morning report ckr

7/30/2019 Morning Report Ckr

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Identity

Name : RP

Age : 14 years old

Gender : Male

Address : Petapahan

Job : student

Medical Record : 789958


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Primary Survey Airway

Stridor (-), gurgling(-), cervical spine control (-)

Breathing

Simetris, RR 20X/minutes

CirculationBP 130/80 mmHg, HR: 84 x/minutes regular and

capillary refilling time


4/22

Primary Survey

Airway

Evaluation

Patient conscious, able to speak

clearly

Assessment: airway clear


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Breathing Evaluation

Inspection: there is an increased effort

to breath, breath frequency of 22times / min, symmetrical chestmovement

Palpation: left fremitus same as theright

Percussion: sonor

Auscultation: vesiculer

Assessment: breathing not disturbed


6/22

Circulation

Evaluation

Pulse rate 84 beats / min, acral warm,

CRT


7/22

Disability

Evaluation

GCS 15, pupil isochor, right 3 mm, left

3 mm, positive light reflex right and left

Assessment: disability not disturbed


8/22

Exposure

Evaluation

Found hematom on the patient's

temple and has wound on his chin

Action: cleaning the wound and

blanketed the patient to prevent

hypothermia


9/22

Secondary Survey

Patient RR, male, 14 years old, was

admitted to AA General Hospital on

November 26th, 2012.

Chief Complain :

vomit 3 times after got traffic accident

because fallen from his motorcyclesince 8 hours before admitted to the

hospital


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Present illness history

A 8 hours before admitted to the hospital,patient got traffic accident because fallenfrom his motorcycle. He used helmet. Patientsaid that he didnt remember the mechanism

of the accident. He got headache after theaccident. pain is felt continuous, lesion inhead area (-), he got vomit 3 times beforecome to the hospital. hematom in hispalpebra sinista

Then, he was transferred to the hospital. Hewoke up at the hospital. There was no bloodemit from his ears and the patient was notvomit at the time.


11/22

Past History Illness :

No related ilnesses

Family history : -


12/22

Physical examination

Generalized condition : moderateillness

Conciousness : composmentis

GCS E4M6V5 Vital sign :

BP : 120/80 mmHg

HR : 84 x/minute

RR : 22x/minute

Temp : 36 C


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Head : localized status

Neck : normal

Thorak : normal

Abdomen : normal

Extremity : normal


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Head

Inspection : hematom on palpebra

sinistra, didnt found the wound in his

head

GCS : 15

Motorik : 5/5/5/5

Locally Status


15/22

Working Diagnosis: Contusio + mild

head injury + linear fracture


16/22

1. Routine blood examination

2. Head CT-Scan

3. 3D scan of head

Examination planning


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Hb : 14,4 gr/dl

Platelet : 309.000/l

Ht : 43,3 %.

WBC : 25.900/l

Routine Blood Examination


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Rontgen


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Conservative:

Bedrest with Fowler position

Ranitidin iv 2 x 1 amp

Ceftriaxone iv 2 x 1 mg

Tramadol 3 x 1 g

Control the symtom of increase

intracranial pressure

Manegement


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