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, stridor (-), gargling (-),

snoring (-)– Airway clear

• 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 patient’s body. The left side of patient’s 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 didn’t 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 : patient’s 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 7th 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