MORNING

REPORT
 Name : Ch. AF
Age : 15 years old
Sex : Male
Address : St. A. Yani
Admission : October, 14th 2019
Doctor in charge : dr. Tri Tuti Hendarwati, Sp.OT

IDENTITY
 A Clear, Cervical Spine Control

B Respiratory rate 20x/m, spontaneous, thoracoabdominal type,

symetris

C Blood Pressure 110/60 mmHg

Pulse 88x/m, regular, strong, CRT < 2 seconds

D Glasgow Coma Scale (E4M6V5), Isochoric

pupil, Ø 2.5 mm/2.5 mm, Light reflex +/+

PRIMARY E Temperature 36,4OC/Axillary

VAS 6/10
SURVEY
 History Taking
Chief complain :
• Pain in the right leg
Anamnesis :
• Since 15 minutes before admitted to the hospital.
Mecanism of trauma :
• The patient is riding a motorcycle at medium speed. When going to turn, another
motorcycle crashes into the patient's leg from the side. Then the patient falls.
History of trauma :
• Loss of consciousness (-), nausea (-), vomiting (-), spasms (-), headaches (-),
bleeding from the mouth, nose, ears (-).
• History of treatment : (-)
SECONDARY SURVEY

GENERAL STATE
Compos mentis, moderate illnes,
good nourish
 Head : Within Normal Limit Neck : Within Normal Limit
Face : Within Normal Limit Chest : Within Normal Limit
Eyes : Within Normal Limit Abdomen : Within Normal Limit
Nose : Within Normal Limit Upper limb : Within Normal Limit
Mouth : Within Normal Limit Lower limb : Localized state
Ears : Within Normal Limit

LOCAL STATE
SECONDARY SURVEY
 LOCALIZE STATE

Right Cruris Region

I : Hematom (-), deformity (+), swelling (+) , vulnus exoriatum
P : Tenderness (+), krepitation (+)

ROM : active and passive movement at genu and ankle joint

limited due to pain

NVD : good sensibility, CRT <2 Seconds

Clinical Finding
 Routine Blood
X-Ray Right Cruris AP/Lat

Planning Diagnostic
 Routine Blood

PARAMETER RESULT REFERENCE VALUE

WBC 12,7 x 103/Ul 4,00 – 10,00

PLT 210 x 103/uL 100 – 300
HGB 12,2 g/dL 12,0 – 16,0

Bleeding time : 2’00” ≤3 minutes

Clothing time : 10’00’’ 6-12 minutes

14/10/2019
X-Ray Righ Cruris AP/Lat
 Close Fracture 1/3 Medial
Os Tibia Fibula Dextra

DIAGNOSE
 PHARMACOLOGY NON PHARMACOLOGY

• IVFD • Rest
• Antibiotic injection
• Immobilization
• Analgetic injection
• Antifibrinolitik injection
• Antiemetik injection
• Corticosteroid injection

Consult Orthopedic Surgeon

MANAGEMENT