putri

Morning ReportWednesday, 8th April 2015M/LK/35 yoChief Complain: Cant move the right leg Explain:it had been happened since 3 hours before addmission. Firstly, the patient was riding a motorcycle and then the patients got hit by a car from the right side and the patient fall. History of unconciousness (-), vomitting (-), seizure (-).PRIMARY SURVEYAirway : ClearBreathing : Spontaneous, RR : 20x/minute.Circulation : Warm acral, HR: 88 x/minute Blood pressure : 120/70 mmHgDisability : GCS 15Exposure : undress, logrollSECONDARY SURVEYHeadHead: Eye: pale inferior conjungtiva -/-, pupil equal, light reflex +/+ Ear/nose/mouth: Normal/normal/normalNeck: no abnormality foundThorax:Look : SymmetricalListen : Vesicular on both hemithoraxFeel : Resonance on both hemithoraxAbdomen Abdomen: Look : symmetrical Listen: peristaltic (+) N Feel: flat and smooth

Extremities : Upper extremities: (L) no abnormality(R) no abnormalityLower ExtremitiesLeft : no abnormalityRight :Right Femoral :Look : deformity (+), swelling (+), Feel : pain (+) NVD (+) normal Move : DOF(+), ROM(+) decreaseRight Genu : no abnormalityRight Cruris :Look: deformity (+), sweeling (+) lacerated wound (+) size 2x1 cm, edge irreguler, base subcutis, active bleeding (+)Feel: crepitation (+) pain (+) NVD (+) normalMove: DOF(+), ROM(+) decrease

Genital : Male, no abnormality was found

Laboratorium Hb/L/T/Htc: 13,9/16100/285000/41,4Ureum creatinin: 17,1/0,78Kgd adr: 117 mg/dlNa/K/Cl: 133/4,3/108

X- Ray Femur

X Ray Cruris

diagnoseclosed (R) Middle third comminutive femur fracture + Open (R) Upper third comminutive tibia fibula Fracture grade II Therapy IVFD RL 20 gtt/iInj antibiotikInj analgesikInj TetagamPlan: Debridement + Backslab

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