MORNING REPORT ER

25-26 APRIL 2023

Supervisor: dr. Made Dwi Yoga Bharata, Sp.B-KBD

KEPANITRAAN KLINIK MADYA

BAGIAN/SMF ILMU BEDAH
RSUD SANJIWANI GIANYAR
2023
ER 25-26th APRIL 2023

Initial Gender Age MR No. Diagnosis Management Care

- WT + Wound Care
78 Vulnus appertum regio digiti I manus D - IVFD NaCl 0,9% 20 tpm
IPNL M 736264 Hospitalization
y.o Susp Ruptur Tendon Digiti I manus D - Paracetamol 3x1gr IV k/p
- Tetagam Inj IM

- WT + Wound Care
42 Vulnus appertum regio digiti III - Tetagam Inj IM
IGABS F 353799 Outpatient
y.o manus S - Paracetamol 3x500mg
- Cefixime 2x100mg

- Immobilization with arm

57 Closed fracture clavicula 1/3 sling
PK F 406475 Outpatient
y.o medial dextra - Paracetamol 3x500 mg PO
- Cefixime 2x100 mg PO

- WT + Exploration
Vulnus ictum et regio plantar pedis - Tetagam Inj IM
60
IPGS M
y.o
539302 sinistra - Paracetamol 3x500mg Outpatient
- Cefixime 2x100mg
Vulnus Appertum Regio Digiti I Manus D
Susp Ruptur Tendon Digiti I Manus D
Patient Identity

Name : IPNL
Gender : Male
Age : 78 years old
Address : Ceremai Street, Bitra
Pekerjaan : Self-employed
MR Number : 736264
Primary Survey

A : Clear (patient airway and no obstruction)

B : Spontaneous, RR 25 time/minute, SpO2 99% on RA
C : Stable, BP 120/80 mmHg, HR: 80 beats/minute, CRT<2 seconds
D : GCS: E4V5M6, round pupils isocor 3 mm/3 mm, RP +/+, impression of
lateralization (-)
E : Temp. 36.4°C

Impression: Patent airway, adequate breathing and stable circulation

Anamnesis
Chief Complaint : wound in the right thumb
Recent Illness History :

Patient came to the ER at Sanjiwani Hospital with complaint of a wound on the thumb of his
right hand due to a knife sliced the thumb an hour before admitted to the ER. The patient said
the thumb injured while fixing his roof. The patient felt pain if the thumb being moved or
bent. There’s no alleviating factor. Other complaints such as open wounds (+) active bleeding
(+), dizziness (-) headache (-), nausea and vomiting(-).

MOI :The patient fixing his roof and patient hold a knife and accidentally injured his right
thumb
Anamnesis
Past Illness History:
This is the first time the patient had a similar complaint. Patient denied any history of chronic
diseases such as HT(-), DM(-), and heart disease also denied.
Family Illness History:
Patient denied history of allergy and history of chronic diseases suc as hypertension, diabetes
mellitus, and cardiac disease in his family.
Personal, Social, and Environmental History :
Patient is a farmer with mild to moderate ativities. History of drinking alcohol and smoking were
denied.
 Secondary Survey
General State
Head : Normocephali
Eyes : Conjunctiva anemic (-/-), icteric sclera (-/-)
ENT : Normal, hyperemic (-/-); mucus (-/-); throat hyperemic (-), wet oral mucosa
and tongue.
Neck : Lymph node enlargement (-)
Cor: S1S2 single regular, gallop (-), murmur (-)
Pulmo : Vesicular (+/+), wheezing (-/-), ronchi (-/-)
Abdomen: No distention, bowel sound (+) normal, tenderness (-), liver and spleen
impalpable.
Extremities: based on localised state
 Physical Examination

Localized Status of Digiti I Manus Dextra

Look : vulnus appertum ± 3 cm with bony base,

active bleeding (+) dislocation (-) oedema (+) hyperemia(+)
Feel : tenderness (+) crepiration (-) palpable warmth CRT < 2 secs
Move :
DIP joint : ROM active (-), ROM passive (+) limited by pain
PIP joint : ROM active and passive (+) limited by pain
 Assessment and Supporting
Examination
Assessment Supporting examination
Vulnus Appertum Regio Digiti I Manus D - Manus Dextra X-ray AP/Oblique
Susp Ruptur Tendon Digiti I Manus D
Supporting Examination
 Assessment and Treatment
Assessment Treatment
- Wound Toilet
Vulnus Appertum Regio Digiti I Manus D - IVFD NaCl 0,9% 20 tpm
Susp Ruptur Tendon Digiti I Manus D - Paracetamol 3x1gr IV k/p
- Tetagam Inj IM
- Debdridement and Exploration Tendon
Rupture at OR (26/04)
Vulnus appertum regio digiti III manus S
Patient Identity

Name : IGABS
Gender : Female
Age : 42 years old
Address : Serongga Tengah
MR Number : 353799
Primary Survey

A : Clear (patient airway and no obstruction)

B : Spontaneous, RR 25 time/minute, SpO2 99% on RA
C : Stable, BP 120/80 mmHg, HR: 80 beats/minute, CRT<2 seconds
D : GCS: E4V5M6, round pupils isocor 3 mm/3 mm, RP +/+, impression of
lateralization (-)
E : Temp. 36.5°C

Impression: Patent airway, adequate breathing and stable circulation

Anamnesis
Chief Complaint : wound in the middle finger
Recent Illness History :

Patient came to the ER at Sanjiwani Hospital with complaint of a wound on middle finger of
the left hand one hour before admitted to the ER due to sliced by a slicing machine while the
machine slicing pandan leaf. Patient felt pain on the site of the wound, There’s no
aggravating or alleviating factor. Other complaints such as open wounds (+) active bleeding
(+) minimal, limited movement (-), dizziness (-) headache (-), nausea and vomiting(-).

MOI :The patient slicing pandan leaf with a machine and accidentally injured her left middle
finger.
 Anamnesis
Past Illness History:
This is the first time the patient had a similar complaint, and the patient denied any history of chronic
diseases such as HT(-), DM(-) and other chronic diseases.
Family Illness History:
Patient denied history of allergy and history of chronic diseases like cancer, hypertension, diabetes mellitus,
and cardiac disease in her family.

Personal, Social, and Environmental History :

Patient is a farmer with mild to moderate activities. History of drinking alcohol and smoking were denied.
 Secondary Survey
General State
Head : Normocephali
Eyes : Conjunctiva anemic (-/-), icteric sclera (-/-)
ENT : Normal, hyperemic (-/-); mucus (-/-); throat hyperemic (-), wet oral mucosa
and tongue.
Neck : Lymph node enlargement (-)
Cor : S1S2 single regular, gallop (-), murmur (-)
Pulmo : Vesicular (+/+), wheezing (-/-), ronchi (-/-)
Abdomen : No distention, bowel sound (+) normal, tenderness (-), liver and spleen
impalpable.
Extremities: based on localised state
 Physical Examination

Localized Status of Digiti III Manus Sinistra

Look : vulnus appertum 2 cm x 2,5cm cm minimal bleeding

(+) dislocation (-) oedema (-) hyperemia(-)
Feel : tenderness (+) crepitation (-) palpable warmth CRT < 2
secs
Move :
DIP joint : ROM active and passive (+)
PIP joint : ROM active and passive (+)
 Assessment and Supporting
Examination
Assessment Supporting examination
Vulnus appertum regio digiti III manus S - Manus Sinistra X-ray AP/Oblique
Supporting Examination
 Assessment and Treatment
Assessment Treatment
Vulnus appertum regio digiti III manus S - WT
- Tetagam Inj IM
- Cefixime 2x100mg
- Paracetamol 3x500mg
Close Fracture of Clavicula 1/3 Medial Dextra
Patient Identity
Name : PK

Gender : Female

Age : 57 years old

Religion : Hindu

Address : Petuluan Temesi

RM : 406475
No
 PRIMARY SURVEY
A : Clear (patent airway and no obstruction)

B : Spontaneous, RR 20 times/minute, SpO2 99% on room air.

C : Stable, BP 120/90 mmHg, HR: 89 beats/minute, CRT<2 seconds

D : GCS: E4V5M6, round pupils isocor 3 mm/3 mm, RP +/+, impression of lateralization

(-) E : Temp. 35.9°C

Anamnesis
Main Complaint: Pain in the right shoulder

History of current illness:

The patient came to the emergency room of Sanjiwani Hospital with consciousness and complained
of pain in the right shoulder since 1 hour before go to the hospital. The pain was felt continuously. In
the beginning patient was riding motorcycle and have a crash accident. After that patient fell down to
the right side but fortunately the patient still wearing helmet. The patient’s shoulder could not be
moved and the pain increased when the patient tried to move the shoulder. The VAS pain scale felt
by the patient was 5. There were no aggravating or alleviating factors for the patient's complaints.
Complaints of nausea/vomiting (-) decreased consciousness (-), fainting were denied, headache (-).
MOI: The patient have a crush accident and fell down to the right side
Anamnesis
Past Medical History

This is the first time patient had a similar complaint and history of any history chronic disease such as

HT, DM and others are denied. History of food allergy or drugs (-).

Family History of Disease

History of chronic diseases such as hypertension, diabetes mellitus, heart disease is denied.

Personal, Social and Environmental History

The patient is a housewife. History of smoking (-), alcohol consumption (-).

 SECONDARY SURVEY
- Head: Normocephali, imprint (-), cephal hematoma (-)
- Eyes : Pale conjunctiva (-/-), icteric sclera (-/-), pupillary reflex (+/+)
- ENT : Quiet impression, otorrhea -/- , Rhinorrhea -/-
- Neck : imprint -, deformity-
- Thorax: imprint (-), symmetrical (+/+)
- Cor : S1S2 single regular, murmur (-), gallop (-)
- Pulmo : Vesicular +/+, rhonki -/-, wheezing -/-
- Abdomen : Trace (-), distension (-), BU (+) normal, defans (-), tenderness
(-)
- Extremities: ~According to localized status
LOCALIZED STATUS
STATUS LOCALIS REGIO CLAVICULA DEXTRA

Look
• Deformity (-), edema (+), hyperemia (+), bone exposure (-), active
bleeding (-)
Feel
• Pressive pain (+) warm palpable, Crepitation (+), CRT<2
seconds, SpO2 99% on room air, Paralysis (-), Parasthesia (-)

Move
• Shoulder Joint: Active ROM (+), passive ROM (+) pain
limited
• Elbow joint: Active ROM (+), passive ROM (+)
• Wrist joint :Active ROM (+), passive ROM (+)
 Diagnosis and Support

Assessment: Proposed Supporting Examination:

Susp CF clavicula dextra dd X-Ray clavicula dextra AP

CF Humerus dextra
Supporting Examination
Conclusion: Fracture undisplaced of
the medial 1/3 of the clavicula dextra
Diagnosis and Management

Diagnosis: Management:
CF 1/3 Medial Clavicula Dextra Immobilization with arm sling
Paracetamol 3x500 mg PO
Cefixime 2x100 mg PO
Vulnus Ictum Regio Plantar Pedis
Sinistra
Identity

Name : IPGS

Gender : Male

Age : 60 years old

Occupation : Farmer

Address : Belega, Gianyar

MR number : 539302
Primary Survey
A : Clear
B : Spontaneous, RR 20 x/minute, spo2 99% RA
C: Stable, BP 120/70 mm Hg, pulse 80 x/min regular lifting strength, CRT < 2
seconds
D : GCS E4V5M6 , 3mm/3mm RP isochor round pupil +/+
E : Temp : 36,5 C
Anamnesis

Chief Complaint: Injury in the left sole

Current medical history:
The patient came to the emergency room at the Sanjihani Hospital with complaints of a
wound in the left sole after being stabbed by a nail 30 minutes after SMRS. It was said
that the patient at that time was clean the ricefield and was accidentally pierced by a nail
and the nail was said to be rusty. There were no factors that aggravated or alleviated the
patient's complaints, other complaints (-).
Anamnesis

Past medical history

The patient has never experienced a similar complaint. History of chronic diseases such
as diabetes mellitus (-), History of drug and food allergies (-)
Family Disease History
History of chronic diseases such as hypertension, diabetes mellitus and heart disease in
the family was denied
Personal, Social and Environmental History
The patient is a farmer with moderate to heavy activity
 SECONDARY SURVEY
PHYSICAL EXAMINATION
General Status
Head : Normocephali
Eyes : Pale conjunctiva (-/-), icteric sclera (-/-), pupil reflex (+/+) isochor
ENT : Impression of calm
Mouth : Mucosa wet mouth (+), cyanosis (-)
Neck : lymphnode enlargement (-)
Physical Examination

Thorax
Inspection: Symmetrical (+/+), retraction (-)
Palpation: Symmetrical chest motion
Percussion: Heart within normal limits
Auscultation: regular single S1S2, murmur (-), vesicular breath sounds (+/+), rhonki (-/-),
wheezing (-/-)
Abdomen
Inspection: Distension (-), scar tissue (-)
Auscultation : BU (+) normal
Percussion: Tympany throughout the abdominal region
Palpation: Tenderness (-), liver and spleen not palpable
Extremities: warm ++/++, according to local status
 Local Status of Examination
LOCAL STATUS OF THE PLANTAR PEDIS SINISTRA REGION
Look
Deformity (-), Vulnus ictum (+) 0.5 x 0.5 cm Hyperemia (+),
edema (-), active bleeding (-).
Feel
Tenderness (+) feels warm, CRT < 2 seconds
Move
Ankle joint : ROM active (+)
Diagnosis dan Management

Vulnus Ictum Regio Plantar Pedis Sinistra Management :

WT
Eksplorasi
Tetagam 1x250 IU
Paracetamol 3x500 mg PO
Cefixime 2x100 mg PO
TERIMA KASIH