Department of Surgery

February, 04 2015

DAFTAR OBDAFTAR OB

Mr Joko COS+Fr costae 2-3

Mrs Suryatmi PO trepanasi meningioma

Mrs Masri Abcess Maxilla

Mrs Salamah Cholelithiasis

Mr Sakir Fr Lefort 3

Name : Mr S Age : 42 y.o Sex : male Address : Lamongan Date examination: february 04, 2015

ANAMNESIS Chief complaint

Pain in the face

Present Illness

Patient referrals from the Ngimbang hospital after a traffic accident 4

hours before admission. Patient riding a motorcycle and hit a parked car

from behind . patients complained pain in the face. Nausea and vomiting

blood approximately 4 times , bleeding from the nose right and left . The

patient also complained of chest pain and breathing heavy. Patients wear

a helmet and a crash helmet when detached . The patient decrease of

consiousness after accident but the patient remember what happened .

History illness

allergy (-), HT (-), DM (-)

Family illness :

(-) Social history :

alcohol (-)

PHYSICAL EXAMINATION PHYSICAL EXAMINATION

VITAL SIGN :

GCS : 456

BP : 101/56 mmHg

PULSE RATE : 118 x/minutes

TEMP : 36,5 oC

RR : 22 x / minutes

Airway and spine control : clear (+), snorring (-), gargling (-), potensial obstruction (-)

Breathing : spontan, simetric (+), RR 22x/minutes, ves/ves, rh-/-, wh-/-, Sp02 99%

Circulation : PR 76x/minutes, acral warm dry red, CRT < 2”, BP 101/56 mmhg

Disability : GCS 456, Light reflex +/+, isocor pupil 3mm/3mm, lateralisasi-

Exposure : temp 36,5C, Vulnus appertum et regio infra orbita uk 5x0,5 cm, Multiple ekskoriasi et regio antebrachii sinistra, lesion in the thorax (+)

PRIMARY SURVEY

Head and neck : anemic (-), icteric (-), cyanosis (-), dyspneu (-), bloody rinorrhea +/+, Bloody otorrhea -/-, brill hematom +/+, scalp hematom et regio frontal, floating maxilla (+)

Thorax : simetric (-), retraction (-), lesion +Pulmo : ves/ves, rh-/-, wh-/-Cor : S1S2 single, murmur (-), gallop (-), lession -

Abdomen : soepel, distended (-), tympani (+), liver and spleen were not palpable, bowel sound (+), lession-

Extremities : acral warm, dry, red, lession-

• Vulnus appertum et regio infra orbita uk 5x0,5 cm

• Vulnus excoriasi et regio mandibulae• Multiple excoriasi et regio antebrachii

sinistra• Lesion in the thorax (+)

Clue and cue Male, 42 y.o Pain in the face Post traffic accident Vomitting blood Bloody rhinorrhea Chest pain and breathing heavy Brill hematom Floating maxilla Staus localized : Vulnus appertum et regio infra

orbita uk 5x0,5 cm, Multiple ekskoriasi et regio antebrachii sinistra, lesion in the thorax (+)

Early Early AssesmentAssesment

Epistaxis

Mild brain injury

Fracture of maxilla

• CBC• CT-BT• GDA • Thorax AP• Head CT scan

CBCCBCDiff 0/0/86/12/2

Hct 35,2

Hb 12

LED 1/2

Lekosit 21.400

Trombosit 250.000

Serum Creatinin 1,2

RBC 208

CT SCANCT SCAN

CT SCAN BONE WINDOWCT SCAN BONE WINDOW

FOTO THORAXFOTO THORAX

AssesmentAssesment

Mild brain injury Fracture Le Fort III

• IVFD Asering loading 500 cc Maintenance Assering 1500 cc/24 hours

• Inj Remopain 3x1 amp• Inj piracetam 4x3 gr IV• Inj tranexamat acid 3x250 mg IV• Inj ceftriaxon 2x1 gr IV• Inj tetagam 250 IU IM

Subjective complaint Vital sign Sign of increased pressure intracranial

Explain to the patient’s family about the diagnosis, etiology, intervention of therapy, complication, and prognosis.