Morning Report

ISMAYUNI SUMIRA 0908120524

Anamnesis
Patient Identity Male, 29 years old, came to AA Hospital on June 8th 2013 Chief Complain Pain around nose, cheeks and lip since 4 hours before admitted to the hospital.

Recent illness History

Patient described a continous and pulsating pain. There was bulging around the eyes, cheeks and lip. There was scratched on the lip. Patients complained difficulty on opening the mouth widely.

Recent Illness History

4 hours before admitted to the hospital, patient got an accident. Patient ride motorcycle with the speed was 40 km/hour and used helmet. The motor cycle crashed from the left side by a car. Patient fell to the right side and the face hit the trotoar. There was no blackout, headache, nauseous and vomit. Bleeding only came out from nose. No teeth detached.

Recent Illness History

The patient then brought up to IS Hospital and got initial treatment before the patient sent to AA General Hospital.

Past Illness History

No history of trauma before

Family Illness History

No family Illness relate with recent patients symptom

Physical Examination
General condition : Mild illness Awareness : Alert Vital sign:
BP HR RR = 120/80 mmHg = 84 x/minute = 20 x/minute

T = 36,8 C

Head and neck : Localized status Thorax : Normal Abdomen : Normal Extremity : Normal

Locallized status (Head and Neck )

Maxillofascial status : Inspection : Periorbital edema left and right Subconjunctiva bleeding (+) on left ocular Conjunctiva not anemis (-) Edema on cheeks Deformity on nose Vulnus excoriatum around lip Diplopia (-)

Locallized status
Palpation : 1. Rima superior orbita D and S : Crepitation (-), discontinuitas (-), tenderness (+) 2. Rima lateral orbita D and S : Crepitation (-), discontinuitas (-), tenderness (+) 3. Rima inferior orbita D and S : Crepitation (-), discontinuitas (-), tenderness (+)

Locallized status
4. Os nasale : Crepitation (-), discontinuitas (-), tenderness (+) 5. Os zygoma D and S: Syimmetric malar imminent D and S (+) Tenderness (+) on zygomaticum S 6. Os maxilla D and S: Crepitation (-), discontinuitas (-), tenderness (+) 7. Margo inferior mandibula D and S : Crepitation (-), discontinuitas (-), tenderness (-)

Locallized status
8. Temporomandibula joint (TMJ) Deformity (-), tenderness (-) when patient open and close the mouth - Intraoral : Laceration mucosa (-), stepping (-), gapping (-), malocclusion (+), floating maxilla (-), trismus (+)

Working diagnosis
nasale bone fracture + left and right maxilla bone fracture + left zygoma bone fracture

Suggestive Examination
Head CT Scan 3D Head X-Ray AP Lateral X-Ray Waters

Head CT Scan 3D

Head Bone Scan

Diagnosis
nasale bone fracture + left and right maxilla bone fracture + left zygoma bone fracture + left corpus mandibular bone fracture

Treatment
IVFD Ringer Lactat 20 gtt/min Ketorolac injection 2x30 mg Ceftriaxone injection 2x1 gr Oral Hygiene Liquid Diets Operation => ORIF

Follow Up
June 10th 2013 S : Pain around nose, cheeks and lip O: General condition : mild illness Counsiousness : Composmentis Vital sign BP = 120/80 mmHg HR = 82 x/minute

ocular sinistra, edema on cheeks, deformity on nose, vulnus excoriatum around lip, maloclution Palpation : tenderness (+) A :

RR =18 x/minute T = 36,8 C

Locallized status : Head an neck Inspection : Edema periorbital, subconjungtiva bleeding on

nasale bone fracture + left and right maxilla bone fracture + left zygoma bone fracture + left corpus mandibular bone fracture

P : Continous therapy

Follow Up
June 11th 2013

: Pain around nose, cheeks and lip

O: General condition : mild illness Counsiousness : Composmentis Vital sign BP = 120/80 mmHg HR = 82 x/minute

ocular sinistra, deformity on nose, vulnus excoriatum around lip, maloclution Palpation : tenderness (+) A :

RR = 18 x/minute T = 36,8 C

Locallized status : Head an neck Inspection : Edema periorbital, subconjungtiva bleeding on

nasale bone fracture + left and right maxilla bone fracture + left zygoma bone fracture + left corpus mandibular bone fracture
P : Continous therapy

Follow Up
June 12th 2013
S : Pain around nose, cheeks and lip O: General condition : mild illness Counsiousness : Composmentis Vital sign BP = 120/80 mmHg HR = 82 x/minute

ocular sinistra, deformity on nose, vulnus excoriatum around lip, maloclution Palpation : tenderness (+) A :

RR = 18 x/minute T = 36,8 C

Locallized status : Head an neck Inspection : Edema periorbital, subconjungtiva bleeding on

nasale bone fracture + left and right maxilla bone fracture + left zygoma bone fracture + left corpus mandibular bone fracture
P : Continous therapy

Follow Up
June 13th 2013 S : Pain around nose, cheeks and lip O: General condition : mild illness Counsiousness : Composmentis Vital sign BP = 120/80 mmHg HR = 80 x/minute

ocular sinistra, deformity on nose, vulnus excoriatum around lip, maloclution Palpation : tenderness (+) A :

RR = 20 x/minute T = 36,5 C

nasale bone fracture + left and right maxilla bone fracture + left zygoma bone fracture + left corpus mandibular bone fracture
P : Continous therapy

Locallized status : Head an neck Inspection : Edema periorbital, subconjungtiva bleeding on

Thank You