MORNING REPORT

IDENTITY
Name : Mr. Ade
Age : 31 y.o
Sex : Male
Address : Poasia
Admission : November 11th 2019
DPJP : dr. Rizal Alisi, Sp. OT
HISTORY TAKING
• Chief Complainment :
Pain on face and hand
• Anamnesis :
Since 2 hours ago
• MOT :
The patient is reapiring the roof of the house the falls in a twisted position with his
face dragged on the ground
• HOT :
No loss of consciousness, no nausea and vomiting, no bleeding from ear, nose, mouth.
PRIMARY SURVEY

A Clear
B RR : 20 breaths/min, Thoracoabdominal
C Blood Pressure : 130/90 mmHg, Pulse rate :72 bpm, regular
D E4M6V5 (GCS 15), isokor pupil, light reflex (+/+)
E Temperature : 36º C
SECONDARY SURVEY
• Generalized state :
Compos mentis, moderate pain, good nutrition
• Localized state :
Regio Mentalis I : Swelling (-), Hematom (-), Wound (+), V. laceratum 4 cm
P : Tenderness (+), Crepitation (-) os. mandibula.
Regio Antebrachial I : Sweeling (-), Hematom (+), Wound (-)
P : Tenderness (-), Crepitation (-)
PLAN OF DIAGNOSE
• Hand X-Ray
• Laboratory Test:
 Routine blood test
 Clotting time/ Bleeding time
 Blood chemistry test
LABORATORY FINDINGS
Result Unit Normal Result Unit Normal
Hematology Leukocyte
Hemoglobin 11.4 g/dl 12.0 – 16.0 NEUT 1.65 10^3/uL 1.50 – 7.00

Leukosit 6.5 10^3/uL 4.0 - 10.0 LYMPH 2.57 10^3/uL 1.00 – 3.70

Trombosit 265 10^3/uL 150 – 450 MONO 0.55 10^3/uL 0.00 – 0.70

Hematokrit 38.6 % 37.0 - 48.0 EO 0.15 10^3/uL 0.00 – 0.40

MCV 83.7 fL 80.0 – 97.0 BASO 0.03 10^3/uL 0.00 – 0.10

MCH 27.9 Pg 26.5 – 33.0

MCHC 33.8 g/dl 31.9 – 37.0
PCT 0.44+ % 0.17 - 035
X-RAY
DIAGNOSE
Fr. Radius Ulna (D) + Vulnus Laceratum Labialis
Inferior
MANAGEMENT
• Non-pharmacology
 Bed Rest
 Education
• Pharmacology
 IVFD
 Antibiotik
 Analgetik
 PPI

Consult to Orthopedic Surgeon