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Morning Report

22 Februari 2017,
Night Shift
Dm. Hidayat + Dm. Claudya
+ Dm. Dionesia
Patient 1
Identity
Name : M. A
Age : 4 month
Sex : Male
Address : kefamenanu
Anamnesis
Chief Complain : Head getting bigger.
Present History: Patients referred from RSU
Kefamenanu with diagnosed suspect Hydrocephalus +
hyperpyrexia and have history of meningitis. The patient's
parents said that 2 weeks lately patien's head getting bigger
than usual. But still with no fever, nausea or vomiting. 2 days
before entering the hospital patient got a high fever. The fever
only get better when the patient take paracetamol and if was
compressed with warm water, and then getting higher again.
Family said that the patient was really quiet from morning till
now before the seizure. Before, the patient usually cry and
move actively. ASI consumption (+), last was last night before
seizure. Seizure (+) 2 times in the morning and only appear
on both of the hands with a duration of 2 till 3 minutes. Every
seizure with a space of 30 minutes. Nausea and vomiting (-).
Defecation and urination was normal
Past medical history
Patients was diagnosed with meningitis when his age is 2
months

Obstetric History
Babies born spontaneously enough months, followed ANC 9
times at puskesmas and get the vitamins, kalak and SF.
Patient weight when his born is 3000 gram, head circumtanse
is unknown.

Family History
No family suffers from the same disease.
Physical examination

AVPU : respone with pain Head : look bigger (Head


circumtanse 44 cm), dilatasion
Pulse : 172x/minute of vena (+), The suture was
Respiratory rate : Widely open(+), The vontanel
was widely open (+)
69 x/minute
Eyes : sunset sign (+),
Temperature : nistagmus horisontal (+),
39C anaemic (-), icteric (-)
Nose : Nostrils breath (+)
weight : 4,9 kg
Ears : normal
height : 66 cm
Mouth : normal
Contd
Thorax : Abdomen :
Simmetric, retraction at I: Flat (+), mass (-)
subcostal(+), breathing
type thoracoabdominal
P: Pain on pressure
difficult to determine,
Pain on pressure (-) hepar and lien not
HS : single S1S2, palpable
murmur (-) gallop (-) Percussion : tympanic
Vesicular +/+, no other (+)
additional breathing A: Bowel sound :
sound. normal
2 month 4 month
laboratory
CBC:
Hb : 13,1 gr/dL
Ht : 41, 5 %
Leukocyte : 16,5 x 103/uL (H)
Plt : 38.700 /uL
Natrium: 145 (H)
Kalium: 5,0
Clorida: 124
Head CT-Scan
Work up

Assesment IVFD D5 NS 490 cc/24


Hydrocephalus jam (500cc)
Hyperpyrexia
02 2 lpm via canul nasal
Decrease of
Putting on nasogastric
consciousness tube
Pamol supp
Warm compress
Putting on VP shunt
Pro GDS test
Patient 2
IDENTITY
Name : Mr. HT
Age : 65 years old
Sex : Male
Address : Rote
Reffered from RSU Baa Rote
Anamnesis
Chief Complaint : Headeche
MOI ( Autoanamnesis and heteroanamnesis)
Patient Referred from RSU Baa Rote with diagnosis of
mild heat injury + Fraktur Basis Cranii + Suspect
Intracranial bleeding + vulnus apertum ramus digiti I pedis
dextra + HT emergency. The Patients family said that
patient fall from the palm tree about 10 meters since 3
days ago. The mechanism of injury is unclear. Patient
family said that his falling towards the back in the supine
position, the patient had unconsciousness > 15 minutes
after falling from the tree. Headeche in area back of the
head (+) , dizziness (+), nausea and vomiting (-), seizures
(-). Defecation and urination was normal.
Primary Survey

A: clear
B : RR: 24 times in a minute
C : Blood preasure : 240/150 mmHg , Pulse: 76 times/minute,
reguler, temperature 37,4 celcius, Sp02 97%
D : compos mentis, GCS E4V5M6, pupil isokor, 3mm/3mm
E : kontusio regio frontalis dextra
kontusio regio anterior ear and mastoid sinistra
vulnus laseratum ramus digiti I pedis dextra
Secondary Survey

Head : kontusio regio frontalis dextra (+)


Eye : anemic (+/+), pupil isokor (+/+), icteric (-/-)
Ear : kontusio regio anterior ear and mastoid sinistra , blood clot(-),
ottorea (-/-)
Nose : normal
Mouth : normal
Thorax

Inspection : chest expansion bilateral simetric,


pattern of respiration is abdominothoracal
Palpation : vocal fremitus R=D
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchie (-/-), wheezing
(-/-)
Abdomen

Inspection : flat (+)


Palpation : distended (-) , tenderness pain (-), mass
(-)
Percusion : timpany sound (+)
Auscultation : peristaltics (+) still normally
Extremity

Look : Vulnus laseratum ramus digiti I pedis dextra


Feel : pain on the right tumbs foot(+), bruised(-)
Move : movement of the left foots was freely
PICTURE
Laboratorium
CBC:
Hb 8,71 gr/dL (L)
RBC 3,38 x 10^6/uL (L)
Ht 28,1 % (L)
WBC 13,4 x 10^3/uL (H)
Plt 143 x 10^3/uL (L)
PT 9.1 L
APTT 42.3 (H)
GDS 109
UR 48,40 mg/dl (H)
CR 0.91 mg/dl
Na 136 mmol/L
K 3.6 mmol/L
Cl 108 mmol/L
Calcium Ion 0.290 mmol/L
Planning Diagnosis
Planning Diagnosis
Assessment

Mild Head Injury


Kontusio cerebri
Intraventrikel Hemorrage
kontusio regio anterior ear and mastoid sinistra
vulnus laseratum ramus digiti I pedis dextra
Planning therapy
Head Up 30 degree
Bed Rest
O2 4 lpm canul nasal
IVFD NS 0,9% 1500 cc 20 tpm /24 jam
Inj. Ceftriaxone 2x1 gr/iv
Inj. Ketorolac 2 x 30 mg amp/iv
Inj. Piracetam 2x3 gr/iv
Inj. Ranitidin 2 x 1 amp/iv
Palmineks 3 x 500 mg /iv
Vit K 3 x10 mg /iv
Mannitol 4 x 125 cc/ iv Wound toilet
Diet soft food
Thank You
_God Bless_