Morning ReportDepartment of SurgeryIDENTITYName : Mr. SunarnoAge : A 35 years old Sex : MaleAddress : LamonganWorker : N!"xamination date: May# $%t& '($5 at $).((ANAMNESISTHEMAINComplaint:*ainint&e+alfaftertra,+ a++ident MOI ( autoanamnesis ) : *atients +ome to t&e "R -it& +omplaints of pain in t&e left +alf after a tra,+ a++ident . sin+e $ &our /efore &ospital admission 0 . *atients also +omplained of pain in t&e left &and . 1oot and left &and are2eryillto/emo2ed.*atientsarereferred/y &ospitalstripeinapositionto&andandleftleg&as /een3ttedspalk.!nitially#patientsrideamotor+y+le &eadingtoSura/aya.Speedingpatient/e+auseit-as afternoon . *atients -ear a &elmet . Suddenly t&e tru+k in front of &im stopped suddenly . 1urt&ermore # patients &itt&e/a+koft&etru+k.*atientsfall-it&&is&ands and left foot rested /ody . 4omplaints of t&e ot&ers: t&e patient -as not a-are of 5 $( min # 2omiting 6 # sei7ures 6 # dis+&arge from t&e ear 6 8 nose 6 .PAST ILLNESS HISTORY: 6 4onsumption Al+o&ol .606 4onsumption drugs .60 6 Drug allergy and food . 606Last meal .60 Primar Sur!eA : 4lear .90# stridor .60# snoring .60# gargling .0 speak :uently .60# a potential o/stru+tion .60" : lesion .60# tra+&eal de2iation .60# Spontaneous# symmetri+al +&est mo2ements# retra+tion .6860# R& .6860# lung sounds .2es 82es0#RR: '%x8mntC : "xtremity .dry -arm red0# ;*: $'38)$ mm' ??@.-it&out >' support0D : A4S %5B# pupillary isokor .3mm83mm0# laterali7ation .60E: emp 3B.?4# Re#io ante$ra%&ii sin: atta+&ed splint# a+ti2e /leeding.60#soft tissue.60# /one expose .60# deformity .sde0Re#io %ruris sin: atta+&ed splint# a+ti2e /leeding.60#soft tissue.60# /one expose .60# deformity .sde0'eneral State o( t&e Patient: mild pain'CS : %5B)ITAL SI'N :;lood *ressure : $'(8)( mmM limitedLo%al StatusRe#io %ruris sin :6 Look : installed splint . 9 0 # soft tissue . 6 0 # /one expose . 6 0 # a+ti2e /leeding . 6 0 # rotation . sde 0 deformity . sde 0 # angulation . sde 0 # +yanosis distal portion . 6 0 # s&ortening . sde 0 1eel : tenderness . 9 0 # akral -arm # 4R 5 'se+Mo2e : R>M limitedHea* an* Ne%+Hea*: normo+ep&al 6# lesion 6Ees: 4onCun+ti2al pallor .6860# s+lera Caundi+e .6 8 60# lig&t re:ex 9 8 9# isokor pupil diameter of 3 mm 8 3 mm# ra++on eyes .60Nose: dis+&arge .60# /loody r&inor&ea .60Ear: dis+&arge .60# /attle sign .60# /loody otor&ea .60Ne%+:lesion .60# ra+&eal de2iation .60# T&ora, an* Lun#T&ora,:&e s&ape of t&e +&est -all .normal0# deformity .60# !4S .d/n0# /reat&ing patterns Dt&orakoa/dominalE.Lun#:Inspe%tion: &e mo2ement of +&est -all symmetri+al# retra+tion 6 8 6# /reat&ing patterns Dt&orakoa/dominalE.Palpation : F &e mo2ement of t&e +&est -all : normalF 4repitation . 6 0 Per%ussion : resonantAus%ultation: F Lung Sounds : 2esi+ular82esi+ularF Additional sound : +ra+kles . 6860 -&ee7ing .6860CorInspe%tion :i+tus +ordis .60Palpation : !+tus +ordis is not strong lift palpation.Per%ussion : ;orderline of t&e &eart .normal0Aus%ultation : S$S' single# a &eart murmur . 6 0 # gallop .60.A$*omentInspe%tion : +ontusio .60# distended .60Palpation :soepel .90#