No. Name : Mr. R Sex : Male

Age : 19 years old No. Reg : 630475

Main complaint : Lacerated wound at mentaleCondition : The condition had suffered for 4 hours due to traffic

accident before the patient was taken to the hospital. There were no events of vomiting and unconsciousness.

Mechanism of injury

: The patient was riding a motorcycle when accidentally struck another vehicle. He was thrown from the motorcycle with his head landed first

Sustained Injury : Mandible Symptom & sign : HeadacheExamination Done

: Physical examination, Laboratory examination, Head CT Scan, skull X-Ray

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Primary SurveyPrimary Survey

A: Clear

B: RR: 22x/minutes, spontaneous, symmetric, thoraco abdominal type

C: BP: 110/70 mmHg, PR: 90 x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal Ø 3 mm/3 mm, Light Reflex +/+

E: T (ax): 36,7 oC

Secondary SurveySecondary Survey

Mandibular Region :I : Seen stitched wound size 4 cm. Hematome (-), wound (+)P : Tenderness (+), Crepitation (+)

Laboratory ResultLaboratory Result

WBC : 16,83 x 103 / μL

RBC : 5,05 x 106 / μL

HGB : 14,5 g/dL

HCT : 42,6 %

PLT : 279 x 103/ μL

CT / BT : 7‘30”/3’00”

Blood Sugar : 91 mg/dl

Ureum : 13 mg/dl

Creatinin : 0,8 mg/dl

GOT / GPT : 32/31 μ/L

Head CT scan

Skull X-Ray

WORKING DIAGNOSIS : - Mild head injury GCS 15 (E4M6V5)- Mandibular fracture

MANAGEMENT : • Apply IVFD• Medicaments• Consult to senior plastic surgeon Advice: immediate ORIF

OPERATION PROCEDURE• Laid patient down onto supine position under GA• Disinfection and draping procedure• Proceed incision mucous on the mandibular• Seen fracture line on mandibular parasimfisis• Applied 2 plate, 5 burr hole with 4 screw and 3 burr

hole with 3 screw• Rinse the wound by NaCl and betadine• Stitch the wound layer by layer• Done

POST OP DIAGNOSIS : - Mild head injury GCS 15 (E4M6V5)- Mandibular fracture

PROGNOSIS

FOLLOW UP

:

:

Good

Vital sign