MORNING REPORT

IDENTITY
• Name : Tn. Ajsuddin
• Age : 21 years old
• Sex : Male
• Address : Buton Utara
• Admission : October, 10th 2019
• Doctor in charge : dr. TriTuti, Sp.OT.
 HISTORY TAKING
Chief complain :
Right hand pain
Anamnesis :
Felt 1 day before being admitted to the hospital because of traffic accident
Mechanism of trauma :
Patient has drive a motorcycle at medium speed, using a helmet. From the
opposite direction the patient grabs the articulated truck so that the patient's
foot hits the truck and then the patient falls.
History of trauma :
• History of unconsciousness (-) , nausea (-), vomiting (-) .
• History of bleeding from nose (-), ears (-) and mouth (-).
• History of previous medication (+)
 Primary survey
A Clear

RR 28x/min, spontaneous,
symmetrical B
BP : 160/70mmHg, HR = 84x/min, regular,
C strong

GCS 14 (E4M5V5), pupil isochors, D

E T = 39,40 C (axillary)
 Secondary survey

General State : composmentis, moderate ill, good nourish

Head : within normally limit
Face : within normally limit
Neck : within normally limit
Chest : within normally limit
Abdominal : within normally limit
Upper limb :within normally limit
lower limb : localized state
 LOCALIZED STATE

Left antebrachii region

Inspection: Deformity (+), hematoma (+), swelling (+),
wound (+), bleeding (+)
Palpation : Tenderness (+), crepitation (+)
ROM : Active and passive movement talocruralis
articulatio is limited due to pain and
NVD : sensibility (+), pulsed artery dorsum pedis(-),
CRT < 2 seconds
Clinical finding
 Plan of Diagnostic

X- ray cruris dextra AP/Lateral

X-RAY
 Diagnosis

Open fracture 1/3 distal os tibia fibula dextra

• IVFD RL • Rest
• Analgetics injection • Immobilisation
• Antipiretic injection • Elevation
• Antibiotic injection • Education

PHARMACOLOGY NON PHARMACOLOGY

CONSUL ORTHOPEDIC SURGEON

 Thank You

BAGIAN ILMU
BEDAH