Post on 02-Jun-2018
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IGD, 23th March 2014Departement of SURGERY
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Identity Name : Mr. M
Age : YO
Sex : male
Address : Lamongan
Admission : 06th April 2014 20.30 am
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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 ofvomit (-) , fainting (-), PTA ().
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History or past illness :
daniel
History of sociality:- Smoke
- Alcohol -
- Herbal Medicine-
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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%
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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 +/+)
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Exposure :
T : 36,6C
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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,
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Localist statusVulnus laceratum suprasiliaris sinistra 4x1cm,
vulnus abrasio nasal,vulnus abrasio manus
dextra, vulnus abrasio pedis dextra, vulnus
laceratum 1x1
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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+
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- CKR- Susp fracture close
zigoma
assesment
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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
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Education
Explaine to the family about the disease of thefamily, about its theraphy and intervention will be
done, and about complication and prognosis .
Take a planty of rest
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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
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Xray skull AP/lateral
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Head CT scan
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Final assesment
CKR
Close fracture zigoma S
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Prognosis
Dubia ad bonam