IGD, 23th March 2014

Departement of SURGERY
Identity
Name : Mr. M
Age : YO
Sex : male
Address : Lamongan
Admission : 06th April 2014 20.30 am



Anamnesis
Chief complaint:
Pain in the left cheek
Present illnes:
Patient came with pain in the left cheek since 1,5
hours before admission. Patient riding motorcycle
used a helmet and then his hit by motorcycle from
the opposite direction. Patient also complained pain
in the left eye. Headache (-), Nausea (-), history of
vomit (-) , fainting (-), PTA ().
History or past illness :
daniel
History of sociality:
- Smoke
- Alcohol -
- Herbal Medicine-
PRIMARY SURVEY
Airway :
Clear, snoring-, gurgling-, potential obstruction-,
speak fluently+
Breathing :
simetric bilaterally+, RR 20x/minute without O2
nasal canul , ves/ves, rh-/-, whz-/-
SPO2= 99%
Circulation and bleeding control :
Acral : Warm and dry to touch Red
BP : 106/69 mmHg
Pulse Rate : 67x/minute
CRT : < 2 seconds
Disability :
GCS 456
Lateralisasi -
Pupil round equal
(right eye 3 mm; left eye 3mm, LR +/+)

Exposure :
T : 36,6C


SECONDARY SURVEY :
K L :
anemis -/-, icterik -/-, cyanosis -/-, dysp
Bloody otorhea -/-, bloody rinorhea -/-
Battle sign -
Pembesaran KGB : -
Floating maxilla -
Thoraks :
I : pergerakan dinding dada simetris, retraksi (-), jejas (-)
P : pergerakan dinding dada : simetris, fremitus vokal : N/N
P : sonor/sonor
A : pulmo : ves /ves, rh -/-, wh -/-
cor : S1 S2 tunggal, reguler, suara tambahan
Abdomen :
I : soepel, jejas (-)
A : BU (+) N
P : supel, nyeri tekan (-), Hepar lien tidak teraba,
P : timpani, shifting dullness
Ekstremitas : Akral HKM, crt < 2,
Localist status
Vulnus laceratum suprasiliaris sinistra 4x1cm,
vulnus abrasio nasal,vulnus abrasio manus
dextra, vulnus abrasio pedis dextra, vulnus
laceratum 1x1


CLUE and CUE
Male, 52 YO
Post accident
GCS 456
Headache +
History of fainting +
History of vomitting + 1x
PTA +
vulnus laceratum 4 cm palpebra superior S
Regio buccal Soedem+, krepitasi+,nyeri
tekan+



- CKR
- Susp fracture close
zigoma
assesment
Planning Dx :
-foto rontgen skull AP
lateral
-CBC
-Head CT Scan

Planning Tx :
-IVFD asering 1500cc/24 ja
-inj ranitidin 2x50 mg IV
-inj piracetam 4x3 g
-inj ceftriaxone 2x1 g
Santagesic 3x1 amp
c/ Sp.BS
c/ Sp.B-KL
Education
Explaine to the family about the disease of the
family, about its theraphy and intervention will be
done, and about complication and prognosis .

Take a planty of rest

Laboratory Findings
Diff count 3/0/77/15/5
Hematocrit 41,1%
Haemoglobin 13,7 mg/dL
Leukocyte 20.300
Trombocyte 339.000
GDA 121
BT 100
CT 700


Xray skull AP/lateral

Head CT scan
Final assesment
CKR
Close fracture zigoma S

Prognosis
Dubia ad bonam