ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT

FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

MORNING REPORT
GROUP 11 :

C014212029 Ahmad Nurfikri Bahar Supervisor :

C014212103 Irvan Usemahu dr. Fadlyansyah Farid, MARS, Sp.OT
C014212115 Muhammad Fily Anugerah Fith
Dahlan
PATIENT IDENTITY
Name : Mr. A

Age : 22 y.o

Gender : male

Address : Makassar

Registration Number : 1028243

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

ANAMNESIS
CHIEF COMPLAINT : PAIN IN THE LEFT THIGH
- suffered since 20 hours before admitted to the hospital. Patient was riding a motorcycle and suddenly hit
a from the front side with left thigh hit the car. After the accident, the patient can’t walk or stand. Befote
the accident the patient can walk normally without any aid.
No history of loss of consciousness
No history of projectil vomitting
No history of operation
No History of hypertension
No History of diabetic

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

PHYSICAL EXAMINATION
GENERAL STATUS VITAL SIGN
GCS 15 (E4M6V5) / Conscious Blood Pressure : 118/67 mmHg

Pulse rate : 121x/min

Respiratory rate : 18x/min

Temperature : 36.7 C

NRS : 4/10

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

PHYSICAL EXAMINATION
CLINICAL FINDINGS (LEFT HIP REGION)

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

PHYSICAL EXAMINATION
CLINICAL FINDINGS (LEFT HIP REGION)

LOOK FEEL
Deformity (+), hematoma (+) , swelling (+), Tenderness (+)
wound (-)
MOVE
Active and passive motion of the hip joint is difficult
to evaluate due to pain.

NEUROVASCULAR DISTAL
Sensibility is good. Pulsation of the dorsalis pedis and
tibialis posterior arteries is palpable. Capillary refill
time is less than 2 seconds.

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

PHYSICAL EXAMINATION
CLINICAL FINDINGS (LEFT FOOT REGION)

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

PHYSICAL EXAMINATION
CLINICAL FINDINGS (LEFT FOOT REGION)

LOOK FEEL
Deformity (+), hematoma (-) , swelling (+), Tenderness (+)
lacerated wound at digiti size 3x1 cm, skin loss at
MOVE
dorsal aspect of digiti I, nail loss at digiti I,
Active and passive motion of MCP and PIP digiti I joint within nornal
excoriated wound at dorsal aspect of pedis (-)
range, Active and passive motion of MCP, PIP , DIP, digiti II, III, IV, V
joint within nornal range,

NEUROVASCULAR DISTAL
Sensibility is good. Pulsation of the dorsalis pedis and
tibialis posterior arteries is palpable. Capillary refill
time is less than 2 seconds.

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

PHYSICAL EXAMINATION
LEG LENGTH DISCREPANCY

RIGHT LEFT

ALL 94 92

TLL 88 86

LLD 2 CM

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

ADDITIONAL EXAMINATION
RADIOLOGY

Pelvic AP
(25/06/2023)

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

ADDITIONAL EXAMINATION
RADIOLOGY

Femur AP + Lateral D/S

(25/06/2023)

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

ADDITIONAL EXAMINATION
LABORATORIUM (23/6/2023)
Result Reference Value Result Reference Value

WBC 10.7 4-10 x 103/uL INR 0.5 <1

RBC 3.57 4-6 X 103/uL HbsAg Non Reactive Non Reactive
HGB 10.8 12-16 g/dL

HCT :33 30-50%

PLT 203 150-400 x 103 /uL

PT 10.8 10-14 second

APTT 20 22 – 30 second

Ureum 36 10-50 mg/dL

Creatinine 0.95 <1.3 mg/dL

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

 DIAGNOSE
Closed fracture intertrochanter extend to subtrochanter left

femur

Nail bed injury left big toe

Excoriated wound at left foot region

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

 MANAGEMENT
• IVFD Ringer Lactate

• Analgesic

• Apply skin traction

• Refer to Orthopedic Consultant

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

THANKYOU