MORNING

REPORT
11 September, 2023
IDENTITY

● Name : Arva
● Age : 14 years old
● Gender : Male
● Address : Batu
● Arrival Date : September 15, 2023
● Patient Type : Trauma
 ANAMNESIS

Main Complaint:
Left index toe pain with vas 5

Curent Medical History:

Left index toe pain with vas 5. Dizziness (-), nausea (-) vomiting (-).
Retrograde amnesia (-). Left digit II feels painful with VAS 5. Bleeding
(-)

MOI : The patient was playing football without wearing shoes then his
foot was hit by a friend's foot on Wednesday last week and this morning,
a cracking sound - The patient limps slightly after the injury
 Primary Survey Initial Diagnosis Action
Airway: Paten -
Patent, gurgling (-), stridor (-)
Breathing: Spontan -
Look: symmetrical chest wall movement
Feel: the patient breathes spontaneously, no
additional breath sounds, rib crepitations (-), step
defect (-)
RR: 18x/minute
SpO2 : 97% on RA

Circulation: Maintenance fluid 10 kg I : 40 ml/ jam

BP: 172/80 mmHg HR: 94 x/m 10 kg II : 20 ml/ jam
CRT <2s, red dry warm acral 10 kg III : (35-
Active bleeding (-) 20)=15 ml/ jam
 Examination Initial Action
Diagnosis
Disability - -
GCS: 456. PBI: 3 mm/3mm. Direct light reflex
+/+, Indirect light reflex +/+
Exposure - -
T : 35.9 ° C
 PHYSICAL
EXAMINATION
THORAX :
HEAD/NECK:
Cor:
Head: Inspection: ictus cordis invisible
Head/neck: a/i/c/d -/-/-/- 2mm/2mm Palpation: ictus cordis palpable at ICS 5 MCL S
isochor pupils, RCL -/-, RCTL -/-, visual Percussion: D heart border at ICS 4 PSL D, heart border S
acuity ODS SDE at ICS 5 MCL S
Auscultation: S1 S2 single, regular, murmur (-), gallop (-)
Neck :
Inspection: tracheal deviation (-) Pulmo:
Palpation: enlarged lymph nodes (-) Inspection: normal chest wall shape, retraction (-)
Palpation: symmetrical D/S chest wall movement
Auscultation : Bruits (-)
Percussion: sonor
Auscultation:
Ves + + Wh - - Rh - -
+ + - - - -
+ + - - - -
 PHYSICAL EXAMINATION
Local Status
Abdomen Regio pedis sinistra
Inspection: L : Edem (-), vulnus (-), Bone expose (-),
Flat, inflammation (-) scar (-) eritem (-) deformitas (-) Bleeding (-)
Auscultation : BS (+) F : Nyeri Tekan (+), krepitasi (-), Step defek
Abdominal percussion: timpany (-), suhu seperti kulit yang lain
Abdominal Palpation: M : ROM terbatas nyeri (+) ROM flexi 5°,
Tenderness (-) superficial and deep. ekstensi 5°
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Extremity:
Dry red warm akral ++/+-, CRT> 2, edema
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 SECONDARY SURVEY GENERALIST STATUS

S : Pain in his digiti 1 left foot Ku : Cukup

not reduced GCS : 456
A:- BP : 143/86 mmHg
M:- HR : 78 x/m
P:- RR : 16 x/m
L : 12.30 T : 36,9 °C
E : The patient collided with his SpO2 98 % on RA
friend's feet while playing BW: 91 kg
soccer
Laboratorium
 PROBLEM LIST & PLANNING
Problem list Definitive Planning Planning Therapy
Diagnosis Diagnosis
An.A, 15 yo. Pain in his left foot because playing footbal • Close fracture • Xray pedis • RICE
basis middle sinistra • Inj. Ketorolac 15 mg
Physical examination : phalanges II • Inj. Ranitidin 50 mg
• Ku : Cukup pedis sinistra • Pro Closed reduction
• GCS : 456
• BP 143/86 mmHg Monitoring
• TTV
• HR 78 x/m
• Skala Nyeri
• RR : 16 x/m
• T : 36,9 °C
• SpO2 98 % on RA
• BB: 91 kg

Regio pedis sinistra

L : Edem (-), vulnus (-), Bone expose (-), deformitas (-)
Bleeding (-)
F : Nyeri Tekan (+), krepitasi (-), Step defek (-), suhu seperti
kulit yang lain
M : ROM terbatas nyeri (+) ROM flexi 5°, ekstensi 5°
Xray Pedis
Sinistra
THANK YOU
Follow Up
The patient goes home of his own accord