MORNING REPORT

IDENTITY
Name : Mr.F
Age : 20 years old
Sex : Male
Address : Kendari
Admission : Desember, 10th 2017
Doctor in charge : dr. Saktrio Darmono, Sp. BP-RE
 HISTORY TAKING
 Main complain :
Face pain
 Anamnesis :

The patient referred from Poasia Primary Health Care with face pain since about 5 hours before
admitted to Hospital due to traffic accident
Mecanism of trauma :
 He was a biker with medium speed, patient did not use helmet. Suddenly another biker from ahead
crashed patient so that patient fell
 History of bleeding from the mouth (-), ear (-), and nose (+)

 History loss of consciousness (-), nausea (-) and vomiting (-).There was no history of consumtion of
drugs and alcohol
 There was history of therapy
 PHYSICAL EXAMINATION
Primary Survey
A: Clear, no obstruction.
B: RR : 20x/mnt, spontaneous, symmetric, and
thoraco abdominal type.
C: BP : 110/80 mmHg, Pulse : 86 x/mnt, adequate, regular.
D: GCS 15 (E4M6V5),
E: T : 36,6ºC
GENERAL STATE
Normally
Normally
Normally
Normally
Normally
Normally
Normally
LOCATION STATE (FACE)
Look : Deformity (+), Swelling (+), Hematom (+) at orbitalis
region
Vulnus appertum post hecting at frontalis region with
size 6 cm and at left mandibula with size 2 cm
 Feel : tenderness (+)
 Rima orbitalis superior : Step off (-)
 Rima orbitalis Inferior : Step off (-)
 Frontonasalis : Step off (-)
 Frontozygomaticum : Step off (+)
 Unstable maxilla : (+)
 Unstable mandibula : (-) :
CLINICAL FINDING
PLAN OF DIAGNOSIS

Blood Routine
X-RaySkull
CT Scan 3 D
 DIAGNOSIS
Maxillofacial Trauma + Susp.Fracture Lefort I-II
 MANAGEMENT
IVFD
Antibiotics
Analgetics
H2 reseptor antagonis

Consult to Plastic surgery

 Thank You

BAGIAN ILMU
Elsa
BEDAH