Morning report 3

rd
Aprl 2014
Konsulen dr. Jean Pello, SpB
DM Desendio KTP
DM Isni Ardhia
1
ST
CASE
BIODATA
Name : Ms. As
Age : 18 years old
Sex : FeMale
Address : Naikoten
Job: College

Anamnesis
Chief Complaint :
pain and laceration on ankle
MOI
patient 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 doesnt 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 (-)
Feel
pain (+)
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
2
ND
CASES
BIODATA
Name : Mr. RF
Age : 68 years old
Sex : Male
Address : Rote Ndao
Job: Farmer

Anamnesis
Chief Complaint :
Difficult urinate
MOI
patient 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 doesnt 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 doesnt 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, cant 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