MORNING REPORT

IDENTITY

• Name : Mrs. N
• Age : 18 Years old
• Sex : Female
• Address : Sindangkasih, Ranomeeto
• Occupation : Student
• Admission : April, 27 2019/09.20 A.M
• Doctor in charge : dr. Benny Murtaza, Sp.OT
 PRIMARY SURVEY
AT 09.20 AM

A Clear, cervical spine control

B Respiratory rate 20x/m, spontaneous,

symetris, reguler, thoracoabdominal type

C Blood Pressure 100/70 mmHg

Pulse 68x/m, reguler, strong

D Glasgow Coma Scale (E4M6V5), pupil

isochoric 2,5 mm/2,5 mm. DLR +/+

E Temperature 36,7OC/axillary
 SECONDARY SURVEY
AT 09.25 PM

HISTORY TAKING
• Chief Complain : pain at the right shoulder
• Anamnesis :
Since one day before admitted to hospital due to sport accident.
• Mechanism of Trauma :
Patient was compete silat, suddenly she slammed down to the
right side by her rival and her right shoulder hit the floor.
• History of Trauma :
 There was no history of unconciouss, nausea and vomiting
 There was no history of drugs or alcohol consumption
 There was history of previous treatment (Ranomeeto Primary
Health Care) : IVFD, analgesic and antibiotic
 Right hand was dominant
 SECONDARY SURVEY
AT 09.28 PM

PHYSICAL EXAMINATION
• Generalized state:
Moderate illness, good nourish, composmentis
• Vital sign:
Blood pressure : 100/70 mmHg
Heart rate 68x/m, regular, strong
Respiratory rate : 20x/m, symmetric, regular
Temperature 36,6 celcius degree/axillary
VAS 5/10
 SECONDARY SURVEY
AT 09.35 AM
PHYSICAL EXAMINATION
Present State
Head : Within normal limit
Face : Within normal limit
Eyes : Within normal limit
Nose : Within normal limit
Mouth : Within normal limit
Ears : Within normal limit
Neck : Within normal limit
Chest : Within normal limit
Abdomen : Within normal limit
Upper Limb : Localized state
Lower Limb : Within normal limit
Genitalia : Within normal limit
 SECONDARY SURVEY
AT 09.38 AM

PHYSICAL EXAMINATION
LOCALIZED STATE RIGHT DELTOID REGION
Inspection
Deformity (+), Hematoma (-), Sweeling (+), Wound (-)

Palpation
There was Tenderness

ROM
Active and passive movement at shoulder joint limited
due to pain

NVD
Sensibility was normally, pulsation radialis artery was
palpable and CRT < 2 seconds
CLINICAL DOCUMENTATION
 PLAN OF DIAGNOSTIC

• Blood routine test (Leukosit, HB,

trombosit)
• Clothing Time/Bleeding Time
• X-ray shoulder dextra AP
erect/supine
LABORATORIUM FINDINGS

• Blood routine test

- WBC : 7,58 x 103/uL
- RBC : 4,36 x 106/uL
- HB : 12,1 g/dL
- PLT : 263 x 103/uL
• Clothing Time/Bleeding Time
- BT : 2’23”
- CT : 7’35”
RADIOLOGY FINDING
 DIAGNOSE

Differential Diagnose :
Diagnose : 1. Frozen Shoulder
Dislocated of Right 2. Caput Humeri
Shoulder Fracture
3. Neurovascular Injury
 MANAGEMENT

Non Farmacology Farmacology

• Rest
• IVFD
• Immobilization
• Analgesic injection
• Compress Ice
• H2RA injection
• Education

Consult To Orthopedic Surgeon