MORNING

REPORT
Thursday, 15th December 2022
Identity

● Name :N
● Age : 13 years old
● Gender : Male
● Address : Batu
● Arrival Date : 14th December 2022
● Patient Type : Trauma
 PRIMARY SURVEY
Incident date: 14th December 2022 at 10.20 am
Arrival Date: 14th December 2022 , at 11.00 am

Anamnesis:
Patient came with pain in his right forearm. MOI the patient fell in the field when playing basketball. When he pursued the ball, he slipped and fell
down with the forearm fell first supported the body. Nausea and vomiting (-), headache or dizziness (-), decrease of consciousness (-)

Examination Initial Diagnosis Action

Airway: - -
Patent, gargling (-), stridor (-)

Breathing: - -
Look: symmetrical chest wall movement,
Feel: the patient breathes spontaneously, no additional breath sounds, rib
crepitations (-), dyspnea (-)
RR: 20x/minute
SpO2 : 99% on RA
Circulation: Hypovolemic Shock Grade I EBV: 37 x 80 = 2960
BP: 136/73 mmHg EBL: 2960 x 15% x 3 = 1332cc
HR: 115x/min, strong pulse
CRT<2s, AHKM IVFD RL 1500cc
Bleeding active (-) Blood examination
 PRIMARY SURVEY
Examination Initial Diagnosis Action
Disability : - -
GCS 456 composmentis, Isochor pupil diameter 3mm/3mm, Light reflex direct
and indirect +/+

Exposure: • Susp. CF antebrachii D dd Splint immobilization

Temp: 36o C Greenstick fracture dd CF X-Ray Antebrachii D AP/Lat
galeazzi D dd CF monteggia
Regio Antebrachii Dextra D
Look: Deformity (+)
Feel: Pain (+)
Move: limited to pain
 SECONDARY SURVEY

ANAMNESIS

Allergy :-
Medication: -
Past illness : -
Last meal : 13/12/22 18.00
Event: Fell down when playing basketball
 SECONDARY SURVEY

History of Present Illness:

Trauma patient came to the ER at 11.00 am with pain in his right forearm. MOI the patient fell in the field
when playing basketball. When he pursued the ball, he slipped and fell down with the forearm fell first
supported the body. Nausea and vomiting (-), headache or dizziness (-), decrease of consciousness (-)

Past Medical History: -

Family Medical History: -
Medicine History: -
Alergic History: -
 SECONDARY SURVEY

GENERALIST STATUS
General Condition : Fair
Consciousness : Composmentis
GCS : 456
BP : 128/78 mmHg
HR : 100x/minute
RR : 20x/minute
SpO2 : 99% on RA
 PHYSICAL
EXAMINATION
HEAD/NECK: EXAMINATION
ABDOMEN:
Head: Inspection : Flat, injury (-), surgical scar (-), lump (-)
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), Isochor pupil Auscultation : Bowel sound (+) 12x/minute
diameter 3mm/3mm, Light reflex direct and indirect +/+ Palpation : Flat, soft, superficial tenderness (-), deep
Nose: rhinorrhea (-/-) tenderness (-)
Ears: otorrhea (-/-) Percussion : Timpany

EXTREMITIES : Dry warm acral, CRT <2 s

THORAX : Localist Status
Cor: Regio Antebrachii Dextra
Inspection: ictus cordis invisible Look: Deformity (+)
Palpation: ictus cordis palpable at ICS 5 MCL S Feel: pain (+)
Percussion: D heart border at ICS 4 PSL D, heart border S Move: limited to pain
at ICS 5 MCL S
Auscultation: S1 S2 single, irregular, murmur (-), gallop (-)

Pulmo:
Inspection: normal chest wall shape, retraction (-)
Palpation: symmetrical D/S chest wall movement
Percussion: sonor
Auscultation: Ves/Ves
 CLINICAL PICTURES

FOTO KLINIS
Laboratory (14/12/22)
 X-Ray Antebrachii D AP/Lat (12/12/22)

Conclusion : Soft tissue edema (+), Bone discontinuity (+) os radius ulna 1/3 medial
 PROBLEM LIST & PLANNING

Problem list Definitive Diagnosis Planning Planning Therapy &

Diagnosis Monitoring

Anamnesis: CF Antebrachii D - Splint immobilization

Trauma patient with pain (+) in right forearm IVFD RL 1500cc
Inj. Ketorolac 30mg
Physical Examination: Inj. Ranitidine 50mg
Regio Antebrachii Dextra Inj. Ceftriaxone 1gr
Look: Deformity (+) Pro ORIF
Feel: Pain (+)
Move: limited to pain

Supporting examination:
Laboratory: Low Hb, High WBC, High neutrofil
X-Ray Antebrachii D AP/Lat: Soft tissue edema (+), Bone
discontinuity (+) os radius ulna 1/3 medial
THANK YOU