MORNING REPORT

MANDIBLE FRACTURE

Nurmuthmainnah
0908120468
Level of competence : 3B
Dignose, early therapy, reffering

History taking

Identity
Name : Tn. F
Age : 16 yo
Admitted to the hospital on : Dec 17th
2013

Chief complaint
the patient couldnt chew food since got
accident 1 days before admitted to the
hospital

Primary Survey

Airway and cervical control

Objective:

a.

Patient could answer questions but he spoke unfluently

when asked because he was difficult to open his mouth.
There was no additional breath sounds (gurgling, snoring,
stidor).

b. Assessment:

No airways obstruction (by solids, liquids)

Patent airway

c. Action:

Oxygen 3L/m with nasal cannul NRM 10L/m

Neck collar should be applied to the patient, but it wasnt
do in emergency unit

Breathing
a. Objective

No lesion or wound on chest wall, symmetrical

chest wall movement, frequency of breathing 22 tpm
regularly.

b. Assessment

Ventilation and lung expansion were good.

c. Action

Oxygen 3L/m with nasal cannul NRM 10

L/m

Circulation
a. Objective

Warm acral, capillary refill time (CRT) <2 s.

Pulse was palpable, 82 tpm regularly
blood pressure was 120/70 mmHg

b. Assessment

Circulation was good

c. Action

IVFD RL (NaCl?) 20 dpm

Disability
a. Objective

b. Assessment

Patient awake
Glasglow coma scale (GCS):

Mini neurologic
test : good

Eyes:

opened spontanously (E4)

Verbal: oriented (V5)
Motorik: could follow instruction (M6)

GCS 15 (E4V5M6)
Pupil isochor 2 mm/2 mm, light reflex (+/+)

Motorics

5
5

Hemyparesis (-)

Exposure
. Temperature was C
Patients clothes should be opened then
covered
. There was excoriation wound on left
eyelid, left cheeck, left mandible, right
elbow.

Secondary Survey

1 day before admitted to the hospital, the patient

got accident when ride motorcycle (without

helmet), Suddenly, he was crushed by another

motorcycle from right side. Then, his
motorcycle fell down to the left. There was
excoriation wound on left eyelid and left cheek,
left mandible and right elbow. His mandible felt
pain. He was conscious and there was no
nauseous, vomit, headache, blood from ear,
and nose. Beside pain, he difficult to open his
mouth, he felt like his mandible was drawn
down. Then, he was brought to RSUD AA.

Past illness history

No disease-related to this complaint.

Family illness history

-

Physical examination

General condition : mild illness

Conciousness : composmentis
Vital signs :

Blood pressure : 120/70 mmHg

Pulse : 82 tpm
RR : 22 tpm
T : 36,3C

Head and neck

Head : excoriation wound in right cheek

Mandible

region : localized status

Neck : normal

Chest
: Normal
Abdomen
: Normal
Ekstremities
: excoriation wound in right
elbow
Limf nodes : Normal
Gentourinarius
: Normal

Head
Mandible region :

Look :
Excoriation wound on
left mandible
Asimmetrycal
mandible
There was space
between maxillary
teeth and mandible
teeth when patient
asked to tighten the
teeth couldnt
tighten the teeth.
Step off (-)

Feel
Tenderness (+) on right and left mandible
Crepitation (-)
Sensibility of lower lip (-)

Move:
Patient can open his mouth but restricted
because of pain, distance between upper lip
to lower lip :
Patient difficult to chew food

Working diagnose
fracture mandible bones + some
excoriation wounds on left eyelid, left
cheek and right elbow

Suggestion Examination
- Head CT Scan 3D

Head
CT scan
3D

Final diagnose
fracture at the body and angle of
mandible bone
Baca lagi regio mandibula, diagnosis
akhir sesuai dengan regio
mandibula, bukan nama tulangnya

therapy

excoriation wound cleaned

povidon iodine
Maloclution Fixation with
interdental wire, or
Reposition and open fixation

Thank you