MORNING REPORT

February 23rd 2011

Emergency Unit
• Trauma • Non Trauma
▫ Mrs. A (26 YO) Abscess
▫ Mr.W (43 YO) Simple head
injury
▫ Mr. MU (41 YO) Simple head
injury, fracture ulna and
radius bone
▫ Mr. PU (57 YO) Lacerated
wound
▫ Mr. AR (18 YO) Lacerated
wound
▫ Ms. Y (20 YO) Contusion
▫ Mr. ZA (21 YO) Lacerated
wound
Mr. MU (41 YO)
• Patient car fell to ravine while avoiding hole.
• Self protection  (-)
• Patient can talk coherently
PRIMARY SURVEY
• Airway : Clear
• Breathing
▫ Ins : movement of the wall chest is
symmetric
▫ RR : 24x/min
▫ Pal : vocal fremitus right = left
▫ Per : Sonor right = left
▫ Aus : basic breath sound is vesicular, Rh -/-,
Wh -/-
• Circulation
Warm Extremity, Capillary Refill < 2”, blood
preasure 100/70 mmHg, pulse : 60 x/min,
Temperature : 36,5 oC
• Disability
GCS E4V5M6, Pupil round, isochoric,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+
• Exposure
No life threatening wound
SECONDARY SURVEY
• Chief Complaint : wound at his left forehead and lower arm
• Additional Complaint : -
• History of Illness :
± 6 hours before admittance, patient got car accident when the car fell
into ravine avoiding the hole. Patient was treated in hospital near the
place where the incident and patient ask to moved to a hospital near
home. Unconsciousness (-), Head impact (+), head pain (+), amnesia
(-), chest impact (-), abdominal impact (-), vomit (-), nausea (-)
HEAD TO TOE
General Examination
GC : Look moderate illness
E4V5M6
BP : 100/70 mmHg
HR : 60 x/m
RR : 24 x/m
T : 36,5°C
AMPLE
• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal : unknown
• Event : Car Accident
Eyes : Pupil round, isochoric, centered,
Direct Light Reflex +/+, Indirect Light Reflex +/+, CA-/-,
SI-/-

Neck : Bruise (-), hematom (-)

Thorax
 Insp : movement of chest wall symmetrical, bruise (-)
 Pal : VF right = left
 Per : sonor right = left
 Aus : Basic breath sound vesikuler, Wh -/-, Rh-/-
Abdomen
Ins : flat, hematom (-), bruise (-)
Pal : smooth, tenderness (-)
Per : tympani
Aus : bowel sound (+)

Extremity : cap. refill < 2”, warm extremity,

edema - -
- -
Localized State
Left forehead
Ins : wound (+), bruise (+), edema (+)
Pal : tenderness (+), crepitation (-)

Left lower arm

Ins : wound (-), bruise (+), edema (+)
Pal : tenderness (+)
X-Ray
DIAGNOSE
• Fracture 1/3 medial os ulna and 1/3 proximal os
radius
TREATMENT
• WT
• Hacting
• Analgetic
• Hospitalized