Morning report

Hannan, Lio, Diana

History

Patient MF, 16th years old, came to

emergency unit of AA general hospital

Chief complaint: Pain in forearm since 2

hours ago

Recent illness history

2 hours ago, patient got traffic accident.
Patient rode a motorcycle and get collission
with other motorcycle, patient fall head
first. Patient not fainted after accident, no
blood appear from nose and ear, and no
vomitting. There is some wound in patient
face.
Patient feel pain in his left hand and it
difficult to move and it become more curve.
Patient not seen a wound in his left hand
and no bone expose.

Past illness history

Patient not have a history of fracture before

this time.

Physical examination
Generalized condition : moderate illness
Conciousness : composmentis
GCS E4M6V5

Vital sign :

BP : 120/70 mmHg
HR : 88 x/1
RR : 20x/1
Temp : 36,6 C

Head: localized status

Neck: normal
Chest: normal
Abdomen: normal
Extremity: localized status

Localized status
Head:
Inspection:
Vulnus laceratum at nose with 2,5x1,5 cm in
size and swelling below the left eye 1x1 cm in
size, bleeding in left eye sclera, conjunctivae
not pallor, sclerae not icterus, pupil reflex +/+,
3 mm/3 mm, symmetrical left-right, complete
teeth, and maloclusion (-)
Palpation :
Crepitus (-), edema (-), tenderness (+),
discontinuity (-).

Localized status
Hand
Look:
Asymmetris between right and left forearm,
swelling in left forearm, deformity in left
forearm, open wound (-), bone expose (-)
Feel:
Crepitation (-), tenderness (+), discontinuity
(-)
Move
Limitation on range of movement wrist joint

Working diagnosis:
Mild head injury and fracture antebrachii
region.

Differential diagnosis:
Dislocation on wrist joint

Further examination
planning
Routine blood count
X-ray imaging in head and antebrachii
region
Head CT-scan

Result of routine blood count:

Hemoglobin: 14,2 g/dl
Haematocryte: 44,2%
Trombocyte: 298.000/l
Leucocyte: 19.900/l

Diagnosis:
Mild head injury + closed fracture of 1/3
medial os radius dextra nondisplaced

Treatment:
Wound treatment
Ketorolac iv 2 x 30 mg
Ceftriaxone iv 2 x 1mg
Immobilisation