Mega Silfia Zulfi

Morning Report

CLOSED FRACTURE RADIUS ULNARIS

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

: : An. RC : male : 13 years

Name JK Age

MAIN COMPLAINT: pain at the Left lower hand 2 hour before came to the hospital.

PRIMARY SURVEY

Airway + Cervical CONTROL

Objective : Answering questions smoothly and clearly without any additional noise Assessment Patent airway

reevaluation Patent airway

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

CIRCULATION & HEMORRHAGE CONTROL

Objective

warm acral CRT < 2 " Pulse rate 98 beats / min, regular, enough stuffing There is no visible bleeding Assessment good hemodynamic

 Action

IVFD Ringer laktat 20 TPM

Re

Evaluation Hemodynamic still good

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

and Neck Thorax Abdominal Genitalia Extremity

: normal : normal : normal : normal : localized

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

= 13 gr% WBC= 10300 /mm3 Ht =40 vol% PLT= 319.000 /mm3

working diagnosis
Closed fracture regio antebrachii sinistra

plan investigations
pairs

splak Routine blood tests, CTBT Ro. Antebrachii sinistra

Diagnose
Closed

fracture radius ulnaris

treatment plan
IVFD

Ringer Lactat 20 tpm ATS Injection 1500 IU Cefriaxone Injection 2 x 500 mg Cetorolac Injection 2 x amp