MORNING

REPORT
(TRAUMA)
 Name : Mr. I
Age : 14 years old
Address : Anduonohu
Occupation : Students
Admission : December, 08th 2019 (08.30 pm)
Doctor in Charge : dr. Tri Tuty, Sp.OT

IDENTITY
 PRIMARY SURVEY
(at 08.30 P.M)

A Clear, cervical spine control

B Respiratory rate 20x/m, spontaneous, symetris,

reguler, thoracoabdominal type

C Blood Pressure 110/80 mmHg

Pulse 78x/m, reguler, strong

D Glasgow Coma Scale (E4M6V5), pupil isochoric.

E Temperature 36,5OC/axillary
 SECONDARY SURVEY
(at 08.33 P.M)
Chief complain: Pain in the right wrist hand

History taking:
Suffered since ± 2 days ago before admitted to Hospital .

Mechanism of trauma:
Patient was riding motorcycle with a speed of 30km/hour, not wearing a helmet.
The patient bumps into another driver in front of him who suddenly turns right.
The patient tried to avoid but could not control his motorcycle and fell with his
right hand hitting the asphalt and supporting his weight.
History of Trauma :
 There was no history of unconsciousness
 There was no history of nausea and vomiting
 There was no history of bleeding from nose (-), ears (-) and mouth (-)
 There was no history of previous medication

HISTORY TAKING
 SECONDARY SURVEY
(at 08.33 P.M)

General State
Moderate Illness, Good Nourish, Compos mentis.

Vital Sign
BP : 110/80 mmHg
HR : 78x/minutes, regular, strong
RR : 20x/minutes, spontaneous,
symmetric, reguler
T : 36,5◦C
 Head : Normally Abdomen : Normally
Face : Normally Upper limb : Localized state
Eyes : Normally Lower limb : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Neck : Normally
Chest : Normally

PRESENT STATE
SECONDARY SURVEY
 L
Right antebrahii region O S
Inspection : Deformity (+), Hematoma (-), swelling (+), wound (-) C T
Palpation : Tenderness (+), krepitation (+)
AA
L T
• ROM : Active and passive movement radiocarpal articulatio is limited due
to pain and I E
• NVD : Sensibility was good, radialis artery pulsation (+), Capillary refill Z
time ≤ 2 sec.
E
Clinical Documentation
Planning Diagnostic :

Blood routine test

(Leukosit, HB, trombosit) X- ray antebrachii dextra AP/Lateral
Clotting time, bleeding time
LABORATORY FINDING

Value Rujukan

WBC 9.08 4.0 – 10.00 103/uL

HB 14.5 12.0 – 16.0 g/dl

PLT 396 150 – 450 103/uL

CT 9’00 1-9 minutes

BT 2’30 1-3 minutes

RADIOLOGY FINDING
 DIAGNOSE
Close fracture 1/3 distal radius dextra

DIFFERENTIAL DIAGNOSE

Neurovascular Injury
Muscle Contusion
Dislokasi
 MANAGEMENT
Pharmacological Non-Pharmacological
• IVFD • Rest
• Analgetic injection • Immobilisation
• Antibiotic injection • Elevation
• Education

Consult : Ortopedic Surgeon