MORNING REPORT

SURGERY DEPARTMENT
G-20

Patients Identity

Name
: An A
Age
: 9 yo
Address
: Lamongan
Hospital admission : Sunday , June 1st,
2014

History Taking
Chief complaint : left finger foot pain
Mechanism of injury : this 9 years old male with
a history pain on the left finger foot pain after got
accident. His finger foot put on wheel bicycle 15
minutes before arrive here..nausea (-). Vomitting
(-), headache (-), neck pain (-), seizure (-).

Primary Survey
Airway and Cervical control
Airway clear
C-Spine stable
Breathing
Symmetric chest wall movement (+)
RR 22x/mnt SpO2 98%
Sonor +/+
Ves +/+ Rh -/- Wh -/ Circulation and Bleeding Control
BP : 127/77 mmHg
Pulse : 92 bpm
Acral warm and dry to touch
CRT <2

Primary Survey
Disability
GCS 456

Exposure
Vulnus amputed pedis sinistra digiti V

Local Sign
Left Pedis Digiti V Sinistra
Look : Bone loss, bone ekspose, blood, debris
Feel : lnot evaluated,
Move :ROM PIP

General examination
Head Neck :
I : vulnus (-), deformitas (-)
P: Tendeners -

Chest : pulmo :

I : Simetric-bilateral moves retraction (-)

P : krepitasi
P : sonor/sonor
A ves/ves, Cor : S1S2 single

Abdomen :

I : soepel, Rubor
P : Tendeness (-)
P : Timpani
A : ,Bowel Sound: N

 Extremities :
L : Vulnus amputated pedis digiti V Sinistra

Clue and cue

Girls 5 yo
Left finger food pain
Pain after got an accident

Assesment
Vulnus Amputed pedis digiti V Sinistra

Planning Diagnosis
Pedis AP/L X-ray
DL
CT/BT

Laboratory Findings

Diffcount : 2/0/68/19/11
HCT : 38.5 %
Haemoglobins : 13 mg/dl
Leukocytes : 7.200
Trombocytes : 525.000
BT : 230
CT : 730
Cl serum : 105 mmol/l
Kalium serum : 3.8 mmol/l
Natrium serum : 135 mmol/l
Urea : 38 mg/dl
Creatinine serum : 1.0 mg/dl

 CF pedis digiti V proksimal Sinistra

Bone ost of digiti V distal sinistra

Planning Therapy
IVFD Ringer Acetate 1500 cc/24h
Inj ketorolac 3 x 30 mg iv
Call orthopaedics and traumatologist

Planning Monitoring
General appearance, Blood Pressure,
Pulse Rate, RR, temperature
Abdomen circumference