MORNING REPORT

May 19th, 2023

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR

NB/LS/CT/EL
 IDENTITY
Name :
Age : 58 years old / Male
Admission : May 19th, 2023 at 15.15 WITA

Registration :
Status : JKN
Phone :
Number
 AUTOANAMNESIS
(at 15.20)
Chief Complain : Pain at left groin
 Suffered since 2 days before admitted to Wahidin Sudirohusodo
hospital. Patient was walking when he fell down due to slippery floor.
He fell to the lateral side with his left hip hit the floor first. After the
accident, the patient could not walk nor stand due to pain. Before the
accident patient could stand and walk without aid. Patient was treated
in Budi Agung Hospital in Palu for a day before sent home. Patient then
came to Wahidin Sudirohusodo hospital for further treatment.
 There was history of trauma in 2013, patient’s right hand was broken
due to accident when riding motorcycle. The patient then had surgery
with plate and screw at right distal radius at Dr. Soetomo Hospital
Surabaya
 There was history of going to bone setter once
 There was no history of hypertension
 There was no history of diabetes mellitus
 GENERAL STATUS
(at 15.25)

 Conscious / Well-nourished
 Vital Signs:

Blood pressure : 153/89 mmHg

Pulse rate : 94 x/min
Respiratory rate : 20 x/min
Temperature : 36,5 0C
NRS : 3/10
CLINICAL FINDING
(at 15.30)
 LOCAL STATUS
(at 15.30)
Left Groin
Look : Deformity (+), swelling (+) hematoma (-), Wound
(-)
Feel : Tenderness (+)
Move : Active and passive movement of hip joint cannot
be evaluated due to pain.
Active and passive movement of knee joint cannot
be evaluated due to pain.
NVD : Sensibility is good. Pulsation of dorsalis pedis and
tibialis posterior arteries are palpable. Capillary
refill time < 2 seconds.
Leg Length Discrepancy

RIGHT LEFT

ALL 100 cm 98 cm

TLL 92 cm 90 cm

LLD 2 cm
RADIOLOGY FINDING
(at 18.29)
RADIOLOGY FINDING
(at 18.31)
 LABORATORY FINDING
(at 15.40)

 WBC : 12.7 x 103/uL  RBS : 129

 HGB : 13.4 gr/dL mg/dl
 HCT : 36 %  Ureum : 33 mg/dl
 PLT : 241 x 103/uL  Creatinin : 1.02
 HbsAg : Non reactive mg/dl
 PT : 9.8 seconds
 ALT : 23 mg/dl
 APTT : 25.9 seconds
 AST : 24 mg/dl
 INR : 0.91
 Sodium : 142 mmol/l
 LED :4
 Potassium : 4.3 mmol/l
 Chloride : 104 mmol/l
DIAGNOSIS
 MANAGEMENT
 IVFD
 Analgetic
 Report to orthopaedic senior, advice:
 Apply skin traction with 3kgs of load at right lower limb
 Report to orthopaedic consultant
APPLIED SKIN TRACTION AT LEFT
LOWER LIMB
(3 kgs load)
RADIOLOGY FINDING
(at 18.27)
RADIOLOGY FINDING
(at 18.36)
CLINICAL FINDING
(at 15.30)
CLINICAL FINDING
(at 15.30)
CLINICAL FINDING
(at 15.30)
 LOCAL STATUS
(at 15.30)
Right Forearm
Look : Deformity (-), swelling (-) hematoma (-), Scar
Wound (+) as long as 3 cm
Feel : Tenderness (-)
Move : Active and passive movement of elbow joint
within normal limit
Active and passive movement of wrist joint within
normal limit
NVD : Sensibility is good. Pulsation of radialis and ulnaris
arteries are palpable. Capillary refill time < 2
seconds.
RADIOLOGY FINDING
(at Budi Agung Hospital )