MORNING

REPORT
20 Mei 2023
Identity

● Name : Mrs. S
● Age : 68 years old
● Gender : Female
● Address : Batu
● Arrival Date : 20 Mei 2023
● Patient Type : Trauma
 PRIMARY SURVEY
Incident date: 20/05/2023, at 17.00 p.m
Arrival Date: 20/05/2023 , at 17.20 pm

Anamnesis:
Main complaint: pain on the right leg
History of illness : pain felt after the patient feel when sweeping in the house yard, VAS 7-8, there is no complaints on the other parts of the body. nausea (-), vomiting (-),
dizziness (-), headache (-).
MOI : patient fell when sweeping in front yard and suddenly slip and she fell in to the right side with her leg hit by her body.

Examination Initial Diagnosis Action

Airway: - -
gargling (-), stridor (-), snoring (-)

Breathing: -
Look: symmetrical chest wall movement (+), lesion (-), deformity (-)
Feel: the patient breathes spontaneously, no additional breath sounds, rib crepitations
(-), dyspnea (-)
RR: 20x/minute
SpO2 : 98% on RA

Circulation: Syok Hipovolemik Grade I BB= 60 kg

BP: 168/90 mmHg EBV = 60 x 60 = 3600 cc
HR: 98 x/min, strong pulse EBL = 3600 x 15% x 3
CRT<2s, warm red dry acral (+/+) = 1620 cc/1jam  1.700 cc/1jam
Bleeding active (-)
 PRIMARY SURVEY
Examination Initial Diagnosis Action

Disability :
GCS 456, pupil isokor 3mm/3mm, RCL +/+, RCTL +/+

Exposure: - Susp. Contusio musculorum regio femur dextra dd - Inj. Santagesik 3x1 amp
Warm red dry acral (+/+) CF os femur dextra dd OF genue dextra - Inj. Omz 2x1 amp
Temp: 36.2 C - Inj. Ceftriaxon 1 gr
- Pro x-ray femur Ap/obliq sinistra
Local status: - Bandage regio femur
Femur dextra
Look : deformity (-), bleeding active (-), edema (-), eritema (-)
Feel : pain (+), VAS 7-8, crepitation (-), step off (-)
M : pain (+) limited

Genue Dextra
L : deformity (-), bleeding active (-), edema (-), vulnus abrasion size 3x4 cm
F : pain (+), VAS 3-4, crepitation (-), step off (-)
M : pain (+), limited
 SECONDARY
SURVEY
GENERALIST STATUS
GCS : 456
BP : 166/91 mmHg
HR : 95x/minute
RR : 20x/minute
SpO2 : 98% on RA
 SECONDARY SURVEY

ANAMNESIS

Allergy :-
Medication: -
Past illness : -
Last meal: 20/05/2023 at 12.00 pm
Event : patient fell when sweeping in front yard and suddenly slip
and she fell in to the right side with her leg hit by her body.
 PHYSICAL EXAMINATION
EXAMINATION

HEAD/NECK: Pulmo:
Head: Inspection: normal chest wall shape, retraction
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), (-), lesion (-)
pupil isokor 3 mm/3mm, Light reflex direct and Palpation: symmetrical D/S chest wall
indirect +/+ movement
Nose: rhinorrhea (-/-) Percussion: sonor
Ears: otorrhea (-/-) Auscultation: vesicular +/+

THORAX : ABDOMEN:
Cor: Inspection : Flat, injury (-), surgical scar (-),
Inspection: ictus cordis invisible lump (-)
Palpation: ictus cordis palpable at ICS 5 MCL S Auscultation : Bowel sound (+) 14x/minute
Percussion: D heart border at ICS 4 PSL D, heart Palpation : Flat, soft, superficial tenderness
border S at ICS 5 MCL S (-), deep tenderness (-)
Auscultation: S1 S2 single, regular, murmur (-), Percussion : Timpany
gallop (-)
 PHYSICAL
EXAMINATION
EXTREMITIES : Dry warm acral, CRT <2 s
EXAMINATION
Localist Status

Femur dextra
Look : deformity (-), bleeding active (-), edema (-), eritema (-)
Feel : pain (+), VAS 7-8, crepitation (-), step off (-)
M : pain (+) limited

Genue Dextra
L : deformity (-), bleeding active (-), edema (-), vulnus abrasion size 3x4 cm
F : pain (+), VAS 3-4, crepitation (-), step off (-)
M : pain (+), limited
CLINICAL PICTURES
Other Examination
 PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning Diagnosis Planning Therapy & Monitoring

Anamnesis: - HT stage II IVFD RL 1700 cc/1 jam

-
- CF colum femur dextra Inj. Ketorolac 3x30 mg
Main complaint: pain on the right leg Inj. Ranitidime 2x50 mg
History of illness : pain felt after the patient feel when sweeping in the house yard, VAS 7-8, there is no complaints on Inj. Ceftriaxon 2x1 gr
the other parts of the body. nausea (-), vomiting (-), dizziness (-), headache (-). PO:
MOI : patient fell when sweeping in front yard and suddenly slip and she fell in to the right side with her leg hit by her Amlodipin 1x10 mg
body. Pro bipolar arthroplasty

Vital Sign
BP : 168/90 mmHg

Status localis:

Femur dextra
Look : deformity (-), bleeding active (-), edema (-), eritema (-)
Feel : pain (+), VAS 7-8, crepitation (-), step off (-)
M : pain (+) limited

Genue Dextra
L : deformity (-), bleeding active (-), edema (-), vulnus abrasion size 3x4 cm
F : pain (+), VAS 3-4, crepitation (-), step off (-)
M : pain (+), limited

Xray Femur Dextra

Fracture of colum femur dextra
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