IGD, 23th of

March
2014
Departement
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 :
KL:
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+

assesment
- CKR
- Susp fracture close
zigoma

 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