MORNING

REPORT
October 5th, 2018
 PATIENT IDENTITY
 Name : Ms. H

 Gender : Female

 Age : years old

 Registration :.

 Admission : September 24th, 2018

 HISTORY TAKING
 Chief Complain : Pain on Left Forearm

 History of illness :

A 29 years old girl patient came to Wahidin General Hospital with complain of pain on left forearm suffered
since 15 minutes before admitted to the hospital. Patient was riding a motorcycle and suddenly hit by the car
from behind. Patient fell to the left side with the left hand outstretched. After the accident the patient had
difficulty moving her left forearm due to pain.
• The patient is a teacher and right handed dominant

• There was history of fracture due to motor vehicle accident 7 years ago, patient did not seek any medical
treatment at that time
• There is no history of loss of consciousness

• There is no history of projectile vomiting

• There is no history of diabetes mellitus or hypertension

 PRIMARY SURVEY
A : Clear
B : RR= 20 x/min, symmetric, spontaneous, vesicular
C : HR= 90 x/min, regular, strong
Blood pressure= 120/80 mmHg
D : GCS 15(E4M6V5), light reflex +/+, pupil isochors Ø : 2.5
mm/2.5mm.
E : T = 36.70 C (axillary)
SECONDARY SURVEY
 LOCAL STATUS
Left Forearm Region
Look : Deformity (+) anterior angulation, Swelling (+), Hematoma (+), Wound (-)
Feel : Tenderness (+)
Move : Active and passive movements of elbow joint cannot be evaluated due to
pain
Active and passive movements of wrist joint cannot be evaluated due to
pain
NVD : Sensibility hypoesthesia only at distribution of median nerve. Radialis and
ulnaris arteries are palpable. Capillary refill time < 2 seconds.
RADIOLOGY FINDING
 LABORATORIUM FINDING
HEMATOLOGY

Result Normal Range KIDNEY FUNCTION

WBC 5.2 x103/uL 4.50-13.50x103/uL
Result Normal Range
RBC 4.52 4.00-5.40x106/uL
Ureum 19 mg/dl 10-50 mg/dl
HGB 10.1 g/dl 12-15 gr/dl
Creatinin 0.57 mg/dl <1.1 mg/dl
HCT 33 % 35- 49 %
LIVER FUNCTION
PLT 247 x 103/uL 150-400x103/uL
SGOT 20 U/L <33 U/L

COAGULATION SGPT 20 U/L <41 U/L

PT 10 second 10-14 second BLOOD CHEMISTRY

APTT 25.3 second 22-30 second GDS 89 mg/dl 140 mg/dl

INR 0.96 ---

 DIAGNOSIS
 Closed Fracture Left Monteggia
 Malunion Left Radius and Ulna
 MANAGEMENT
 IVFD RL

 Analgesic

 Immobilization with long arm back slab with elbow slightly flexed

 Reffered to orthopedic consultant

THANK YOU