MORNING REPORT

IDENTITY
Name : Ch. T
Age : 13 years old
Sex : Male
Address : Mataiwoi
Admission : Dec, 8th 2017
Doctor in charge : dr. Benny Murtaza,
Sp. OT
 HISTORY TAKING
 Main complain :
Pain at both legs
 Anamnesis :
a referred patient from public health center motaha with main complain pain
at both legs after hit by iron sheeting that suffered since 5 hours before
admitted the hospital.
Mechanism of trauma :
patient was on a truck which contain iron sheeting, then suddenly the truck brake
and hit his both legs
There was no history of unconsciousness
There was history of medication : Ivfd, wound splint, immobilitation
 Primary survey
A
Clear

RR 204x/min regular, spontaneous B

symmetrical
C BP 90/50 mmHg
Pulse = 88x/min, regular, strong

D
GCS 15 (E4M6V5), pupil isocord

E T = 36.20 C (axillary)
 SECONDARY SURVEY
Head : Normally Thoraks : Normally
Nose : Normally Abdomen : Normally
Mouth : Normally Upper extremity : Normally
Ears : Normally Lower extremity
Vital sign: :Localized
Neck : Normally BP: 110/70
Pulse : 84
RR: 24
Temp.: 36,6 degree celsius
 LOCALIZED STATE
Lower extremity Left
- Inspeksi : Deformity (-), swelling (-), hematoma (-), active
bleeding (+) multiple incisivum wound at cruris and pedis, tendon
expos at regio cruris
-Palpasi : tendernes (+), Crepitation (-)
- ROM : Active and passive movement at ankle joint is limited due
to pain.
-NVD : Sensibility was good, pulsation at dorsalis pedis artery was
Lower extremity Right
palpable
- Inspeksiweak, capillary
: Deformity (-),refill time >2
swelling (-),seconds.
hematoma (-), Incisivum
wound at regio maleolus medial sixe 8x5 cm , bone expos at regio
maleolus medial
-Palpasi : tendernes (+), Crepitation (-)
- ROM : Active and passive movement at ankle joint is limited due
to pain.
Clinical Finding
 Plan of Diagnostic

Blood Routine
X-ray Pedis D, pedis and cruris S
-Tampak defek soft tissue
pada regio cruris kiri 1/3
distal sisi anterior
- Aligment baik,
trabekulasi tulang normal
- Celah dan permukaan
sendi baik
- Tak tampak destruksi
tulang maupun garis fraktur

Kesan: defek soft tissue

pada regio cruris kiri 1/3
distal sisi anterior
 Diagnosis

Multiple Vulnus Incisivum at cruris and pedis

region S +
Vulnus Incisivum at pedis region D
 MANAGEMENT
 IVFD
 Drips antibleeding
 Antibiotics
 Analgesics
 H2RA
 Consult general surgeon

 Wound care, imobilitation, elevation