Download - Laporan Jaga Faraktur Radius Ulna_ING
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Morning Report
Mega Silfia Zulfi
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CLOSED FRACTURE RADIUS ULNARIS
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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
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IDENTITY :Name : An. RC
JK : maleAge : 13 years
MAIN COMPLAINT:pain at the Left lower hand 2 hour before
came to the hospital.
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PRIMARY SURVEY
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Airway + Cervical CONTROLObjective :Answering questions smoothly and clearly without any additional noise
AssessmentPatent airway
reevaluationPatent airway
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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
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AssessmentNo interference lung expansion
reevaluationFrequency of breathing 24 times / minNo interference lung expansion
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CIRCULATION & HEMORRHAGE CONTROL Objective
warm acralCRT < 2 "Pulse rate 98 beats / min, regular, enough stuffingThere is no visible bleeding
Assessmentgood hemodynamic
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ActionIVFD Ringer laktat 20 TPM
Re EvaluationHemodynamic still good
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DISABILITY Objective
GCS 15Pupil: isokor, Ø 2mm/2mm, light reflex direct and indirect (+ / +), no lateralitation sign
Assessmentgood mini neurological status
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EXPOSURE Undress and covered
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Secondary survey
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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
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Patients are aware, no collide head, nose and mouth is not bleeding, hematoma (-), no wound was found on other body parts. Nausea (-), vomiting (-).
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Medical history first:No one associated with the disease now
Family history of the disease:No one associated with the disease now
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physical examinationGeneral condition: Mild Illnessconsciousness: composmentis, GCS 15 (E4 V5 M6) Vital sign:HR: 98 times/minuteRR: 24 times/minuteT: 36.7 º C
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Head and Neck: normalThorax : normalAbdominal : normalGenitalia : normalExtremity : localized
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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
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Rontgen Ro. Thorax
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Ro Antebrachii
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Laboratory Hb = 13 gr% WBC= 10300 /mm3 Ht =40 vol% PLT= 319.000 /mm3
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working diagnosisClosed fracture regio antebrachii sinistra
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plan investigations pairs splak Routine blood tests, CTBT Ro. Antebrachii sinistra
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Diagnose Closed fracture radius ulnaris
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treatment plan IVFD Ringer Lactat 20 tpm ATS Injection 1500 IU Cefriaxone Injection 2 x 500 mg Cetorolac Injection 2 x ½ amp
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