MORNING REPORT

Wednesday, July 27th 2016

Dr. dr. I Ketut Suyasa Sp.B, Sp.OT (K)

MEL/END/DGT/MHD/SAW-YRS/TMT/KSS/PWP/MRY
 Resume
TOTAL PATIENT : 5 Patients
ADMISSION : 5 Patients
OPERATION : 1 Patient
RSPTN : - Patient
 Kadek Agustini/F/ 26 y.o.
T.arr 16.00 T.acc 11.00 CM 16032073

Conscious patient complained pain on her right leg after got

accident 5 hours prior admission.
Patient rode motorcycle then suddenly slipped, with her right leg
crushed by bus tire.
History of unconciousness (-), nausea (-), vomitting (-).
Patient was referred from Wangaya General Hospital by GP diagnose
with OF Right Fibula Middle Third + Crush Injury Right Leg

Primary Survey:
A : Clear
B : Spontaneous, RR 20x/min
C : BP: 120/80 mmHg PR: 84x/min
D : Alert
Secondary Survey
GCS : E4V5M6
Head : Cephalhematome (-)
Neck : Tenderness (-), bruise (-), step off (-)
Eye : conjunctiva pale -/-
ENT : Otorrhea -/-, rhinorrhea -/-
Maxillofacial : Bruise (-), swelling (-), malocclusion (-)
Thorax :
Insp : Symetric , bruise (-)
Palp : Tenderness (-), crepitation (-)
Perc : Sonor/sonor
Aus : S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, wh -/-
Abdomen:
Insp : Bruise (-), distension (-)
Aus : BS (+)
Palp : defans (-)
Per : tymphani
Pelvis : Bruise (-), stable pelvis
Extremities : Warm
~ Local status
Regio Right Leg
L : Swelling (+) over the posterior leg, degloving wound (+) over the distal thigh
posterior until distal posterior leg 65x25 cm, muscle exposed (+), active bleeding
(+), achilles tendon exposed (+)
F : Tenderness (+) at posterior leg, crepitation at the distal leg when applied
splint, a. popliteal (+), a. tibialis posterior (+), a.tibialis anterior (+), a. dorsalis
pedis (+), SaO2 digiti 1 97%, SaO2 digiti 2 96%, SaO2 digiti 3 98%, SaO2 digiti 4
96%, SaO2 digiti 5 97%, CRT < 2
M : Active ROM Genu (+) limited due to pain
Regio Right Knee
L : Degloving wound (+) over the distal thigh posterior until distal
posterior leg 65x25 cm, muscle exposed (+), active bleeding (+)
F : Tenderness (+) at posterior leg, a. popliteal (+) Palpable, CRT <2
M : Active ROM Genu limited due to pain
Active ROM Ankle limited due to pain
Active ROM MT-IP limited due to pain
Regio Right Ankle
L : Swelling (+) over the posterior leg, degloving wound (+) over the
distal thigh posterior until distal posterior leg 65x25 cm, muscle exposed
(+), active bleeding (+), tendon achilles exposed (+)
F : Tenderness (+) at posterior leg, crepitation at the distal leg when
applied splint, a. tibialis posteror (-), a.tibialis anterior (-), a.dorsalis
pedis (-), SaO2 digiti 1 76%, SaO2 digiti 2 64%, SaO2 digiti 3 50%, SaO2
digiti 4 49%, SaO2 digiti 5 40%, CRT > 2
M : Active ROM Genu limited due to pain
Regio Right Foot
L : Swelling (+) over the dorsum pedis, bruise (+) over the dorsum
pedis
F : Tenderness (+) at the lateral side dorsum pedis, crepitation (+) when
aplied Splint, a. dorsalis pedis (+), SaO2 digiti 1 97%, SaO2 digiti 2
96%, SaO2 digiti 3 98%, SaO2 digiti 4 96%, SaO2 digiti 5 97%,
CRT < 2
M : Active ROM MT-IP(+) limited due to pain
 Assessment
Crush Injury Right Leg Region
OF Right Fibula Distal Third
Susp CF Metatarsal Digiti IV and V

Imaging
Pelvis X-ray AP View (Sanglah Hospital)
Right Thigh X-ray AP/Lateral View (Sanglah Hospital)
Right Knee X-ray AP/Lateral View (Sanglah Hospital)
Right Leg X-ray AP/Lateral View (Wangaya Hospital)
Right Ankle X-ray AP/Lateral View (Wangaya Hospital)
Right Foot X-ray AP/Oblique View (Sanglah Hospital)
Pelvis X-ray AP View (Sanglah Hospital)
Right Thigh X-ray AP/Lateral View (Sanglah
Hospital)
Right Knee X-ray AP/Lateral View (Sanglah
Hospital)
Right Leg X-ray AP/Lateral View (Wangaya
Hospital)
Right Ankle X-ray AP/Lateral View (Wangaya
Hospital)
Right Foot X-ray AP/Oblique View (Sanglah
Hospital)
Diagnosis:
Crush Injury Right Leg Region
OF Right Fibula distal third grade 3B
CF Right Neck Metatarsal 4
CF Right Neck Metatarsal 5

Treatment
Orthopaedic
Antitetanus, Analgetic, Antibiotic
Debridement + ORIF Pinning
Clinical Picture Durante Op
Clinical Picture Post Op
Right Leg X-ray AP/Lateral View Post Op
 Hery Iskandar/ M / 20 y.o.
T.arr 18.30 T.acc 6.30 CM 16032082

Unconscious patient got traffic accident 12 hours prior to admission.

Patient rode motorcycle and then fell down with unkwon mechanism.
History of consciousness (-), nausea (-), vomitting (-).
The patient was referred by Buleleng General Hospital by GP Diagnosed
with Mild head injury with SAH, EDH, Brain swelling

Primary survey :
A : On OTT
B : On Ventilation with RR 28x/mnt
C : Stable, BP 140/90, PR 90 x/mnt
D : Pain Respone
Secondary Survey :
GCS E1VxM3
Head : Cephalhematome (+) Frontotemporal Sinistra
Neck : Tenderness (-), bruise (-), step off (-)
Eye : RP +/+ isokor, Conjuctiva anemis -/-
Thorax :
Insp : Symetric , bruise (-)
Palp : Tenderness (-)
Perc : Sonor/sonor
Aus : S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, whe -/-
Abdomen :
Insp : Bruise (-), distension (-)
Aus : BS (+)
Palp : defans (-)
Per : tymphani

Pelvis : Bruise (-), stable pelvis

Extremities : Warm
~ Local status
Left Shoulder Region

L : Swelling (+), Bruise (+) over the shoulder, skin tenting (-)
F : Tenderness (+) over the lateral third, a.radialis (+) palpable, CRT<2,
SO2 99%,
M: Active ROM Shoulder cant be evaluated
Active ROM (+) Elbow cant be evaluated
Assessment
Severe Head Injury
Brain Swelling
EDH Left Temporoparietal
SAH
CF Left Clavicula

Imaging
Head CT Scan (Buleleng Hospital)
Cervical X-ray Lateral (Sanglah Hospital)
Thorax X-ray AP (Buleleng Hospital)
Shoulder X-ray AP (Sanglah Hospital)
Pelvis X-ray AP (Sanglah Hospital)
Head CT Scan (Buleleng Hospital)
Cervical X-ray Lateral (Sanglah Hospital)
Thorax X-ray AP (Buleleng
Hospital)
Shoulder X-ray AP (Sanglah Hospital)
Pelvis X-ray AP (Sanglah Hospital)
Diagnosis:
Severe Head Injury
Brain Swelling
EDH Left Frontotemporal Region
SAH
CF Left Clavicle Middle Third Allmann Type I

Treatment:
Neurosurgeon :
Trepine-Clot Evaluation

Orthopaedi :
Analgetic
Immobilization with Arm Sling
 I Gede Agus Indrayana/ M / 26 y.o
T.arr 20.00 T.acc 19.00 CM 16032105

Conscious patient complained of pain on his left hand 1 hours prior

to admission.
His rode motorcycle then left hand grazed truck from left side
History of unconciousness (-), nausea (-), vomiting (-).

Primary Survey
A: Clear
B: Spontaneus, RR: 20x/mnt
C: Stable Hemodynamic, BP: 110/80 mmHg, HR: 84x/mnt
D: Alert
Secondary Survey
GCS : E4V5M6
Head : Cephalhematome (-)
Neck : Tenderness (-), bruise (-), step off (-)
Eye : conjunctiva pale -/-
ENT : Otorrhea -/-, rhinorrhea -/-
Maxillofacial : Bruise (-), swelling (-), malocclusion (-)
Thorax :
Insp : Symetric , bruise (-)
Palp : Tenderness (-), crepitation (-)
Perc : Sonor/sonor
Aus : S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, wh -/-
Abdomen:
Insp : Bruise (-), distension (-)
Aus : BS (+)
Palp : defans (-)
Per : tymphani
Pelvis : Bruise (-), stable pelvis
Extremities : Warm
~ Local status
Left Hand Region
L: Open wound (+) 6x4 cm at the dorsal ringer finger, extensor
tendon exposed and bone exposed (+) active bleeding (+), fat
bubble (+)
F: Tenderness (+), CRT < 2, SaO2 all finger 99%
M : Active ROM Ring Finger MCP/IP limited due to pain
Assessment:
OF Left Phalang Media at Ring Finger

Radiology :
Left Hand X-ray AP/Oblique
Left Hand X-ray AP/Oblique
Diagnose
OF Dislocation Left Base Phalang Media at Ring Finger

Treatment :
Analgetic, Antibiotic, Antitetanus
P/ Debridement + ORIF Pinning
Clinical Pic Post Op
Left Hand X-ray AP/Oblique (Post
Operative)
 Ellen O Connor / F /28 y.o
T.arr 23.00 T.acc 22.00 CM 16032117

Conscious patient came to the emergency room complained pain

on her left leg after fell down 1 hours prior admission.
Patient walked then slipped in to the hole of DSDP with her left
leg bump the hole.
History of unconcious (-), nausea (-), vomiting (-).

Primary Survey
A: Clear
B: spontaneus, RR: 22x/mnt
C: stable, BP:130/80 mmHg, HR: 90x/mnt
D: Alert
Secondary Survey
GCS : E4V5M6
Head : Cephalhematome (-)
Neck : Tenderness (-), bruise (-), step off (-)
Eye : conjunctiva pale -/-
ENT : Otorrhea -/-, rhinorrhea -/-
Maxillofacial : Bruise (-), swelling (-), malocclusion (-)
Thorax :
Insp : Symetric , bruise (-)
Palp : Tenderness (-), crepitation (-)
Perc : Sonor/sonor
Aus : S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, wh -/-
Abdomen:
Insp : Bruise (-), distension (-)
Aus : BS (+)
Palp : defans (-)
Per : tymphani
Pelvis : Bruise (-), stable pelvis
Extremities : Warm
~ Local status
Left Leg Region
L : Swelling (+) at middle leg, deformity (+) angulation, open wound at
middle leg
1x2 cm, active bleeding (+), fat bubble (+),
F : Tenderness (+) at distal leg, crepitation (+) when aplied splint,
a.dorsalis pedis(+) palpable, CRT < 2, parasthesia (-)
 Assessment
OF Left Cruris Middle Third grade 1
Susp OF Left Tibia Middle Third
Susp OF Left Fibula Middle Third

Imaging
Left Leg X-Ray AP/Lateral
Left Leg X-Ray AP/Lateral
Diagnosis:
OF Isolated Left Tibia Middle Third grade I (S 82.3)

Treatment
Analgetic, antibiotic, antitetanus
P/ Debridement + ORIF PS
 Shafina / F / 13 y.o
T.arr 23.00 T.acc 21.00 CM 16032118

Conscious patient complained pain on her left thigh after fall down 2
hours prior to admission.
Patient rode motorcycle hit by motorcycle from the behind and then
patient fell dwon with left thigh bump to the ground
History of unconciousness (-), nausea (-), vomiting (-).

Primary Survey
A: Clear
B: Spontaneus, RR: 22x/mnt
C: Stable Hemodynamic, BP: 130/90 mmHg, HR: 94x/mnt
D: Alert
Secondary Survey
GCS : E4V5M6
Head : Cephalhematome (-)
Neck : Tenderness (-), bruise (-), step off (-)
Eye : conjunctiva pale -/-
ENT : Otorrhea -/-, rhinorrhea -/-
Maxillofacial : Bruise (-), swelling (-), malocclusion (-)
Thorax :
Insp : Symetric , bruise (-)
Palp : Tenderness (-), crepitation (-)
Perc : Sonor/sonor
Aus : S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, wh -/-
Abdomen:
Insp : Bruise (-), distension (-)
Aus : BS (+)
Palp : defans (-)
Per : tymphani
Pelvis : Bruise (-), stable pelvis
Extremities : Warm
~ Local status
 LLD D S
2 cm

FL 79 77

AL 73 71
Left Lower Extrimity Region
L : Swelling (+) over the middle third, bruise (+) Lateral side of Thigh,
deformity (+) shortening and external rotation
F : Tenderness (+) over the middle third, Crepitation (+) when applied
splint, CRT < 2 , a. dorsalis pedis pulse (+) , Sat O2 98 %,
M : Active ROM Knee (+) limited due to pain
Active ROM Ankle (+) 30/40
Active ROM MTP-IP (+) 45/90
Assessment :
Susp CF Left Femur Middle Third

Radiology :
Left Thigh X-ray AP/Lateral view
Left Thigh X-ray AP/Lateral view
Diagnosis :
CF Left Femur Middle Third (AO 32-A3)

Treatment :
Analgetic
Immobilization with Skin Traction 5 kg loaded
P/ ORIF PS
[ THANK
YOU ]