MORNING

REPORT
Koas Jaga 17 September 2023
Identity

● Name : Tn. L
● Age : 37 years old
● Gender : Male
● Address : Batu
● Arrival date : Monday, 18/09/2023 05.50 WIB
● Incident date : Monday, 18/09/2023 05.30 WIB
● Patient Type : Trauma
 PRIMARY SURVEY
Arrival date : Monday, 18/09/2023 05.50 WIB
Incident date : Monday, 18/09/2023 05.30 WIB

MOI: The patient was riding a motorbike wearing a helmet at a speed of 30-50 km/hour
and then the patient was hit by another motorbike from behind. Then the patient
complained of pain in the right shoulder and was go to RSKH.
Anamnesis:
The patient came to the Karsa Husada Emergency Room on 18/09/2023 at 05.50 WIB
with the main complaint of pain in the right shoulder with a VAS score 9 after being hit from
behind while riding a motorbike. The patient complained of persistent pain, radiating to the
upper right chest and chest pain when taking a deep breath. The patient does not
experience fainting, headache (-), nausea (-), vomiting (-), retrograde amnesia (-).The
patient has not taken any treatment so far.
 Identity Examination Initial Diagnosis Action
Airway: Paten -
Patent, gargling (-), stridor (-)
Breathing: Breathing -
Look: symmetrical chest wall movement, lesion (-) spontaneusly
Feel: the patient breathes spontaneously, no
additional breath sounds, rib crepitations (-), step
defect (-)
RR: 24x/minute
SpO2 : 97% on RA
 PRIMARY SURVEY
Examination Initial Diagnosis Action
Circulation: - -
BP 132/95 mmHg
HR: 75 x/m
CRT <2s, red warm dry acral
Active bleeding (-)
Disability: - -
GCS 456
PBI 3 mm/3mm, RCL +/+, RCTL +/+
Action : -
 PRIMARY SURVEY
Examination Initial Diagnosis Action
Exposure: -
Temperature: 36.2⁰C, CRT<2s

Localist status
Regio Clavicula Dextra Close Fracture -
Look: Edema (-), Eritema (+), deformitas (-) Clavicula dextra
Feel: pain (+), crepitation (+)
Moves:
Limitation of ROM (+)
Flexion shoulder joint 0-5 degree
Extension shoulder joint 0-5 degree
Rotation interna shoulder joint 0-5 degree
Rotation externa shoulder joint 0-5 degree
Abduction shoulder joint 0-5 degree
Adduction shoulder joint 0-5 degree
 SECONDARY SURVEY

GENERALIST STATUS

GCS: 456
TD: 129/90 mmHg
HR: 68x/menit
RR: 23x/menit
T: 36,2 ⁰ C
SpO2 : 97% on RA
 SECONDARY SURVEY
ANAMNESIS
Secondary Survey
Alergi: -
Med: -
Past: -
Last meal: pukul 04.00 WIB
Event: The patient was riding a motorbike wearing a helmet at a speed of 30-50
km/hour and then the patient was hit by another motorbike from behind. Then
the patient complained of pain in the right shoulder and was goto RSKH.
Physical Examination:
TD: 129/90 mmHg
HR: 68x/menit
RR: 23x/menit
T: 36,2 ⁰ C
SpO2 : 97% on RA
 PHYSICAL
EXAMINATION
Pulmo:
HEAD/NECK: Inspection: normal chest wall shape, retraction (-), looks
Head
symmetrical (+/+)
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), Isochor
Palpation: symmetrical D/S chest wall movement
pupil diameter 3mm/3mm, Light reflex direct and indirect
+/+
Percussion: sonor all lung fields
Neck : Auscultation: Ves/Ves, rh (-/-), wh (-/-)
Inspection: tracheal deviation (-)
Palpation: enlarged lymph nodes (-) Abdomen:
Auscultation : Bruits (-) Inspection : Flat, injury (-), surgical scar (-)
Auscultation : Bowel sound (+) 17x/minute
THORAX : Percussion : Timpany all abdomen fields
Cor: Palpation : Flat, soft, superficial tenderness (-), deep
Inspection: ictus cordis invisible tenderness (-)
Palpation: ictus cordis palpable at ICS 5 MCL S
Percussion: Right heart border at PSL D ICS 4, left heart Extremities : Dry warm acral, CRT <2 s, pain (+),
border ICS 5 MCL S limitation ROM of region Shoulder dextra (+)
Auscultation: S1 S2 single, regular, murmur (-), gallop (-)
CLINICAL PICTURE

HGB 14.9 g/dL (n 12.3 - 15.3)
RBC 5.30 10^6/uL (n 4.1 - 5.1)
HCT 43.0 % (n 34.0 - 47.0)
MCV 81.1 fL (n 80.0 - 97.0)
MCH 28.1 pg (n 26.5 - 33.5)
MCHC 354.7 g/dL (n 31.5 - 35.0)
RDW-SD 37.2 fL (n 35 - 47)
RDW-CV 12.7 % (n 11.5 - 14.5)
WBC 9.83 10^3/uL (n 4.4 - 11.3)
LABORATORY
Hitung Jenis PPT 10.0 detik 9.9-11.8
EO% 2.4 % (n 2 - 4) APTT 29.2 detik 25-31.3
BASO% 0.5 % (n 0 - 1)
NEUT% 73.0 H % (n 50 - 70)
LYMPH% 19.0 L % (n 25 - 40)
MONO% 5.1 % (n 2 - 8)
EO# 0.24 10^3/uL
BASO# 0.05 10^3/uL
NEUT# 7.17 10^3/uL
LYMPH# 1.87 10^3/uL
MONO# 0.50 10^3/uL
IG% 1.2 % < 0.5
IG# 0.12 10^3/uL (n < 0.03)
PLT 280 10^3/uL (n 150 - 450)
PDW 11.3 fL (n 10 - 18)
MPV 9.7 fL (n 6.6 - 11)
P-LCR 23.1 % (n 15.0 - 25.0)
PCT 0.27 % (n 0.150 - 0.400)
LED 12 mm/jam (n 0 - 20)
 PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning Planning Therapy &
Diagnosis Monitoring
Anamnesis:
Main complaint:pain in the right shoulder
Anamnesis:
- Pain with a VAS score 9 after being hit
from behind while riding a motorbike
- Persistent pain, radiating to the upper
right chest and chest pain when taking
a deep breath
- Fainting (-), headache (-), nausea (-),
vomiting (-), retrograde amnesia (-)

MOI: was riding a motorbike wearing a

helmet at a speed of 30-50 km/hour and
then the patient was hit by another
motorbike from behind
 PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning Planning Therapy &
Diagnosis Monitoring
Localist status Close Fracture Xray Shoulder Inj. ketorolac 30 mg
Regio Clavicula Dextra Clavicula Dextra IV
Look: eritema (+), edema (-), deformitas (+) Inj. Ranitidine 50
Feel: pain (+), crepitation (+) mg IV
Moves:
Limitation of ROM (+)
Flexion shoulder joint 0-5 degree
Extension shoulder joint 0-5 degree
Rotation interna shoulder joint 0-5 degree
Rotation externa shoulder joint 0-5 degree
Abduction shoulder joint 0-5 degree
Adduction shoulder joint 0-5 degree
Xray Shoulder Dextra
(Pre Op-18/9/23)
Xray Shoulder Dextra
(Post Op-18/9/23)
Tn. Latif/ 37 th/3F/ Post ORIF Clavicula D & Closed reduction shoulder D H+1/dr.
Bambang, Sp.OT

S : nyeri di bahu kiri dan punggung, demam -, mual -, muntah -

O:
BP : 121/80 mmHg
HR : 81 x/ menit
RR : 18 x/ menit
T : 36.8°C
SpO2 : 95% on RA
RR : 16x/ menit

Pemeriksaan Fisik
K/L : a/i/c/d -/-/-/-
Tho : ves +/+ rh -/- wh -/-
Cor : S1|S2 tunggal
Abd : soefl, BU +, nyeri tekan -
Ext : AKHM, CRT < 2 s
Status lokalis:
Regio shoulder dextra
L : luka operasi di bahu kanan tertutup kassa
F : nyeri tekan +
M : ROM shoulder abduksi 30°, adduksi 30°
Fleksi 60°, ekstensi: 45°

A
Post ORIF Clavicula D & Closed reduction shoulder D H+1

P
Inj. Ceftriaxon 2 x 1 gram
Inj. ketorolac 3 x 30 mg
Inj. ranitidine 2 x 50 mg
Inf. RL 20 tpm
THANK YOU