MORNING

REPORT
June 2023
Identity

● Name : Tn. F
● Age : 39 years old
● Gender : Male
● Address : Batu
● Arrival Date : 7 June 2023
● Patient Type : Trauma
 PRIMARY SURVEY
Incident date: 28/05/2023 at 08.30 pm
Arrival Date: 28/05/2023 at 09.30 pm

Anamnesis:
Main complaint: pain in the right shoulder.

Current medical history: The patient came to the emergency room with complaints of right shoulder pain and difficulty moving. Pain is felt with
VAS Score 8, nausea (-) vomiting (-) headache (-).

MOI: The patient fell 2 days ago as a result of slipping on the terrace floor of the house with the right shoulder supporting.
 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: 22x/minute
SpO2 : 99% on RA

Circulation: Syok Hipovolemik Grade I EBV = 70x70 = 4900 ml

BP: 118/74 mmHg EBL = 4900 x 15% x 3 = 2205 cc/jam
HR: 96 x/min, strong pulse
CRT<2s,
Bleeding active (-)

Disability : - -
GCS 456, isochor pupil diameter 3mm/3mm, Light reflex direct and indirect + /+,
Amnetia retrograde (-)

Exposure: Susp. CF Clavicula Dextra - IVFD RL 2205 cc/ jam

Temp: 36.3C - Inj Ketorolak 15mg
Local status: - Inj. Ranitidine 25 mg
- Arm sling
Regio Shoulder (D)
Look: Deformitas (+), eritema (+),
Feel: nyeri (+) krepitasi (+), step off (+)
Move: ROM terbatas nyeri, abduksi (-), adduksi (-), rotasi (-)
 SECONDARY
SURVEY
GENERALIST STATUS
GCS : 456
BP : 111/74 mmHg
HR : 96 x/minute
RR : 20 x/minute
SpO2 : 99 % on RA
 SECONDARY SURVEY

ANAMNESIS

Allergy :-
Medication: -
Past illness : -
Last meal: 7/06/2023 at 14.00 wib
Event : The patient fell 2 days ago as a result of
slipping on the terrace floor of the house with the
right shoulder supporting.
 PHYSICAL EXAMINATION
EXAMINATION

Pulmo:
HEAD/NECK:
Inspection: normal chest wall shape, retraction (-), lesion in
Head:
behind the back
Eyes: Anemic conjunctiva (-/-), icteric sclera (-/-), Isochor
Palpation: symmetrical D/S chest wall movement
pupil diameter 3mm/3mm, Light reflex direct and indirect
Percussion: sonor
+/+,
Auscultation: bronchovesikuler
Nose: rhinorrhea (-/-)
Ears: otorrhea (-/-)
ABDOMEN:
Inspection : Flat, injury (-), surgical scar (-), lump (-)
THORAX :
Auscultation : Bowel sound (+) 10x/minute
Cor:
Palpation : Flat, soft, superficial tenderness (-), deep
Inspection: ictus cordis invisible
tenderness (-)
Palpation: ictus cordis palpable at ICS 5 MCL S
Percussion : Timpany
Percussion: D heart border at ICS 4 PSL D, heart border S at
ICS 5 MCL S
Auscultation: S1 S2 single, regular, murmur (-), gallop (-)
 PHYSICAL
EXAMINATION
EXTREMITIES : CRT <2
EXAMINATION
Local status:
Regio Shoulder (D)
Look: Deformitas (+), eritema (+),
Feel: nyeri (+) krepitasi (+), step off (+)
Move: ROM terbatas nyeri, abduksi (-), adduksi (-), rotasi (-)
CLINICAL PICTURES
Lab (7/06/2023)
X-Ray Shoulder D AP(07/06/2023)
 PROBLEM LIST & PLANNING

Problem list Definitive Diagnosis Planning Diagnosis Planning Therapy & Monitoring

The patient fell 2 days ago as a result of slipping on the terrace floor of the CF 1/3 Middle Clavicula - Inj. Ketorolac 15 mg
-
house with the right shoulder supporting. Dextra - Inj. Ranitidin 25 mg
- Pro ORIF
Regio Shoulder (D)
Look: Deformitas (+), eritema (+),
Feel: nyeri (+) krepitasi (+), step off (+)
Move: ROM terbatas nyeri, abduksi (-), adduksi (-), rotasi (-)
THANK YOU