MORNING

REPORT
Monday, 10th of July 2023
Identity

● Name : Mr. E
● Age : 36 years old
● Gender : Male
● Address : Batu
● Arrival Date : Thursday, 6th of July 2023
● Patient Type : Trauma
 PRIMARY SURVEY
Incident date: 17:00 WIB (July 6th, 2023)
Arrival date: 19:00 WIB (July 6th, 2023)

Anamnesis:
Chief Complaint: pain on the right side of the chest
The patient arrived at the Emergency Department of Karsa Husada at 19:00 WIB on July 6th, 2023, with the complaint of pain on the right
side of the chest after being elbowed by a friend while playing soccer. The patient complains of chest pain while breathing, accompanied by
shortness of breath, nausea (+), and vomiting (+) upon arrival at the ED. loss of consciousness (-).

MOI: At 5:00 PM (WIB) on July 6th, 2023, while playing soccer, the patient was elbowed by an opponent directly on the right side of the
chest. The patient experienced pain, shortness of breath, and difficulty speaking. Subsequently, the patient was taken to Madinah Hospital and
then transferred to Etty Hospital.
Examination Initial Diagnosis Action
Airway: Clear, gargling (-), stridor (-) Paten -
Breathing: Breathing NRBM 8 LPM
Look: symmetrical chest wall movement, lesion (+) contusion (+) flail spontaneusly Observations if there is any emergency such
chest (-) as: Pneumothorax or Haematothorax
Feel: rib crepitations (-)
RR: 25x/minute
SpO2 : 95% on RA100% NRBM 8 lpm
Circulation: - No signs of shock, administered intravenous
BP : 161/109 mmHg ; HR: 83x/m; CRT <2s, red warm dry acral Ringer's lactate at maintain dose 2,600
Active bleeding (-) cc/24 hours
 PRIMARY SURVEY
Examination Initial Diagnosis Action
Disability : - - GCS observation
GCS: 456
Pupils: Both pupils are equal in size and react to light (3mm/3mm)
Exposure: • Blunt Chest Trauma / Thoracic - Inj. Ketorolac 30 mg
Temperature: 36.7°C Blunt Trauma - inj. Ranitidine 50 mg
• Susp Closed Fracture of Ribs VII- - IVFD RL  2,600 cc/24
Local Status: VIII on the right side hours
Right Thoracic Region - Observations of Clinical
L: Contusion (+), bruising on the chest (+), deformity (+) and Generalist Status
F: Palpable deformity on ICS 7-8. Tenderness on ICS 7 (+) with VAS score of 7.
Crepitus on ICS 7 (+). Percussion is tympanic.
M: Symmetric chest wall movement (+), no flail chest
 SECONDARY SURVEY

GENERALIST STATUS

GCS: 456
BP : 156/98 mmHg
HR: 83x/menit
RR: 25x/menit
T: 36.7°C
SpO2 : 95% on RA  100% on NRBM 8 LPM
 SECONDARY SURVEY

ANAMNESIS

S: Pain on the right side of the chest.

Allergies: Denied
Medications: Denied
Past medical history: Denied
L: The patient's last meal was at 2:00 PM on July 6th, 2023.
E: At 5:00 PM (WIB) on July 6th, 2023, while playing soccer,
the patient was elbowed by an opponent on the right side of the
chest.
 PHYSICAL
HEAD/NECK: EXAMINATION
Abdomen:
Head Inspection : Flat, injury (-), surgical scar (-)
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), Isochor pupil diameter Auscultation : Bowel sound (+) 10x/minute
3mm/3mm, Light reflex direct and indirect +/+ Percussion : Timpany all abdomen fields
Palpation : Flat, soft, superficial tenderness (-), deep tenderness (-)
Neck :
Inspection: tracheal deviation (-) Extremities : Dry warm acral, CRT <2 s
Palpation: enlarged lymph nodes (-)
Auscultation : Bruits (-) Local Status:
Right Thoracic Region
THORAX : L: Contusion (+), bruising on the chest (+), deformity (+)
See local status F: Palpable deformity on ICS 7-8. Tenderness on ICS 7 (+) with VAS score
of 7. Crepitus on ICS 7 (+). Percussion is tympanic.
Cor: M: Symmetric chest wall movement (+), no flail chest
Inspection: ictus cordis invisible
Palpation: ictus cordis palpable at ICS 5 MCL S
Percussion: Right heart border at PSL D ICS 4, heart border Left at MCL S ICS 5
Auscultation: S1 S2 single, regular, murmur (-), gallop (-)

Pulmo:
Inspection: normal chest wall shape, retraction (-), looks symmetrical (+/+)
Palpation: symmetrical D/S chest wall movement
Percussion: sonor all lung fields
Auscultation: Ves/Ves, rh (-/-), wh (-/-)
CLINICAL PICTURE
 PROBLEM LIST & PLANNING
Problem list Initial Diagnosis Planning Diagnosis Planning Therapy &
Monitoring
Anamnesis: • Blunt Chest Trauma / • Complete Blood Count - Monitor the patient's vital signs
• Chief Complaint: pain on the right side of the chest Thoracic Blunt Trauma • X-ray Thorax AP - IV RL 20 drops per minute
• The patient complains of chest pain while breathing, accompanied by shortness of breath, • Susp Closed Fracture of - Non-rebreather mask at 8 liters
nausea (+), and vomiting (+) upon arrival at the ED. loss of consciousness (-). Ribs VII-VIII on the right per minute
• MOI: At 5:00 PM (WIB) on July 6th, 2023, while playing soccer, the patient was elbowed by side - Ketorolac injection 3 times, 30
an opponent directly on the right side of the chest. mg each time
• The patient experienced pain, shortness of breath, and difficulty speaking. - Ranitidine injection twice, 50
mg each time
- Tramadol drip 50 mg in 100 cc
Physical Examination: - Monitor TTV (temperature,
• BP : 156/98 mmHg (susp. Increased by Pain) blood pressure, heart rate,
Local Status: respiratory rate), general
Right Thoracic Region condition, and clinical
L: Contusion (+), bruising on the chest (+), deformity (+) symptoms
F: Palpable deformity on ICS 7-8. Tenderness on ICS 7 (+) with VAS score of 7. Crepitus on ICS
7 (+). Percussion is tympanic.
M: Symmetric chest wall movement (+), no flail chest
Laboratory Finding (06/07/2023)
X-Ray Thorax AP (06/07/2023)
 PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning Diagnosis Planning Therapy &
Monitoring
Laboratory Findings (06-07-2023): • Thoracic Blunt Trauma • USG - Hospitalized
• Elevated SGPT: 93.8 U/L (normal range < 41) • Suspicion of Hepatic Trauma • CBC Evaluation - Monitor Vital sign
• Elevated SGOT: 51.7 U/L (normal range < 37) (temperature, blood pressure,
X-Ray Thorax AP heart rate, respiratory rate),
• Intact thoracic bone general condition, and clinical
• Susp Cardiomegaly symptoms
- IV RL 20 drops per minute
- Tramadol drip 50 mg in 100 cc
NS
THANK YOU