MORNING REPORT

May 17th , 2016

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
PI/SG
 IDENTITY
Name : AN

Age : 49 years old / Female

Admission : May 17th , 2016 at 22.00

Registration : 745719

Status : BPJS
 AUTOANAMNESIS
(at 22.01)
Chief Complain : Pain at left thigh

 Suffered since 5 hours before admitted to Wahidin

General Hospital due to fall
 Patient slipped when walking and fell down with
her left hip directly hit the floor. After the fall, her
left hip was painful and she cannot walk.
 History of unconsciousness (-), nausea (-), vomit (-)
 History of prior treatment (-)
 The patient was recently diagnosed with breast
cancer and undergoes chemotherapy
 PRIMARY SURVEY
(at 22.01)

A : Clear
B : RR 18 x/min, spontaneous, thoracoabdominal
type
C : BP 130/80 mmHg, HR 80x/min strong, regular

D : GCS 15 (E4M6V5), pupil isochoric, diameter 3

mm/3mm, light reflex +/+
E : T: 36,7 oC
 SECONDARY SURVEY
(at 22.03)
Left Thigh Region
Look : Deformity (+), Swelling (+), Hematoma (+),
Wound (-)
Feel : Tenderness (+)
Move : Active and passive movement of hip joint is
limited due to pain
Active and passive movement of knee joint is
limited due to pain
NVD : Sensibility is good, pulsation of dorsalis pedis and
tibialis posterior arteries are palpable, CRT is less
than 2 seconds
 Right Left
ALL 81 79
TLL 71 69
LLD 2 cm
CLINICAL FINDINGS
(22.05)
RADIOLOGICAL FINDINGS
(at 22.08)
RADIOLOGICAL FINDINGS
(at 22.08)
RADIOLOGICAL FINDINGS
(at 22.08)
 LABORATORY FINDINGS
(at 22.30)
 WBC : 4.9/ ul GOT : 21 U/L
 HBG : 11.6 g/dl GPT : 16 U/L
 HCT : 35 % Albumin : 5.0
 PLT : 423.000/ul
 CT : 8’00’’
 BT : 4’00’’
 HBsAg : Non-reactive
 GDS : 115 mg/dl
 DIAGNOSIS
 Closed fracture left intertrochanter femur
AO Classification : 31-A3 IC-1 MT-1 NV-1
 Right Breast Cancer
 MANAGEMENT
 IVFD
 Analgetic
 Report to Orthopaedic senior, advice:
 Apply skin traction load 3 kg at left lower limb.

 Plan for Open reduction internal fixation