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MORNING

REPORT
Name : Ms. A
Age : 18 years old
Sex : Female
Address : Raha
Admission : February, 22th 2018
Doctor in charge : dr. Rizal Alisi, Sp.OT.
Ekstremitas : Tampak ulkus pada ibu jari kaki kiri yang meluas ke dorsum pedis, pus (+), dolor (+), edema (+), hiperemis (+), gangrene (-), kotor (+), pulsasi a. dorsal

History Taking
 Chief complain :
Wound at the right foot
 Anamnesis :
Suffered since 2 months ago. At previous, the patient had an accident and complain of pain at the right leg, swollen
and hard to move it. After that, the patient didn’t immediately taken to hospital. It getting worst since 3 weeks ago.
The patient cleaned the wound with rivanol and Ampicillin powder until now. There was history of fever (+).
headache (-), nausea (-), vomit (-). Defecate and urinate was normally.
History of trauma (+) : Patient was riding motorcycle at moderate speed. She hit by other motorcycle from front
side, and then she felt.
Medical history : One month ago, the patient was treated at Raha Hospital for 1 week.
History of the same symptoms (-)
History of other diseases (-)
Generalized State
General Condition : Moderate illness Head : Normally
Face : Normally
Conciousness : Composmentis, Eye : Normally
Vital Sign : Nose : Normally
Mouth : Normally
BP : 100/60 mmHg
Ear : Normally
RR : 18 x/m Neck : Normally
HR : 80 x/m Chest : Normally
Upper limb : Normally
T : 37,7 0c
Lower limb : Localized state
• deformity (+), • Tenderness (-) • Active and passive • Sensibility (-), CRT (-),
swelling (-), pus (+) motion of genu joint pulsation of pedals dorsalis
and ankle joint artery (-)
limited because of
pain
Inspection Palpation ROM NVD
Complete blood count

Chemistry Blood

X – Ray Cruris
Dextra Ap /Lat
WBC : 5.98 x 10³ /uL
HGB : 7.7 g/dL
PLT : 507 x 10³/uL
GDS : 108 mg/dl
Fracture 1/3
Proximal
DIAGNOSE Right Tibia +
Gangrene at
Right Leg
IVFD

Antibiot
ic

CONSULT
ORTHOPEDIC
SURGERY

Analgeti
c

H2RA
Thank You