptoms and signs

-

Treatment Pre Hospital (Before UKIS ER) Wound Toilet,

Hecting,

Oxygenization,

IVFD; Ringer Lactate


3/21

PRIMARY SURVEY

Airway : CLEAR

Look : no obstruction

Listen : no extra breath sound (no gurgling, no snoring,

no stridor, no horseness) Feel : there were warm air from both nose and mouth

Breathing : CLEAR

Inspection: bruise (-), chest wall movement

symmetrical, RR 20 x/min, hematoma ()

Pal : crepitation (-)

Per : sonor right = left

Aus : Basic breath sound bronchial, rh -/-, wh -/-


4/21

Circulation : No Sign Of Shock

Warm extremities,

Pulse = 100 x/menit Bp = 110/70 mmHg

Temp= 36,50C

CRT


5/21

Secondary Survey

Chief complaint : Pain on bruises in Face

and others

Additional Complaint : Pain on Abdominal


6/21

History of illness

Patient came accompanied with her

family to UKIs ER reffered by

TEBET HOSPITAL in case of

Trauma. The history of trauma isunknown. Patient came to TEBET

HOSPITAL at 2 pm and transfered to

UKI HOSPITAL at 9 pm. The familyalso didnt know what happened to

the patient. Patient came conscious

but her jaw was broken she couldnttalk.


7/21

HEAD TO TOE

Head : Normocephaly

Eyes : Pupil circular, isochoric 3mm/3mm,centered, Direct Light Reflex +/+, Indirect

Light Reflex +/+, CA +/+

Ear : normal, LCS (-), blood (-)Neck : Bruise (-), hematoma (-)

1. Vulnus excoriation on regio maksilofacia

2. Vulnus laceratum on regio frontalisregio nasal, and regio auris destra

et sinistra (covered by bandage)


8/21

Thorax :- Inspection : bruise (-), movement of chest wall

symmetrical

- Palpation : crepitation (-), palpation pain (-)

- Percussion : sonor right = left, percussion pain

(-)

- Auscultation: Basic breath sound Vesicular

right=left, wh-/-, rh-/-.


9/21

Abdomen

- Inspection : flat, bruise (-),

- Auscultation : bowel sound (+) 5x/min

- Palpation : tenderness (-), defense

muscular (-)

- Percussion : tympani, percussion

pain (+)


10/21

In NGT bag, seen black fluid


11/21

Superior Extremities

Warm, CRT


12/21

Inferior Extremities

Look: edema (-), hematoma (-), rotation (-), Vulnusexcoriation and vulnus laceratum on digiti 1,2 regio pedis

dextra

Feel: pain on palpation (+), crepitation (-)

Move: active with no limitation


13/21

CT Brain:

Bone Window


14/21

CT Brain : Fraktur Corpus Os Mandibula

dextra + Proc. Zygomaticus


15/21

CT Brain :Brain Window


16/21

Laboratory Findings

Hb : 8.6

Leu : 16.770

Ery : 3.860.000


17/21

AMPLE

Allergy : -

Medication : -

Past Illness : -

Last Meal : unknown

Event : Traffict Accident


18/21

Working diagnose

Mild Head Injury + Suspect Intra Abdominal

Bleeding + Anemia + Fractur Corpus Os

Mandibula Dextra + protuberentiaMandibula Dextra + Proc. Zygomaticum +

Vulnus Excoriation + Vulnus Laceratum


19/21

TREATMENT

Non Medicamentosa :

Hospitalized Diet:

Calori needed 30cc/kgbb/hari

Partial Parenteral Nutrition

Medicamentosa :

IVFD :

Futorolit 30mg/kgbb/hari (kristaloid + dextrose) * =


20/21

TREATMENT

Medica Mentosa

Omeprazole (ppi) tab 2x40mg

Ketesse (analgetik) tab 3x35mg

Vit K inj Meropenem inj 3x500mg

Transfusion Planning PRC 300 cc


21/21

Planning

Maintenance

Observation :

Conciousness, Vital Sign

NGT until the fluid is clear

Nutrition :

Changing of nutrition uptake

Surgical Planning:Orif

Consul: Mouth Surgery

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