Morning Report

Wednesday, 8th April 2015

M/LK/35 yo

Chief Complain : Cant move the right

leg
Explain :
it had been happened since 3 hours
before addmission. Firstly, the patient
was riding a motorcycle and then the
patients got hit by a car from the right
side and the patient fall. History of
unconciousness (-), vomitting (-),
seizure (-).

PRIMARY SURVEY
Airway : Clear
Breathing : Spontaneous, RR :
20x/minute.
Circulation : Warm acral, HR: 88
x/minute
Blood pressure : 120/70 mmHg
Disability : GCS 15
Exposure : undress, logroll

SECONDARY SURVEY
Head
Head

Neck
Thorax:

: Eye: pale inferior conjungtiva -/-,

pupil equal, light reflex +/+
Ear/nose/mouth :
Normal/normal/normal
: no abnormality found
Look : Symmetrical
Listen : Vesicular on both
hemithorax
Feel
: Resonance on both
hemithorax

Abdomen
Abdomen : Look : symmetrical
Listen : peristaltic (+) N
Feel
: flat and smooth

Extremities :
Upper extremities :
(L) no abnormality
(R) no abnormality

Lower Extremities
Left : no abnormality
Right :
Right Femoral :
Look : deformity (+), swelling (+),
Feel : pain (+) NVD (+) normal
Move : DOF(+), ROM(+) decrease

Right Genu : no abnormality

Right Cruris :
Look : deformity (+), sweeling (+)
lacerated
wound (+) size 2x1 cm,
edge
irreguler, base subcutis, active
bleeding (+)
Feel : crepitation (+) pain (+) NVD (+)
normal
Move : DOF(+), ROM(+) decrease
Genital : Male, no abnormality was
found

Laboratorium
Hb/L/T/Htc :
13,9/16100/285000/41,4
Ureum creatinin : 17,1/0,78
Kgd adr
: 117 mg/dl
Na/K/Cl
: 133/4,3/108

X- Ray Femur

X Ray Cruris

diagnose
closed (R) Middle third comminutive
femur fracture + Open (R) Upper third
comminutive tibia fibula Fracture
grade II

Therapy
IVFD RL 20 gtt/i
Inj antibiotik
Inj analgesik
Inj Tetagam
Plan : Debridement + Backslab

Post Op