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Morning Report

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Past illness history :

Trauma -

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PRIMARY SURVEILLANCE

Airway : Clear (+), Snoring (-), Gargling (-)

Cervical (stable)

Breathing : RR 22 x/mnt, reguler

Ins: simetry/simetry, no wound, hematom (-)

Pal: simetry/simetry, tenderness (-)

Per: sonor/sonor

Aus: vesikuler/vesikuler, wheezing (-), rhonkhi (-)

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Circulation :Akral HKM

Pulse = 88 x/min, regulerCRT

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Look : - abrasion injuries at left elbow

- hematome left knee

- deformitas at femur sinistra

Feel: - pulsasi A.poplitea and left dorsalis pedis strong palpable

- tenderness at femur sin

- feel warmer at left leg than right leg

Move: - left leg ROM limited due to pain

- false movement (+)

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SECONDARY SURVEILLANCEVT : Pulse : 84 x/min RR : 20x/min BP: 120/78 mmHg

H/N : a/i/c/d -/-/-/- trakhea deviation (-), increased JVP (-),

rhinorrhea (-),ottorhea (), wound (-)

Thorax :I : symetry

P : krepitasi (-), mass (-)

P : sonor/sonor

A : ves/ves Rh-/-, Wh -/-

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Cor : S1 S2 Tunggal Murmur (-) Gallop (-)

Abdomen :

I : Flat

P : Soefl, H/L unpalpabe, VU empty, Defans

Muskular (-)

P : tymphany

A : Bowel sound (+) normal.

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Ekstremitas

Look : - abrasion injuries at left elbow

- hematome left knee

- deformitas at femur sinistra

Feel: - pulsasi A.poplitea and left dorsalis pedis strong palpable

- tenderness at femur sin

- feel warmer at left leg than right leg

Move: - left leg ROM limited due to pain

- false movement (+)

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AMPLE Allergy : -

Medication : long term use of drug (-)

Past disease : previous accident (-)

Last Meal : alkohol (-)

Event before accident : Patient ride a

motorcycle at 7.00 am and then px fall

down, struck a roadblock on left side. Px

still conscious, but felt pain at both thigh

and can not be moved.

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Ass 1

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Planning Diagnosa

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Hasil Laboratorium

Diffcount 2/1/62/29/6 (1-2/0-1/49-67/25-33/3-7)

Hematokrit 40,4 (L 40-54% P 35-47%)

Hemoglobin 13,1 (P 13,0-18 L: 14-18)

Leukosit 10.400 (4000-11000)

Trombosit 278.000 (150000-450000)

GDA 112

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Gambaran RadiologisFoto Femur Dextra AP/L

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Ass 2

Close fractur corpus femur sinistra 1/3

medial comminutive complete

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Planning Therapy

IVFD RL1500 cc/loading

DC

Inj. Ranitidine 2x50mg Inj. Metamizole 3x1 g

Splint

Konsul dr. Sp.OT

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Planning Monitoring

Vital Sign

Urin production

Pulse dan Movement Dystal EkstremityDistal

Subyektif complain

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Planning Education

Explaine to the patient about the condition

Explain to the patient about the treatment

and complication.

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