MORNING

REPORT
September 21th, 2023
IDENTITY

● Name : An. Bayu

● Age : 15 years old
● Gender : Male
● Address : Batu
● Arrival Date : September 21th, 2023
● Patient Type : Trauma
 PRIMARY SURVEY
Incident date: September 21, 2023 at 10.30 WIB
Arrival Date: September 21, 2023 at 11.30 WIB

Main Complaint : Pain in the index finger of the left hand

Anamnesis: the patient came to the ER because of pain in the

index finger of the left hand with a VAS of 8-9 after being hit by
a sickle

MOI: The patient was cut on his left index finger while looking
for grass using a sickle.
 Examination Initial Diagnosis Action
Airway: Patent -
Patent, gurgling (-), stridor (-), snoring (-)
Breathing: Spontaneous -
Look: symmetrical chest wall movement, lesion (-)
Feel: the patient breathes spontaneously, no additional breath
sounds, rib crepitations (-), step defect (-)
RR: 18x/minute
SpO2 : 99% on RA
Circulation: HT stage 1 -
BP: 142/77 mmHg Tachycardia
HR: 102x/m
 Examination Initial Diagnosis Action
Disability Susp. Open Fracture Pressure &
GCS: 456. PBI: 3 mm/3mm. Direct light reflex +/+, Indirect Os Phalang proksimal splint
light reflex +/+ digiti II manus S
Regio Manus S
L: vulnus appertum measuring 2x1cm in digit II of the
proximal phalange, dirty, bone exposed (+), active bleeding
(+), edema (+), erythema (+), deformity (+), vulnus abrasion
measuring 0.5x3cmF: tenderness (+) on the second digit of
the S manus, felt cold, crepitus (-), step off (+), radial artery
pulse (+), felt strong, attempted sensory stimulation (+)M:
ROM Limitation (+)
Exposure
T : 36.7° C. CRT <2s, red warm dry acral, active bleeding (-)
 SECONDARY SURVEY

Symptoms: The patient complained of pain in the index finger of the left hand with
a VAS of 7-8 after being hit by a sickle. Patients complain of pain when lifting the
index finger. Syncope (-), headache (-), nausea (-), vomiting (-), retrograde
amnesia (-). The patient was taken to the local midwife and put on a pressure
bandage and given painkillers
Allergy: -
Med: painkiller (by midwifery)
Past illness: Asthma (-), HT +, DM -
Last meal: 09.00 (September 21th ,2023)
Event: The patient was cut on his left index finger while looking for grass using a
sickle.
 GENERALIST STATUS

GCS : 456
TD : 132/89 mmHg
HR : 88/menit
RR : 17x/menit
T : 36.2 C
SpO2: 98% on RA
 PHYSICAL
EXAMINATION
THORAX :
Cor:
HEAD/NECK: Inspection: ictus cordis invisible, lesion (-),
Palpation: ictus cordis palpable at ICS 5 MCL S,
Head Percussion: Right heart border at PSL D ICS 4,
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), heart border Left at MCL S ICS 5
Isochor pupil diameter 3mm/3mm, Light reflex direct Auscultation: S1 S2 single, regular, murmur (-),
and indirect +/+ gallop (-)
Ears : bloody Otorea (-/-)
Nose : epistaksis (-/-) Pulmo:
Mouth: cyanosis (-), trismus (-) Inspection: normal chest wall shape, retraction
(-), looks symmetrical (+/+)
Neck : Palpation: symmetrical D/S chest wall
Inspection: scar (-), mass (-), tracheal deviation (-) movement
Palpation: tenderness (-), enlarged lymph nodes (-) Percussion: sonor all lung fields
Auscultation : Bruits (-) Auscultation: Ves/Ves, rh (-/-), wh (-/-)
 PIP joint digital I flexion 0-90°
PHYSICAL PIP joint digital I extension 0-5°
EXAMINATION PIP joint digital II flexion 0-10°
Abdomen: PIP joint II extension 0-3°
Inspection : Flat, injury (-), lesion (-) PIP joint digit III Flexion 0-90°
Auscultation : Bowel sound (+) 23x/minute PIP joint III extension 0-5°
Palpation : Flat, soft, superficial tenderness PIP joint digit IV Flexion 0-90°
(-), deep tenderness (-) PIP joint IV extension 0-5°
Percussion : Timpany all abdomen fields PIP joint digital V flexion 0-90°
PIP joint V extension 0-5°
Extremities : Dry warm acral, CRT <2 s
Localist status Saturation
Manus Sinistra Region Digiti 1 99%
L: vulnus appertum measuring 2x1cm in digit II of Digiti 2 97%
the proximal phalange, dirty, bone exposed (+), Digiti 3 100%
active bleeding (+), edema (+), erythema (+), Digiti 3 100%
deformity (+), vulnus abrasion measuring 0.5x3cm Digiti 4 100%
F: tenderness (+) on the second digit of the S Digiti 5 100%
manus, felt cold, crepitus (-), step off (+), radial
artery pulse (+), felt strong, sensory stimulation (+)
M: ROM Limitation (+)
CLINICAL
PICTURES
 PROBLEM LIST & PLANNING
Problem List Initial Planning
Diagnosis Diagnosis
• Pain in the index finger of the left hand with a VAS of 7-8 after being Susp. Open Xray manus S
hit by a sickle while looking for grass. Fracture Os AP/ oblique
• Pain when lifting the index finger. Phalang CBC, FH
• Medication: local midwife and put on a pressure bandage and given proksimal
painkillers digiti II manus
Manus Sinistra Region S
L: vulnus appertum measuring 2x1cm in digit II of the proximal
phalange, dirty, bone exposed (+), active bleeding (+), edema (+),
erythema (+), deformity (+), vulnus abrasion size 0.5x3cm
F: tenderness (+) on the second digit of the S manus, felt cold, crepitus
(-), step off (+), radial artery pulse (+), felt strong, sensory stimulation (+)
M: ROM Limitation (+)
PIP joint digital II flexion 0-10°
PIP joint II extension 0-3°
Digiti 2 97%
Xray manus S
S AP/ oblique
(21/09/2023 at
RSKH)
 Laboratory Examination
CBC (21/09/2023)
Hb 13.9
WBC 10.500 H

Kimia Darah (21/09/2023)

Ureum 31.74 mg/dL
Creatinin P H 1.13 mg/dL

Electrolyte (21/09/2023)
Na+ 138.7 mmol/L
K+ 3.71 mmol/L
Cl 103.2
 PROBLEM LIST & PLANNING
Problem List Definitive Planning
Diagnosis
• Pain in the index finger of the left hand with a VAS of 7-8 after Open Fracture Pressure & splinting
being hit by a sickle while looking for grass. Os Phalang Wound care
• Pain when lifting the index finger. proksimal digiti Pro ORIF
• Medication: local midwife and put on a pressure bandage and II manus S type IVFD RL 20 tpm
given painkillers 2 Inj Ketorolac 30 mg
Manus Sinistra Region Inj Ranitidine 50 mg
L: vulnus appertum measuring 2x1cm in digit II of the proximal Inj Ceftriaxone
phalange, dirty, bone exposed (+), active bleeding (+), edema 2x1gr
(+), erythema (+), deformity (+), vulnus abrasion size 0.5x3cm Inj Tetagam IM
F: tenderness (+) on the second digit of the S manus, felt cold,
crepitus (-), step off (+), radial artery pulse (+), felt strong,
sensory stimulation (+)
M: ROM Limitation (+)
PIP joint digital II flexion 0-10°
PIP joint II extension 0-3°
Digiti 2 97%
XRAY manus S AP/oblique:Soft tissue edema, discontinuity on os
phalang distal digiti II manus S
THANK YOU