laporan jaga faraktur radius ulna_ing

Morning Report

Mega Silfia Zulfi

CLOSED FRACTURE RADIUS ULNARIS

CasesThe patient was 13 years old, fell from a mango tree with a height of about 2-3 meters. The patient complained of pain in his left hand and can not be moved

IDENTITY :Name : An. RC

JK : maleAge : 13 years

MAIN COMPLAINT:pain at the Left lower hand 2 hour before

came to the hospital.

PRIMARY SURVEY

Airway + Cervical CONTROLObjective :Answering questions smoothly and clearly without any additional noise

AssessmentPatent airway

reevaluationPatent airway

BREATHINGObjectiveFrequency of breathing 24 times / min, regularinspectionSymmetrical chest wall movement left with rightauscultationVesicular breath sounds left same as rightAudible heart soundspalpationVocal fremitus left with rightpercussionSonor in all lung fields

AssessmentNo interference lung expansion

reevaluationFrequency of breathing 24 times / minNo interference lung expansion

CIRCULATION & HEMORRHAGE CONTROL Objective

warm acralCRT < 2 "Pulse rate 98 beats / min, regular, enough stuffingThere is no visible bleeding

Assessmentgood hemodynamic

ActionIVFD Ringer laktat 20 TPM

Re EvaluationHemodynamic still good

DISABILITY Objective

GCS 15Pupil: isokor, Ø 2mm/2mm, light reflex direct and indirect (+ / +), no lateralitation sign

Assessmentgood mini neurological status

EXPOSURE Undress and covered

Secondary survey

anamnesis The chief complaint :

Pain in lower left arm and can not be moved from 2 hours before came hospital

Present illness history:2 hours before came to the hospital, the patient complained of pain in lower left arm and can not be moved due to falling from a mango tree with a height of about 2-3 meters. Patient falls muddy ground with his left arm folded position to the inside

Patients are aware, no collide head, nose and mouth is not bleeding, hematoma (-), no wound was found on other body parts. Nausea (-), vomiting (-).

Medical history first:No one associated with the disease now

Family history of the disease:No one associated with the disease now

physical examinationGeneral condition: Mild Illnessconsciousness: composmentis, GCS 15 (E4 V5 M6) Vital sign:HR: 98 times/minuteRR: 24 times/minuteT: 36.7 º C

Head and Neck: normalThorax : normalAbdominal : normalGenitalia : normalExtremity : localized

Localized status Regio antebrachii sinistraLook:edema (+), wound (-), endorotation (-), exorotation (-), shortening (-), lenghtening (-), injuries (-),Feel: warm acral, tenderness (+) capillary refilling <2 seconds,crepitation (-)Move: limited movement in the region of antebrachii sinistra

Rontgen Ro. Thorax

Ro Antebrachii

Laboratory Hb = 13 gr% WBC= 10300 /mm3 Ht =40 vol% PLT= 319.000 /mm3

working diagnosisClosed fracture regio antebrachii sinistra

plan investigations pairs splak Routine blood tests, CTBT Ro. Antebrachii sinistra

Diagnose Closed fracture radius ulnaris

treatment plan IVFD Ringer Lactat 20 tpm ATS Injection 1500 IU Cefriaxone Injection 2 x 500 mg Cetorolac Injection 2 x ½ amp