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MORNING REPORT

Monday, 18
th
November 2013
Diah Permata Sari
N (40 YO)
M : Hit a parking truck on the side road, chest
hit the steer, leg got stuck in gas pedal.
I : Right Leg
S : Pain, active bleeding (+), unable to move
his leg
T : Wound toilet, then Stitch the wound



History of Illness
Patient come to Pelabuhan Hospital, with
bleeding from open fracture on his right leg.
Base on the patient story, he got his injury when
he was driving a container. At that time he want to
turn left when suddenly a car came from right to
left, then by reflect the driver pull the steer from
left to right and finally hit a parking truck on the
side road.
The patient chest hit the steer and his right leg got
stuck on the gas pedal.

HEAD TO TOE

Eyes : pupil isocors 3mm/3 mm, centered, light
reflex +/+
Ear : Bruise (-), secretion of fluid (-)
Neck : Bruise (-), centered
Thorax :
Insp : bruise (-), movement of chest wall
symmetrical
Pal : crepitation (-)
Per : sonor right = left
Aus : Basic breath sound vesicular right and left

Abdomen :
Ins : distended, bruise (-)
Aus : bowel sound (+)
Pal : tenderness (-),
muscular defense (-)
Per : tympani
Blood pressure : 80/60 mmHg
Pulse : 68 x/minute
Respiratory : 20 x/minute
Extremity:
Warm extremities, cap. refill time < 2, edema (-
)

Local Condition
The Right leg
(open fracture)
Inspection :
bruise (+)
open wound with active
bleeding


Diagnosis

Open fracture at the right leg
Tibia bone fracture

Planning
Clean the wound
Stitch the wound
Give tetanus toxoid injection
(1 cc) intramuscular injection
into the deltoid
Give tetagam injection (1 cc)
intramuscular injection into
the deltoid

Instruction
Laboratory
Rontgen
Antibiotic treatment
Analgetic treatment
Vital signs
observation