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Morning Report

Saturday, August 31st2013

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Anamnesis

Patient J, male, 16 years old, came to AA

Hospital on August 28th2013

Chief complain:

Pain in the cheek and cant open the mouth

since 4 hours before admission to the hospital

after had a traffic accident

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PRIMARY SURVEY

at Bangsal

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Airway

Objective

gurgling (-) stridor (-)

Assesment

Clear airway

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Breathing

Objective

breathing spontaneously

RR : 20x/minutesSymmetrical chest (+)

AssesmentClear breathing

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Circulation

Objective

IVFD turned on (1 line)

HR: 79x/ minutes, regular

BP: 110/70 mmHgCRT: < 2 seconds

Distal of extremities : Warm

Assesment

stable hemodinamic , clear circulation

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DISABILITY

Objective

GCS 15

isochor pupils. Diameter : 3 mm, light reflect(+/+)

Assesmentclear mini neurologic assesment.

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EXPOSURE

Objective

T : 36,5 C

tampon in nose

bandage in forehead and chin (sewed laceration)

no other source of bleeding

Assesment

hypothermia (-) fever (-)

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SECONDARY SURVEYat Bangsal

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Mechanism of trauma

4 hours before admitted to AA hospital, patient had a trafficaccident. Rode a motor cycle with speed about 40km/h, no helmet.

crashed by a car from the left and patient thrown away to theright.

He cant clearly remember what hit his face and right

forearm. He got degradation of conciusness approximately 30 minutes

admitted to the local hospital and refered to AA Hospital.

nauseous(-), vomit (-), no seizures, there was a headache,there was blood from nose but not from ear.

The mouth can not open widely, no teeth detached. No interference on speaking but swallowing, no disfagia.

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Past illness history

No history of trauma before

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Physical Examination

General condition: mild illness

GCS 15

Vital sign: BP : 110/70 mmHg

HR: 79x /minutes

RR: 20x/minutes

Temp:36,50C

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Head and Neck :Localized

Chest : normal

Abdomen : normal

Extremity : normal

Limph node : normal

Genitourinary : normal

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Localized status

Head and neck

Inspection:asymetrical face, swollen at right cheek and nose

Laceration at forehead and chin

Echymosis periorbita (+) Malocclusion, trismus (-)

Nose deviation (+)

Subconjungtival bleeding (+)

Eyeball retraction, exophtalmus, enophtalmus (-)

Raccoon eyes and battlessign (-)

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Head and neck

Palpation:

tenderness at regio zygomaticomaxilla, nasale

swollen in cheek ,nose, periorbita

nose deviation (not representative)crepitation and fracture line (can not be assessed)

eyeball movement, visus (no interference)

diplopia (-)

hearing and olfactory (no interference)tounge movement (not representative)

no insensible in cheek, forehead and lips

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Working Diagnosis

Mild head injury with GCS 15 + os maxilla + os

nasal fracture

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Examination Planning

- Blood examination : Hb, Hematocryte,

Leucocyte, Platelet

- CT Scan 3D

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Laboratory findings

Blood

Hb : 11,6 gr/dl

Ht : 36,4 %

WBC : 27,9/L

Trombosit : 461.000 /l

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Final Diagnosis

Mild head injury with GCS 15 + Pan Facial

Fracture (os maxilla + os nasal + of frontale

fracture)

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Treatment Planning

Pro ORIF (after there is no swelling)

Ceftriaxone 2x1 gr

Ketorolac 3x30 mg Liquid Meal Diet

Nose compress

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Thank You