Morning report

28 Oktober 2015

Patient identity (1)

• Name : Miss N• Sex : Female• Age : 16 years old • Address : Gg. Budiman

Chief complaint

• Headache

Present illness history

Patient come to the hospital with complaint of headache approximately 90 minutes before enter emergency room. This complaint is felt after she got into an accident. Her motorcycle hit another vehicle and then she fell down to left side and her head hit the ground. According to her, after the accident she was fainted for about 3 minutes. Nausea (+), vomiting (-), visual disturbance (-). There is no bleeding from nose or ears.

Past medical history

•History of hypertension (-) •History of DM (-)

Physical examination

Vital sign• GCS : 15 (Compos Mentis)• Blood pressure : 120/70• Hate rate : 92 x / min • Respiratory rate : 20 x / min• Temperature : 36,5°C

Physical examination

• Head: normosefali• Eyes: anemic conjunctiva (-/-), icteric sclera (-/-), • Pulmonary: Normochest, breath sounds basic:

Vesicular (-/-), Wz (- / -), Rh (- / -)• Heart: Regular S1S2, Galoop (-), Murmur (-)• Abdomen: flat, nontender, turgor (+), bowel

sounds (+) normal• Extremities: CRT <2”

Localized Status

• vulnus excoriatum 4 cm x 3 cm a/r antebrachii sinistra

• vulnus excoriatum 2 cm x 1 cm a/r pedis dextra

• vulnus excoriatum 2 cm x 1 cm a/r pedis sinistra

• Contusio a/r temporal sinistra

X-Ray

Diagnosis

• Mild brain injury

Therapy Head up 30° Oxygen 3 lpmNaCl 20 dpmPiracetam 1 ampCiticolin 1 ampKetorolac 1 ampRanitidin 1 amp

Prognosis

• Ad vitam : bonam• Ad functionam : bonam• Ad sanactionam : bonam

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