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    Transféré par

    Muh Fitrah
    9 vues12 pages
    The patient, an 11-year-old boy, was admitted to the hospital after being in a traffic accident where he fell from a moving pickup truck and hit his head and waist on the ground. He complained of headaches and had vomiting after the accident. On examination, he had edema on his head but no other external injuries. He was given IV fluids, pain medications, antibiotics, and anti-acids. X-rays of his skull and pelvis were ordered. The preliminary diagnosis was head trauma and pelvic trauma. He was also referred to general surgery for further evaluation.

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    The patient, an 11-year-old boy, was admitted to the hospital after being in a traffic accident where he fell from a moving pickup truck and hit his head and waist on the ground. He complained of headaches and had vomiting after the accident. On examination, he had edema on his head but no other external injuries. He was given IV fluids, pain medications, antibiotics, and anti-acids. X-rays of his skull and pelvis were ordered. The preliminary diagnosis was head trauma and pelvic trauma. He was also referred to general surgery for further evaluation.

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    9 vues12 pages

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    Transféré par

    Muh Fitrah
    The patient, an 11-year-old boy, was admitted to the hospital after being in a traffic accident where he fell from a moving pickup truck and hit his head and waist on the ground. He complained of headaches and had vomiting after the accident. On examination, he had edema on his head but no other external injuries. He was given IV fluids, pain medications, antibiotics, and anti-acids. X-rays of his skull and pelvis were ordered. The preliminary diagnosis was head trauma and pelvic trauma. He was also referred to general surgery for further evaluation.

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    sur 12

    MORNING REPORT

    IDENTITY
    • Name : Ch. A
    • Age : 11 years old
    • Sex : male
    • Address : pohara
    • Admission : november, 20th 2018
    • Doctor in charge : dr. H.Syamsul rijal, Sp.B.
    HISTORY TAKING
    Chief complain : Headache
    Anamnesis :
    Post traffic accident 4 hours before being hospitallized
    Mechanism of trauma :
    The patient is a pick-up passenger. The patient fell from the car he was in and fell to the ground. A car
    that is being driven at medium speed. The patient falls to the back and the head and waist bone
    touch the ground.
    History of trauma :
    • History of unconsciousness (-) , nausea (+), vomiting (+) 3 times
    • History of bleeding from nose (-), ears (-) and mouth (-).
    • History alcohol (-), drugs (-)
    • History treatment (+) patient referral from RS. Kota Kendari
    PRIMARY SURVEY

    A = clear, cervical supine control


    B = RR : 22x/m (thoracoabdominal), simetris
    C = BP : 90/60mmHg, P: 74x/m, reguler, strong lift
    D = GCS E4M6V5, isocorous pupil 2,5mm/2,5mm, RCL +/+, RCTL
    +/+
    E = T: 36oC/Axilla
    SECONDARY SURVEY

    • Generalized status : being sick, composmentis, good


    nutrition
    • Locality status :
    • Regio cephalic (regio occipitale)
    • I : edema (+) hematom (-) wound (-) size 3x3
    • P : tenderness (+) crepitation (-)
    SECONDARY SURVEY

    • Locality status :
    • Regio pelvic
    • I : edema (-) hematom (-) abrasions
    • P : tenderness (+) crepitation (-)
    Clinical finding
    Clinical finding
    Plan of Diagnostic

    • Blood routine
    • Xray skul AP/Lateral
    Diagnosis

    TCR + trauma pelvic


    • IVFD RL • Rest
    • Analgetics
    injection
    • H2RA injection
    • Antibiotic injection

    PHARMACOLOGY NON PHARMACOLOGY

    CONSUL GENERAL SURGERY


    Thank You

    BAGIAN ILMU
    BEDAH

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