Santi Fr Zigoma

8/10/2019 Santi Fr Zigoma

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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 ().


4/19

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%


6/19

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 +/+)


7/19

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+


12/19

- CKR- Susp fracture close

zigoma

assesment


13/19

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


16/19

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

Santi Fr Zigoma

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