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Sabtu 22-12-2012
BIODATA
Name : Jitron Nenotek Age : 18 years old Sex : Male Address : Job : Student Arrive to hospital : 13.30
Anamnesis
Chief Complaint :
Wound in chick
Mechanism of Injury
Patient fall from electric pole + 10meters. His position is facing to down and he rest on his arm. But his chin cras a box.
History
After this acident patien fell unusual in his teeth and hard to open because paint. No unconscious, vomit and nausea. The patien is refferenced from Bajawa Hospital.
Primari Survei
A: Clear, B : RR: 24 times in a minute, simetric C : Blodd preasure : 120/80mmHg, heart rate : 96 times/minute, reguler D : hard to open mouth E : vulnul laseratum et mandibula
Secondary Survei
GCS : E4 V5 M6 Eye : anemis (-), pupils refleks +/+, isocord Ear : otorhuoe (-/-) Nose : Rhinoroe (-/-) Jaw : vulnus laceratum at mandibula, clear, hacktinged, deformitiy (+),diameter 4cm, creepitation (-), paint (+),
Toraks
Inpeksi : cheest floating simetric, brush (-) Palpation : crepitation (-), paint (-) Auscultation : breath sound is vesicular
Abdoment
Inspektion : Brush (-) Auscultation : intestinal sound +, Palpation : tenderness paint no, Perkusion : normal
Extremitas
Look : vulnus laseratum at cubital regio sinistra, clear, hacktinged, size 3cm, deformity (-), shortening (-) Fell : paint (+), NAV normal, CRT <2 seconds, pultation arteri (+), crepitation (-), Move : Free moving
Radiologi
Linear fractur ini mandibula
Assesment
Fracture parasymphis mandibula dextra
Planning
IVFD RL 20 tpm Cafotaxim 2 x 1gr Ranitidin 2 x 1 amp Ketorolac 3% 2x 1 amp Wound toilet, hakting Fixtation
THANK YOU