MORNING REPORT

Friday , August 22th 2014

Residents on duty :
SEN/DIT/HAZ
BAI/AFI
WIL
Consultant in charge :
Prof. Dr. dr. Respati S. Drajat. SpOT (K)

MUHAMAD ZARFAN /M /20

Y.O
ToAcc : 3 days previously
ToArr : 10.51
Proc Start : 13.00
Proc End : 14.00

Time

General
Status

10.51

A : Patent
B:
spontaneous
symmetrical
RR=20x/m
C:
BP=120/80
HR=90x
D:
GCS= 456

Problem

Open wound at
right hand

MOI:
Motorcycle rider
collision with
another
motorcycle

ISS: 4
RTS: 7.841
PS: 99.8%
Working
Diagnosis
Open wound at
3rd Extensor
zone of R Little
Finger

Problem
Solving /
Management

Final Diagnosis

Analgetic
Antyibiotics
Human Tetanus
Immunoglobulin
Debridement
Repair (83.73)

Open wound at 3rd

Extensor zone of R
little Finger (S67.8)
Partial rupture
Centralslip of R Liitle
Finger (S67.8)

MUHAMAD ZARFAN /M /20 Y.O

MUHAMAD ZARFAN /M /20 Y.O

MUHAMAD ZARFAN /M /20 Y.O

MUHAMAD ZARFAN /M /20 Y.O

HASAN MARUF /M /33 Y.O

ToAcc : 09.00
ToArr : 10.56

Time

General
Status

Problem

10.56

A : Patent
B:
spontaneous

Cannot move all

lower limb

ISS: 4
RTS: 7.841
PS: 99.8%
Working
Diagnosis
Burst Fr V Th XII
ASIA C
Spinal Cord
Injury

symmetrical
RR=22x/m
C:
BP=130/70
HR=90x
D:
GCS= 456

MOI:
Fall from high
place

Problem
Solving /
Management
Analgetic
In line
imobilization
(93.53)
Patient refuse
all treatment

Final Diagnosis

Burst Fr V Th XII
ASIA C (S22.0)
Spinal Cord Injury

HASAN MARUF /M /33 Y.O

JOKO PRASETYO /M /12 Y.O

ToAcc : 16.00
ToArr : 17.03
Proc Start : 18.00
Proc End : 19.30

Time

General
Status

16.03

A : Patent
B:
spontaneous
symmetrical
RR=20x/m
C:
BP=120/80
HR=100x
D:
GCS= 456

Problem

Pain and
deformity in
Left elbow and
wrist

MOI:
Motorcycle rider
collision with a
car

ISS: 4
RTS: 7.841
PS: 99.8%
Working
Diagnosis
CF dislocation
Left elbow
CF lateral
condyle Left
humerus
CF left distal
radius

Problem
Solving /
Management
Analgetic
Closed
reduction
Long arm cast
(93.53)

Final Diagnosis

CF dislocation Left
elbow (S52.0) (AO
21.B1)
CF lateral condyle
Left humerus
(21A(1-3) (AO
13.B1)
CF left distal radius
(S52.5) (AO 23.A1)

JOKO PRASETYO / M/ 12 Y.O

JOKO PRASETYO / M/ 12 Y.O

JOKO PRASETYO / M/ 12 Y.O

JOKO PRASETYO / M/ 12 Y.O

JOKO PRASETYO / M/ 12 Y.O

FAJAR ANDIKA/ M /2 Y.O

ToAcc : 17.30
ToArr : 19.24
Proc Start : 05.00
Proc End : 07.00

Time

General
Status

19.24

A : Patent
B:
spontaneous
symmetrical
RR=18x/m
C : BP
100/70
HR=100x
D:
GCS= 456

ISS: 9
RTS: 7.841
PS: 99.5%
Problem

Open wound at
right hand

Working
Diagnosis

Problem
Solving /
Management

Final Diagnosis

Traumatic
amptutation DIP
joint R middle
and ring finger

Analgetics
Anyibiotics
Human Tetanus
Immunoglobulin
Debridement
Repair stump
(79.64)

Traumatic
amptutation DIP
joint R middle and
ring finger (S68.8)

Finger Tip Injury

R Index Finger
MOI:
Stucked by
bycycle gear

Finger Tip Injury R

Index Finger (S68.8)

FAJAR ANDIKA / M / 2 Y.O

FAJAR ANDIKA / M / 2 Y.O

FAJAR ANDIKA / M / 2 Y.O

FAJAR ANDIKA / M / 2 Y.O

DEWI / F /49 Y.O

ToAcc : 06.30
ToArr : 19.46
Proc Start : 07.00
Proc End : 10.00

Time

General
Status

19.46

A : Patent
B:
spontaneous

ISS: 9
RTS: 7.841
PS: 99.4%
Problem

Open wound at
right knee

Working
Diagnosis

Problem
Solving /
Management

Final Diagnosis

OF
Supracondyler of
R Femur

Analgetics
Anyibiotics
Human Tetanus
Immunoglobulin
Debridement
(79.65)
Skeletal traksi
(78.55)
K-wire insertion
(78.18)

OF Supracondyler of
R Femur (S72.41)
(AO 33.B3)

Open wound at
right foot
symmetrical
RR=18x/m
C : BP
130/80
HR=80x
D:
GCS= 456

OF Proximal
Phalanx of R 2nd
and 5th toe

MOI:
Motorcycle
collision with
another
motorcycle

OF Proximal Phalanx
of R 2nd and 5th toe
(S92.51) (AO 08.A1)

DEWI / F /2 Y.O

DEWI / F /2 Y.O

DEWI / F /2 Y.O

DEWI / F /2 Y.O

DEWI / F /2 Y.O

DEWI / F /2 Y.O

DEWI / F /2 Y.O

DEWI / F /2 Y.O

SYAIFUL BAHRI / M /22 Y.O

ToAcc : 20.30
ToArr : 20.57
Proc Start : 21.30
Proc End : 22.30

Time

General
Status

20.37

A : Patent
B:
spontaneous

Problem

Open wound at
right foot

ISS: 9
RTS: 7.841
PS: 99.4%
Working
Diagnosis

Problem
Solving /
Management

Of of R Ankle
Weber A

Final Diagnosis

Debridement
Moist dressing
(79.60)

Of of R Ankle Weber
A (S82.61) (AO
44.C2)

Patient refuse
all treatment

OF of R Talus
(S92.11) (AO 08.C1)

OF of R Talus
symmetrical
RR=18x/m
C : BP
120/90
HR=100x
D:
GCS= 456

CF Base of R 5
Metatarsal
MOI:
Motorcycle
crashed
pedestrian

th

CF Base of R 5th
Metatarsal (S92.31)
(AO 8.A1)

SYAIFUL BAHRI / M /22

Y.O

SYAIFUL BAHRI / M /22

Y.O

TOHA /M /78 Y.O

ToAcc : 20.30
ToArr : 21.02
Proc Start : 08.00
Proc End : 12.00

ISS: 9
RTS: 7.841
PS: 99.4%

Time

General
Status

Problem

21.02

A : Patent
B:
spontaneous

Open wound
and deformity
at left lower leg

symmetrical
RR=20x/m
C : BP
140/90
HR=100x
D:
GCS= 456

MOI: Crashed
by motorcycle

Working
Diagnosis
OF Middle Third
of L Tibia Fibula
gr IIIA

Problem
Solving /
Management

Final Diagnosis

Debridement
(79.67)
External
Fixation (78.15)

OF Middle Third of L
Tibia Fibula gr IIIA
(S82.10) (AO 41.B1)

TOHA /M /78 Y.O

TOHA /M /78 Y.O

TOHA /M /78 Y.O

TOHA /M /78 Y.O

TAUFIQ UTOMO /M /24 Y.O

ToAcc : 20.00
ToArr : 21.43
Proc Start : 12.00
Proc End : 14.00

Time

General
Status

Problem

21.43

A : Patent
B:
spontaneous

Open wound
and deformity
at left lower leg

symmetrical
RR=20x/m
C : BP
120/70
HR=80x
D:
GCS= 456

ISS: 9
RTS: 7.841
PS: 99.4%
Working
Diagnosis

Problem
Solving /
Management

Final Diagnosis

Skin loss
dorsal of R
Foot

Analgetics
Antibiotics
Human
Tetanus
Imunoglobul
in
Debridemen
t (79.67)
Pinning
(78.18)
Repair
Buddy
Tapping
(93.53)

Skin loss dorsal

of R Foot (S97)

OF of R 5th
Metatarsal
MOI: Motorcycle
collision with
another
motorcycle

CF Distal
Phalanx of R
Little Finger

OF of R 5th
Metatarsal
(S92.31) (AO
08.A1)
CF Distal
Phalanx of R
Little Finger
(S62.6) (AO
07.A1)

TAUFIQ UTOMO /M /24

Y.O

TAUFIQ UTOMO /M /24

Y.O

TAUFIQ UTOMO /M /24

Y.O

TAUFIQ UTOMO /M /24

Y.O

TAUFIQ UTOMO /M /24

Y.O

TAUFIQ UTOMO /M /24

Y.O

OUTPATIENT
N
O

IDENTIFIED

DIAGNOSE

PROGRAMME

MUHAMAD
ZARFAN /M /20
Y.O

Open wound at 3rd Extensor

zone of R Little Finger

Debridement
Repair

HASAN
MARUF /M /33
Y.O

Burst Fr V Th XII ASIA C

Spinal Cord Injury

In line imobilization
Patient refuse all
treatment

SYAIFUL BAHRI /
M /22 Y.O

Of of R Ankle Weber A
OF of R Talus
CF Base of R 5th Metatarsal

Debridement
Moist dressing
Patient refuse all
treatment

TAUFIQ
UTOMO /M /24
Y.O

Skin loss dorsal of R Foot

OF of R 5th Metatarsal
CF Distal Phalanx of R Little
Finger

Debridement
Pinning
Repair
Buddy Tapping