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    (Trauma) 14 Des 22 - An - Nashwan - CF Antebrachii D

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    nadiya salma
    N, a 13-year-old male, arrived at the ER after falling while playing basketball and injuring his right forearm. Upon examination, he had deformity and pain in his right forearm with limited range of motion. X-rays showed soft tissue swelling and a bone break in the radius and ulna. He was diagnosed with a closed fracture of the right forearm and given splint immobilization, IV fluids, medications, and was scheduled for an open reduction and internal fixation surgery.

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    (Trauma) 14 Des 22 - An - Nashwan - CF Antebrachii D

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    nadiya salma
    30 views14 pages
    N, a 13-year-old male, arrived at the ER after falling while playing basketball and injuring his right forearm. Upon examination, he had deformity and pain in his right forearm with limited range of motion. X-rays showed soft tissue swelling and a bone break in the radius and ulna. He was diagnosed with a closed fracture of the right forearm and given splint immobilization, IV fluids, medications, and was scheduled for an open reduction and internal fixation surgery.

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    (Trauma) 14 Des 22_An.nashwan_CF Antebrachii D

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    N, a 13-year-old male, arrived at the ER after falling while playing basketball and injuring his right forearm. Upon examination, he had deformity and pain in his right forearm with limited range of motion. X-rays showed soft tissue swelling and a bone break in the radius and ulna. He was diagnosed with a closed fracture of the right forearm and given splint immobilization, IV fluids, medications, and was scheduled for an open reduction and internal fixation surgery.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    30 views14 pages

    (Trauma) 14 Des 22 - An - Nashwan - CF Antebrachii D

    Uploaded by

    nadiya salma
    N, a 13-year-old male, arrived at the ER after falling while playing basketball and injuring his right forearm. Upon examination, he had deformity and pain in his right forearm with limited range of motion. X-rays showed soft tissue swelling and a bone break in the radius and ulna. He was diagnosed with a closed fracture of the right forearm and given splint immobilization, IV fluids, medications, and was scheduled for an open reduction and internal fixation surgery.

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    You are on page 1of 14

    MORNING

    REPORT
    Thursday, 15th December 2022
    Identity

    ● Name :N
    ● Age : 13 years old
    ● Gender : Male
    ● Address : Batu
    ● Arrival Date : 14th December 2022
    ● Patient Type : Trauma
    PRIMARY SURVEY
    Incident date: 14th December 2022 at 10.20 am
    Arrival Date: 14th December 2022 , at 11.00 am

    Anamnesis:
    Patient came with pain in his right forearm. MOI the patient fell in the field when playing basketball. When he pursued the ball, he slipped and fell
    down with the forearm fell first supported the body. Nausea and vomiting (-), headache or dizziness (-), decrease of consciousness (-)

    Examination Initial Diagnosis Action


    Airway: - -
    Patent, gargling (-), stridor (-)

    Breathing: - -
    Look: symmetrical chest wall movement,
    Feel: the patient breathes spontaneously, no additional breath sounds, rib
    crepitations (-), dyspnea (-)
    RR: 20x/minute
    SpO2 : 99% on RA
    Circulation: Hypovolemic Shock Grade I EBV: 37 x 80 = 2960
    BP: 136/73 mmHg EBL: 2960 x 15% x 3 = 1332cc
    HR: 115x/min, strong pulse
    CRT<2s, AHKM IVFD RL 1500cc
    Bleeding active (-) Blood examination
    PRIMARY SURVEY
    Examination Initial Diagnosis Action
    Disability : - -
    GCS 456 composmentis, Isochor pupil diameter 3mm/3mm, Light reflex direct
    and indirect +/+

    Exposure: • Susp. CF antebrachii D dd Splint immobilization


    Temp: 36o C Greenstick fracture dd CF X-Ray Antebrachii D AP/Lat
    galeazzi D dd CF monteggia
    Regio Antebrachii Dextra D
    Look: Deformity (+)
    Feel: Pain (+)
    Move: limited to pain
    SECONDARY SURVEY

    ANAMNESIS

    Allergy :-
    Medication: -
    Past illness : -
    Last meal : 13/12/22 18.00
    Event: Fell down when playing basketball
    SECONDARY SURVEY

    History of Present Illness:


    Trauma patient came to the ER at 11.00 am with pain in his right forearm. MOI the patient fell in the field
    when playing basketball. When he pursued the ball, he slipped and fell down with the forearm fell first
    supported the body. Nausea and vomiting (-), headache or dizziness (-), decrease of consciousness (-)

    Past Medical History: -


    Family Medical History: -
    Medicine History: -
    Alergic History: -
    SECONDARY SURVEY

    GENERALIST STATUS
    General Condition : Fair
    Consciousness : Composmentis
    GCS : 456
    BP : 128/78 mmHg
    HR : 100x/minute
    RR : 20x/minute
    SpO2 : 99% on RA
    PHYSICAL
    EXAMINATION
    HEAD/NECK: EXAMINATION
    ABDOMEN:
    Head: Inspection : Flat, injury (-), surgical scar (-), lump (-)
    Eyes: Anemic conjunctiva (-/-), icteric sclera (-), Isochor pupil Auscultation : Bowel sound (+) 12x/minute
    diameter 3mm/3mm, Light reflex direct and indirect +/+ Palpation : Flat, soft, superficial tenderness (-), deep
    Nose: rhinorrhea (-/-) tenderness (-)
    Ears: otorrhea (-/-) Percussion : Timpany

    EXTREMITIES : Dry warm acral, CRT <2 s


    THORAX : Localist Status
    Cor: Regio Antebrachii Dextra
    Inspection: ictus cordis invisible Look: Deformity (+)
    Palpation: ictus cordis palpable at ICS 5 MCL S Feel: pain (+)
    Percussion: D heart border at ICS 4 PSL D, heart border S Move: limited to pain
    at ICS 5 MCL S
    Auscultation: S1 S2 single, irregular, murmur (-), gallop (-)

    Pulmo:
    Inspection: normal chest wall shape, retraction (-)
    Palpation: symmetrical D/S chest wall movement
    Percussion: sonor
    Auscultation: Ves/Ves
    CLINICAL PICTURES

    FOTO KLINIS
    Laboratory (14/12/22)
    X-Ray Antebrachii D AP/Lat (12/12/22)

    Conclusion : Soft tissue edema (+), Bone discontinuity (+) os radius ulna 1/3 medial
    PROBLEM LIST & PLANNING

    Problem list Definitive Diagnosis Planning Planning Therapy &


    Diagnosis Monitoring

    Anamnesis: CF Antebrachii D - Splint immobilization


    Trauma patient with pain (+) in right forearm IVFD RL 1500cc
    Inj. Ketorolac 30mg
    Physical Examination: Inj. Ranitidine 50mg
    Regio Antebrachii Dextra Inj. Ceftriaxone 1gr
    Look: Deformity (+) Pro ORIF
    Feel: Pain (+)
    Move: limited to pain

    Supporting examination:
    Laboratory: Low Hb, High WBC, High neutrofil
    X-Ray Antebrachii D AP/Lat: Soft tissue edema (+), Bone
    discontinuity (+) os radius ulna 1/3 medial
    THANK YOU

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