MORNING REPORT

IDENTITY Name
Mr. Indra

Age
22 y.o

Address
Lambuya

Admission
Sunday, 1 September 2019

Doctor in charge
dr. Tri Tuti Hendrawati, Sp. OT
HISTORY TAKING
Chief ComplaintPain on the right foot

Anamnesis:
Suffered since 3 days ago before admitted to the hospital.
Accompanied by discharge of pus. Initially, the patient was
operation amputatum diigiti I and II his foot because an accident at
the Bahteramas Hospital 1 month ago. Patient said he came to the
puskesmas for replaced the veil in every day. Fever (-),. Defecation
and urination was normal

History of same complaint (-)

History of HT (-), DM (-)
History of medication (-)
 SECONDARY SURVEY
PHYSICAL EXAMINATION

General Condition Blood Pressure Heart Rate

GCS 15 (E4M6V5)
Mild illness 140/90mmHg 80x/minutes, regular,
Well-nourished strong

Respiratory Rate Temperature VAS

20x/minutes,
spontaneous, 36.7°C/Axillary 6
thoracoabdominal type,
symmetric
SECONDAY SURVEY
GENERAL STATE
Head : Normal
Face : Normal
Eyes : Normal
Nose : Normal
Mouth : Normal
Ears : Normal
Neck : Normal
Chest : Normal
Abdomen : Normal
Superior Extremity : Normal
Inferior Extremity : Localized
Genitalia : Normal
 SECONDARY SURVEY
LOCALIZED STATE
Pedis Dextra Region
Inspection
Bandages was attached, blood (+)

Palpation
Tenderness (+)

ROM
Active and passive movement at right ankle joint and
fingers are limited due to pain

NVD
Sensibility and CRT are difficult to evaluate
PLANNING
DIAGNOSTIC
X-Ray Pedis Dextra AP/Lateral
Routine Blood Test
 Routine Blood Test
PARAMETER RESULT REFERENCE VALUE

WBC 6,1 x 103/Ul 4,00 – 10,00

RBC 5,06 x 106/Ul 4,00 – 6,00
HGB 14,8 g/dL 12,0 – 16,0
HCT 43,8 % 37,0 – 48,0
PLT 270 x 103/uL 150 – 400
 WORKING DIAGNOSE

Infection post amputation digiti I and II Pedis Dextra

MANAGEMENT

Non-Pharmalogical Pharmalogical
• Rest • IVFD RL
Consult Orthopedic • Elevation • Antibiotic injection
• Education: • Analgetic injection
Surgeon
Nutrition, higienity
• Wound care
• Debridement
Thank You