MORNING

REPORT
Monday 10th of July 2023
Identity

● Name : Mrs. S
● Age : 74 years old
● Gender : Female
● Address : Batu
● Arrival Date : 6th of July 2023
● Patient Type : Trauma
 PRIMARY SURVEY
Incident date: 13:30 WIB (July 6th, 2023)
Arrival date: 15:55 WIB (July 6th, 2023)

Anamnesis:
Main complaint: Pain in the left thigh up to the hip

Anamnesis : The patient arrived at the Emergency Department of Karsa Husada at 15:55 WIB on July 6th, 2023. With the complaint: pain in the left thigh after a twisting
fall. The patient fell with the body weight on the left side. Tenderness (+) in the region of femur up to the left hip with a VAS score of 8. Limited mobilization (+),
shortening (+).

MOI : At 1:30 PM at home, the patient was walking and felt dizzy (history of vertigo). The patient held onto the wall but couldn't support themselves and eventually fell,
with the left leg bearing the body weight.

Examination Initial Diagnosis Action

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

Breathing: - -
Look: symmetrical chest wall movement (+), lesion (-), deformity (-)
Feel: the patient breathes spontaneously, no additional breath sounds, rib crepitations
(-), dyspnea (-)
RR: 25x/minute
SpO2 : 93% on RA

Circulation: • Uncontrolled hypertension BB= 65 kg

BP: 163/76 mmHg • Syok Hipovolemik Grade I EBV = 65 x 60 = 3.900
HR: 82 x/min, strong pulse EBL = 3.900 x 15% x 3
CRT<2s, warm red dry acral (+/+) = 1.755 cc/hour
Bleeding active (+)
• Pro X-ray thorax
 PRIMARY SURVEY
Examination Initial Diagnosis Action

Disability : -
GCS 456, pupil isokor 3mm/3mm, RCL +/+, RCTL +/+

Exposure: - Susp. Closed Fracture Collum Femur Sinistra - IVFD NS 1.755 cc/jam
Warm red dry acral (+/+) dd Closed Fracture Intertrochanter Sinistra - Inj. Ketorolac 30 mg
Temp: 37.4°C - Inj. Ranitidine 50 mg
- Immobilization with a splint
Local Status: - DC (+)
Regio Femur Sinistra - X-ray AP Pelvis, AP Lateral Hip, AP
Look: Visible shortening in the left leg (+), in the neutral position, the left leg appears externally rotated. Contusion (+) Lateral Femur
Feel: Tenderness on palpation (+) with a VAS score of 8, Crepitus (+), Dorsalis pedis artery palpable and regular, CRT
< 2 seconds.
Movement: Limited range of motion (+)
Range of motion in the femur joint:
Flexion: limited due to pain (0°)
Extension: limited due to pain (0°)
 SECONDARY
SURVEY
GENERALIST STATUS
GCS : 456
BP : 163/76 mmHg
HR : 82 x/minute
RR : 25 x/minute
SpO2 : 93% on RA
 SECONDARY SURVEY

ANAMNESIS

Allergy :-
Medication: Amlodipine (rarely), Ranitidine, Norages
Past illness : Hypertension (+), Vertigo (+)
Last meal: The patient's last meal was at 8:00 AM on July 6th,
2023.
Event :
At 1:30 PM on July 6th, 2023, at home, the patient was walking
and felt dizzy (history of vertigo). The patient held onto the wall
but couldn't support themselves and eventually fell, with the left
leg bearing the body weight.
 PHYSICAL EXAMINATION
EXAMINATION

HEAD/NECK: Pulmo:
Head: Inspection: normal chest wall shape,
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), retraction (-), lesion (-)
pupil isokor 3 mm/3mm, Light reflex direct and Palpation: symmetrical D/S chest wall
indirect +/+ movement
Nose: normal Percussion: sonor
Ears: normal Auscultation: vesicular +/+

THORAX : ABDOMEN:
Cor: Inspection: Flat, injury (-), surgical scar (-),
Inspection: ictus cordis invisible lump (-)
Palpation: ictus cordis palpable at ICS 5 MCL S Auscultation : Bowel sound (+) 15x/minute
Percussion: D heart border at ICS 4 PSL D, heart Palpation : Flat, soft, superficial tenderness
border S at ICS 5 MCL S (-), deep tenderness (-)
Auscultation: S1 S2 single, regular, murmur (-), Percussion : Timpany
gallop (-)
 PHYSICAL
EXTREMITIES :
EXAMINATION
EXAMINATION
Dry warm acral, CRT <2 s See local status.

Localist Status
Regio Femur Sinistra
Look: Visible shortening in the left leg (+), in the neutral position, the left leg appears externally rotated. Contusion
(+)
Feel: Tenderness on palpation (+) with a VAS score of 8, Crepitus (+), Dorsalis pedis artery palpable and regular,
CRT < 2 seconds.
Movement: Limited range of motion (+)
Range of motion in the femur joint:
Flexion: limited due to pain (0°)
Extension: limited due to pain (0°)
CLINICAL PICTURES
 PROBLEM LIST & PLANNING
Problem list Initial Diagnosis Planning Diagnosis Planning Therapy &
Monitoring
Anamnesis: - Uncontrolled - IVFD NS 1.755 cc/hour
• Complete Blood Count
• Main complaint: Pain in the left thigh up to the hip Hypertension - Inj. Ketorolac 30 mg
- Susp. Closed Fracture • X-ray AP Pelvis, AP - Inj. Ranitidine 50 mg
• pain in the left thigh after a twisting fall. The patient fell with the body weight on the left side. Tenderness (+) in Collum Femur Sinistra - Blood sample
Lateral Hip, AP Lateral -
the region of femur up to the left hip with a VAS score of 8. Limited mobilization (+), shortening (+). dd Closed Fracture Immobilization with a
Intertrochanter Sinistra Femur splint
• MOI : The patient fell to the left when hit by a motorcycle. The patient did not know what he hit his head on, and - DC (+)
which part fell first.

Generalist Status
• BP : 163/76 mmHg

Localist Status
Regio Femur Sinistra
Look: Visible shortening in the left leg (+), in the neutral position, the left leg appears externally rotated. Contusion
(+)
Feel: Tenderness on palpation (+) with a VAS score of 8, Crepitus (+), Dorsalis pedis artery palpable and regular,
CRT < 2 seconds.
Movement: Limited range of motion (+)
Range of motion in the femur joint:
Flexion: limited due to pain (0°)
Extension: limited due to pain (0°)
Laboratory Findings (06-07-2023)
X-Ray (06-07-2023)
 PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning Diagnosis Planning Therapy &
Monitoring
Laboratory Findings: - Uncontrolled - IVFD RL 20 dpm
-
HGB L 10.5 g/dL 12.3 - 15.3 Hypertension - Education about the
HCT L 32.9 % 34.0 - 47.0 - Closed Fracture Condition (Closed
MCV L 65.5 fL 80.0 - 97.0 Intertrochanter Sinistra Fracture Intertrochanter
MCH L 20.9 pg 26.5 - 33.5 - Anemia Microcytic Sinistra) And possibility
Microciter to get operative
K+ L 3.15 mmol/L 3.5 - 5.5 - Hypokalemia procedure Arthroplasty
- Informed Consent
X-ray : - Hospitalization
Result: - Fast 6 hrs Pre Operation
• Closed Fracture Intertrochanter Sinistra - Ceftriaxone 2 x 1 gr
Prophylaxis
- Ketorolac 3 x 30 mg
- Metoclopramide 1 x 10
mg
Post Operation X-Ray (07-07-2023)
THANK YOU