MORNING REPORT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR

July 9th, 2014

JA/NS/PU
IDENTITY
Name : H
Age : 12 years old / Male
Admission : July 9th, 2014 at 13.15
Registration : 67 14 38
Status : BPJS
AUTOANAMNESIS
(at 13.17)


Chief Complain : Wound on the right thigh
Suffered since 4 hours before admitted to Wahidin
General Hospital due to motorvehicle accident.
Patient was the passenger of the motorcycle when
he was hit from behind by another motorcycle. He
fell to the right side and the motorcycle fell on his
thigh.
History of unconsciousness (-), vomit (-), seizure (-)
PRIMARY SURVEY
(at 13.20)
A :
Clear
B : RR 20 x/min, spontaneous, thoracoabdominal
type
C : BP 110/80 mmHg, HR 90 x/min strong, regular
D : GCS 15 (E
4
M
6
V
5
), pupil isochoric, diameter 3
mm/3mm, light reflex +/+
E : T: 36,8
o
C
SECONDARY SURVEY
(at 13.25)
Right Thigh Region
Look : Pin point wound (+) at the lateral aspect
Deformity (+), hematome (-), swelling (+),
Feel : Tenderness (+)
NVD: sensibility is good, pulsation of dorsal pedis
artery and tibialis posterior artery are palpable, CRT
<2
Move : Active and passive motions of ankle joint and knee
joint are difficult to be evaluated due to pain
R L
ALL 91 cm 92 cm
TLL 87 cm 88 cm
LLD 1 cm
LEG LENGTH DISCREPANCY
RADIOLOGY FINDINGS
(12.25)
LABORATORY FINDINGS
(at 19.30)
WBC : 13.700/ ul
RBC : 3.740.000/ ul
HBG : 10,7 g/dl
HCT : 32,4 %
PLT : 238.000/ ul
CT : 730
BT : 230
HBsAg : non-reactive

PREOPERATIVE DIAGNOSIS
Open fracture 1/3 Middle (R) Femur Fracture
Gr I
Anemia
MANAGEMENT
IVFD RL
Antibiotic
Analgesic
Tetanus Toxoid
Report to Orthopaedic senior, advice:
Debridement and Open Reduction Internal
Fixation


Operation Report
(21.40 22.50)
1. Patient lied supine under spinal Anaesthesia
2. Disinfection and draping procedure until right femur was seen as operating field.
3. Incision on skin at lateral aspect right thigh with posterolateral approach sized 10 cm,
and deeper layer by layer until fascia lata.
4. Incising Fascia lata and separating lateral vastus muscle from intermuscular septum to
anterior
5. Deeper incision until os femur was found
6. Identification of fracture site at 1/3 middle right femur
7. Performing open reduction
8. Internal fixation by using Broad Plate 8 hole and 8 pieces of Cortex Screw self tapping
4,5 x 30mm
9. Wound debridement with NaCl 0.9% and applying drain and Gentamicin 1 ampoule on
wound.
10. Stitching wound layer by layer, approximation on the edge of wound, and then covered
with tulle and sterile gauge
8. Operation finished.
Post Operative Diagnosis
Open fracture 1/3 Middle (R) Femur Fracture
Gr I (AO 32.A3)
Anemia