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IDENTITY

Name : Mr. H
Age : 28 years old
Address : Moramo, Tanjung tiram
Admission : february, 24rd 2018
Doctor in Charge : dr. Saktrio Darmono S, Sp.BE-RE
HISTORY TAKING
 Main complaint : Pain on the face
Anamnesis : (autoanamnesis)
 Patient referred from primary healt care abeli with pain on right side of his face caused by hit by iron wire.
Mechanism of Trauma :
Patient helping a car that stuck in a mud by tied the iron wire to pull it out. When he pulled the wire, it
accidentally cut off and hit the right side of his face
History :
 There was no history of syncope (-), nausea (-), vomit (-)
 There was no history of blood ear (-), Nose (-), mouth (-)
 There was no history of drugs and alcohol consumption
 There was no history of medicine
PRIMARY SURVEY

A : Clear
B : RR 20 x/m, simetris, spontaneous, thoracoabdominal type
C : BP 120/70 mmHg, HR 86 x/min, regular, strong lift, CRT <
2 second
D : GCS 15 (E4 M6 V5)
E : T 36,7˚C Axillar
GENERAL STATE
Head : Within normal limits .
Eyes : Localizated state
Nose : Within normal limits
Mouth : Within normal limits
Ears : Within normal limits
Neck : Within normal limits
Chest : within normal limits
Abdomen : Within normal limits
Upper limb : Within normal limits
Left lower limb : Within normal limits
LOCALIZED STATE

ORBITALIS REGION DEXTRA :


I : Deformity (+), swelling (+), hematoma (-), laceratum wound (+) Orbital region size
4,1 x 0,2 x 0,3 cm,
P : Tenderness (+) nasal region,

ORBITALIS REGION SINISTRA :


I : Deformity (+), swelling (+), hematoma (-), Escoriatuwound (+) Orbital region size
0,4 x 0,2 cm,
P : Tenderness (+) nasal region

- there was no step off of at rima orbita superior and inferior region,
- frontozigomaticum region. There was step off of fronto nasal region.
- Maxila and Mandibula region was stable.
- There was no trismus and maloklusi
CLINICAL FINDINGS
CLINICAL FINDINGS
PLANNING

Plain photo skull AP/Lat


Routine Blood Test
Hemostatis Factors Test
LABORATORY FINDINGS

PARAMETE
RESULT
ROUTINE BLOOD TEST R
February 24th 2018 WBC 7,84 x 103/uL
HB 12,8 g/dL
PLT 231 x 103/Ul
RBC 4,71 X 106/uL
RADIOLOGY FINDINGS

Plain photo
skull AP/Lat
RADIOLOGY FINDINGS

Plain photo
skull AP/Lat
DIAGNOSE

Fracture Os Nasal and Laceratum


Wound at right orbitalis Region
MANAGEMENT
Non- Farmacology
Farmacology :
Wound care
IVFD
Rest
Analgetic
H2R Antagonis
Consult to Plastic
Surgeon
TERIMA
KASIH