Morning Report
Cases
The patient was 13 years old, fell from a mango tree with a height of about 2-3 meters. The patient complained of pain in his left hand and can not be moved
IDENTITY
Name JK Age
MAIN COMPLAINT: pain at the Left lower hand 2 hour before came to the hospital.
PRIMARY SURVEY
BREATHING
Objective Frequency of breathing 24 times / min, regular inspection Symmetrical chest wall movement left with right auscultation Vesicular breath sounds left same as right Audible heart sounds palpation Vocal fremitus left with right percussion Sonor in all lung fields
Assessment
No interference lung expansion reevaluation Frequency of breathing 24 times / min No interference lung expansion
warm acral CRT < 2 " Pulse rate 98 beats / min, regular, enough stuffing There is no visible bleeding Assessment good hemodynamic
Action
Re
DISABILITY
Objective
GCS 15 Pupil: isokor, 2mm/2mm, light reflex direct and indirect (+ / +), no lateralitation sign Assessment good mini neurological status
EXPOSURE
Undress
and covered
Secondary survey
anamnesis
The chief complaint : Pain in lower left arm and can not be moved from 2 hours before came hospital Present illness history: 2 hours before came to the hospital, the patient complained of pain in lower left arm and can not be moved due to falling from a mango tree with a height of about 2-3 meters. Patient falls muddy ground with his left arm folded position to the inside
Patients
are aware, no collide head, nose and mouth is not bleeding, hematoma (-), no wound was found on other body parts. Nausea (-), vomiting (-).
Medical
history first: No one associated with the disease now Family history of the disease: No one associated with the disease now
physical examination
General condition: Mild Illness consciousness: composmentis, GCS 15 (E4 V5 M6) Vital sign: HR: 98 times/minute RR: 24 times/minute T: 36.7 C
Head
Localized status
Regio antebrachii sinistra
Look:edema
(+), wound (-), endorotation (-), exorotation (-), shortening (-), lenghtening (-), injuries (-), Feel: warm acral, tenderness (+) capillary refilling <2 seconds,crepitation (-) Move: limited movement in the region of antebrachii sinistra
Ro.
Thorax
Rontgen
Ro Antebrachii
Laboratory
Hb
working diagnosis
Closed fracture regio antebrachii sinistra
plan investigations
pairs
Diagnose
Closed
treatment plan
IVFD
Ringer Lactat 20 tpm ATS Injection 1500 IU Cefriaxone Injection 2 x 500 mg Cetorolac Injection 2 x amp