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MORNING REPORT

October 19th, 2013 EMERGENCY ROOM WAHIDIN SUDIROHUSODO GENERAL HOSPITAL MAKASSAR
ZT

IDENTITY
Name Age Admission : AF : 14 years old / Male : October 20th, 2013 at 00.00

Registration : 63 31 15 Status : Jamkesda

AUTOANAMNESIS
(at 00.04)

Chief Complain : pain on the right thigh

Suffered since 3 hours before admited to Wahidin General Hospital due to traffic accident. The patient riding a motorcycle and suddenly got a crash with a car from the left side. The patient fall to ther right side History of unconsciousness (-), vomit (-), nausea (-)

PRIMARY SURVEY
(at 00.10)

A B C

D
E

: patent : RR = 20 x/min, symmetric, spontaneous, thoracoabdominal type : BP = 110/80 mmHg, HR = 88 x/min, regular, strong : GCS 10 (E2M5V3), light reflex +/+, pupil isochors, d = 2,5 mm/ 2,5 mm : T = 37,4oC (Axillary)

SECONDARY SURVEY
(at 00.12)

Right Thigh Region I : Wound (-). Deformity (+), swelling (+), hematoma (+). P : Tenderness (+) ROM : Active and passive movement of knee joint are limited due to pain Active and passive movement of hip joint are limited due to pain NVD : Pulsation of the dorsalis pedis artery palpable. Tibialis posterior palpable Capillary refilling time < 2, extend big toe (+)

LABORATORY FINDINGS
(00.28)

Hb Ht Leukocyte Trombocyte BT CT HbsAg

13.8 g/dL 38.7 g/dL 12.300 g/dL 345.000 g/dL 730 300 (-)

RADIOLOGY FINDINGS
(00.30)

CT SCAN

Normal

DIAGNOSIS

Moderate head injury GCS 10 Closed fracture proximal third of right femur,

MANAGEMENT

IVFD Analgesic Report to Orthopaedic senior, advice :

Skin traction, load 3 kg

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