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MORNING REPORT

Department of Surgery
Muhammadiyah Lamongan Hospital
H-27
PATIENT’S STATUS
Patient’s Identity

■ Name : Mr. MPH


■ Gender : Male
■ Age : 54 y.o
■ Address : Lamongan
■ Admission’s date : 3/4/2018
ANAMNESIS
■ Chief complaint : pain of left chest
■ Present History :
a patien come to IGD of lamongan muhamadiyah hospital with a complaint that
the he suffered a pain on his left chest after he had a traffic accident, 4 hours before he
menaged go to hospital. He keeps feeling the pain, the patien also complains that he
suffered a crowded and pain on his left arm and his right leg. After the accident the
patient finally came into his realization and remember the accident, nausea-, vomiting -,
seizure -, history of allergy -, history of drug consumption-, the last eat and drink at
15:00.
Mechanism of Injury
The patien was riding a motorcycle along with his helmet with the speed
50km/h, and then there was a car hit him from behind till he fell under the car ,
overthrown and dragged down to 100m.
ANAMNESIS
■ Past History : DM and HT denied
■ Family history : there is no family complaint like this, DM and HT denied
Primary Survey

■ A : Clear, gargling (-), snoring (-), speak fluently (+), potensial obstruksi (-)
■ B : Spontan, RR 24 x/mnt, ves/ves, crackles -/-, Wh-/-, SaO2 98% without O2 nasal 4lpm
■ C : Extremity CDR, CRT < 2”, N 100 x/mnt, TD 150/ 80 mmHg
■ D : GCS 456, lateralisasi -, PBI 3mm/3mm, RC +/+
■ E : temp 37 C
Secondary Survey

■ Head and neck : a-/i-/c-/d-  look at localize status


■ Tho : sim, ret -/-
■ P : ves/ves, crackles -/-, wh -/-
■ C : S1S2 single, murmur-, gallop –
■ Abd : flat, soepel, met -, bowel sound +N , tenderness-, H/L unpalpable, tympani
■ Ext : aie -, akral CDR, edema -/-,  loo ak localize status
Status Localized
■ Cranial
L: Vulnus ekskoriasi multiple on face , deformitas-, activ bleeding –
F: krepitasi -, tenderness+
■ Thorax
L: Lesion at left back +, activ bleeding -
F: kreptasi -, tenderness+
 Antebrachii sin
L: Deformitas +, edema +, active bleeding -
F: tenderness +, Krepitasi -,
M: ROM limited by pain
 Femur Dextra
L: Dislokasi +, edema+, activ bleeding -,
F: tenderness +
M: ROM limited by pain
RESUME
■ Male, 54y.o
■ Left of Cheest pain Lesion at left back +, tenderness+
 Deformitas +, edema + tenderness + ROM limited by pain at left leg
 Dislokasi +, edema - , activ bleeding + tenderness + ROM limited by pain raight arm
ASSESMENT

■ Open Fr. Antebrachii


■ Dislocation hip joint
■ GDA 239
■ Lekosit 19.0 ■ RDW 11
■ Neutrofil 92.2 ■ Trombosit 218
■ Limfosit 2.1 ■ MPV 6
■ Monosit 2.8
■ HbsAg negative
■ Eusinofil 1.8
■ Metode 1 non reaktif
■ HCT 38,3
■ LED 1 5
■ LED 2 10
■ Basofil 1.1
■ Eritrosit 4.94
■ Hb 12,6
■ MCV: 77.50
■ MCH 25.50
■ MCHC 32.90
Planning
■ Dx : DL, Thorax A/P Lat, Femur A/P lateral, antebrachii
A/P lateral, ct-scan .
■ Tx:
– Imobilisasi ( splint)
– Inf . Asering loading 500cc maintenance1500cc/ day
– Inj. Ketorolac 3x1
– Inj. Ranitiidin 2x1
– C/SpOT , SpB
RE - ASSESMENT

■ Haemato thorak
■ Close Fr. Costae sternum
■ Close Fr. Cruris 1/3 distal
■ Open fr. Antebrachii
■ Dislocation hip joint
■ Tx:
– Reposisi dislokasi hip , Debridement , back slab, Pro
orif C/SpOT
– C/ Sp.BKonservatif , analgesik kuat
THANK YOU

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