Morning Report

Meisya Rahmatia Syardi

Anamnesis
Patient R, 65 years old, male, came
to Emergency room RSUD AA on June
19th 2013
Chief complain:
Patient felt pain in the left side of
chest near arm after traffic accident
3 hour before admitted to the
hospital.

Primary Survey
Airway:
Patient talk spontaneously,
gargling (-), snoring (-)
Airway clear

stridor (-),

Breathing:
breath spontaneously, RR = 25x/minutes,
symetrical chest movement
Breathing clear

Primary survey
Circulation:
Heart rate 83x/minutes, BP: 180/110 mmHg,
CFR < 2 second
Circulation clear

Disability
Pupil reaction +/+, diameter (2mm/2mm)
GCS 15 (E4M6V5)
Motorik : 5
Disability clear

 Exposure:
Completely undress the patient
Bruise in the left side of the chest and
hematome in the lower left side of
stomach
Cover patient with blanket

Reevaluation
Airway : stridor (-), gargling (-), snoring (-)
clear
Breathing : RR = 25x/minutes, symetrical chest
movement
clear
Circulation : HR = 83x/minutes, BP: 180/110 mmHg, CFR < 2
second

clear
Disability : Pupil reaction +/+, diameter (2mm/2mm),
GCS 15 (E4M6V5), Motorik : 5
clear
Exposure clear

Secondary Survey
Recent illness history:
3 hour before admitted to the hospital,
patient got traffic accident. He rode a
pedicap. A car with 100 km per hour got
crushed from the right side of the
pedicap. Patient fell from the pedicap to
the left side about 4 meters away.

Recent illness history

The first body part that touched bitumen
road was the left side of patients body.
The left side of patients chest was hit by a
rock. He had unconsciousness state.
Patient was brougth to the hospital in
Perawang and was referenced to RSUD AA.

Recent illness history

At RSUD AA, primary survey was
done. Patient didnt vomit
immediately after the trauma. There
was no bloody discharge from nose,
ears, or mouth.
Patient complained about pain in the
left side of chest near arm after the
accident. Patient felt pain when
breathing and more pain when
cough.

 Past Illness : Family Illness : patients father had

hipertension.

Physical examination
General condition: moderate illness
Consciousness: composmentis
Vital sign:
BP: 180/110 mmHg
HR: 83x/ minutes
RR: 25x/minutes
Temp: 36,70C

Physical examination

Head and neck : normal

Thorax : local status
Abdomen: normal
Pelvis : local status
Genitourinarius: normal
Extremity: normal

Thorax
Inspection: deformity (+), Asimetrical
lateral
sinistra
movement
while
breathing, bruise in the left chest
Palpation: empty side in the 7 th rib of
the left chest near arm, crepitation (-),
pain when pressed (+)
Percussion: sonor/sonor
Auskultasion:
Vesikular
(right)
&
Vesikular (left)

Pelvis
Inspection: hematome in the left
pelvis
Palpation: crepitation (-)

Working Diagnosis
7th rib fracture lateral in the left +
hipertension

Suggestive examination
X-ray thorax PA Lateral

Rontgen Thorax

Final diagnose
7th rib fracture lateral in the left +
hipertension

Treatment
Non farmacological:
Bed rest

Farmacological:
Analgetic

Observation

Thank You