Morning report

Thursday , 12 August 2021

DM Kinanti
DM Grace

dr. Alders, Sp. B

1. Patient Identity
Name : Mr. JL

Sex : Male

Age : 57 year old

Admission date : Wednesday, August 8th 2021

No. MR : 546232

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 History Taking
Major Complaint/Discomfort : Open fracture tibial and fibula, closing fracture in femur
Current Medical History:
The patient came by as referred from Rote Hospital with the diagnoses of syok hemorrhargic that has been taken
care of post trauma, with history of unconscious, vomitus (+), seizure (-), patient has good orientation, tenderness
in the right side of arm and foot.

Mechanism of Injury:
At 4 o’clock in ther morning patient was driving a motorcycle, when a pickup car from the opposite direction and
hit patient on the tibia. Patient lost control of balance and fell with right side position first. Patient was unconcious
right at the spot of falling.

History of past illness : -

History of medicine : RS Rote IVFD NaCl 0,9% 2 L, continue 30 dpm

Ketorolac inj.3x30 mg IV
Inj tranexami acid 3x500 mg IV

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 PRIMARY SURVEY

Airway : patent, clear

Breathing :RR: 25x/min, Snoring(-), gurgling (-), SpO2 99%
Circulation :BP 90/60, HR103x/min, palpable, shock(-),
temperature: 36,7 ͦ C
Disability :E4V5M6
Exposure :Open fracture 1/3 tibial fibula, Closed fracture 1/3
distal femur, Vulnus amputatum digitatum V manus
dextra, neurologic function still on normal side, can’t seem to
move foot.

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 SECONDARY SURVEY

Skin : fast turgor

Head :Normocephal, hematom (-)
Eye :CA +/+, SI -/-, Hematoma palpebra (-)
Ear :ottorhea(-), lession(-)
Nose :Rhinorhea (-), breathing while nostril moving(-)
Mouth :Cyanosis(-)
Heart :S1S2 single, regular, murmur(-), gallop (-)
Lung :Vesicular(+/+), rh (-/-), wh(-/-)
Neck :Symmetry (+), lession (-)
Abdomen : normal, bowel sound (+), tenderness(-), lesiion(-),
tympanic (+)

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 3/8/2021 Unit
HB 7.2 g/dL (L)
RBC 2.50 x10^6/Ul
HCT 21.0 % (L)
RDW-SD 36fl (L)
Leucocyte 11.31x 10^3 /uL (H)
Total Neutrophiles 9.09x 10^3/ml (H)
Total Monocyte 0.84/Ml (H)
Cl 116 mmol/L (H)
Calcium Ion 1.06 mmol/L (H)
Blood Sugar 99 mg/dL
Creatinin 3.32 mg/dL (H)
Urea N 39.00 mg/Dl (H)
PT 10.40 secs (L)
APTT 29.60 secs

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Malaligmnet , open Fracture 1/3 proximal os.
tibia fibula, soft tissue swelling

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 Assessment
Open Fracture 1/3 tibia fibula
Closed Fracture 1/3 distal femur
Vulnus amputatum digiti manus dextra

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 TREATMENT
• ER
- Continue therapy from Baa Hospital, IVFD NaCl 0,9% 500 cc 20 dpm IV
-O2 2-3 dpm
-antrain inj 1 amp IV

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