CASUALTY REPORT

Day/date: Wednesday/ March 15th 2017

Doctors on duty: Arum, MD / Razki, MD/ Yoni,
MD- Dita, MD / Ucha, MD-Lutfi. MD

Consultant on duty:
Fauziah Fardizza, MD, ORL-HNS, PhD
IDENTITY

Male, 23 years old

Chief complaint

Patient was consulted from

Neurology department with post
bleeding from both nostrils after
traffic accident
 Medical History (1)

Patient was consulted from Neurology department with post

bleeding +/- 10-15 ml from both nostrils after traffic accident 6
hours prior admission. Patient was riding motorcycle with non
face full-covered helmet. Patient was felt down and face was hit
the road.
There was pain on forehead, nose and cheek area (VAS 5)
since 6 hours prior to admission.
There was history of nasal drip 6 hours prior to admission but
currently this symptoms disappeared.
There were no history of lost consciousness.
 Medical History (2)

There were no symptoms of nasal congestion since the

accident until now. There were history of smell disorder,
nauseous and vomiting.
Patient has history of nose implant surgery with plastic surgeon
at 2014
Other ear, nose and throat symptoms was denied
Patient was treated by Neurology and Plastic surgeon and
scheduled for ORIF
Physical Examination
General condition: There was no dyspnea,
slightly ill. no stridor and no
conciouss retraction

Vital sign:
BP : 110/70 mmHg
RR : 16x/min
T : 36,6
HR : 88x/minO2
Sat : 99%
ENT Examination

Ear Right Ear :Wide ear canal, no discharge nor ear wax, intact
tympanic membrane
Left Ear : Wide ear canal, no discharge nor ear wax, intact
tympanic membrane

Nose Right nostril: narrow nasal cavity, inferior turbinate

eutrophy, no discharge, clotting+ deviated septum+, good air
passage
Left nostril: narrow nasal cavity, inferior turbinate edema,
no discharge, clotting+, deviated septum-, good air passage
Throat Pharyngeal arch was symmetric, not hyperemic, uvula in the
middle, tonsil T1-T1 not hyperemic, posterior pharyngeal wall
no clotting
 Localized Status

Frontal region
There were laceration and
edema, there were no
crepitation, hematoma nor
deformity
Right & Left orbital region
There were no laceration nor
excoriation.
There were no hematoma,
edema, crepitation nor
deformity
Intercantal distance 1,5-1,7
cm
 Localized Status

Nasal region
There was edema,
deformity
There was laceration,
excoriation,
hematoma, deformity,
crepitation
Localized Status
 Localized Status
Zygomatic region: there
was no ekscoriatio,
hematom, laseration.
There was edema,
deformitas. Crepitaion
difficult to evaluated. There
was no malar depressed
Maxillary region: there was
no ekscoriatio, hematom,
laseration. There was
edema, deformitas.
Crepitaion difficult to
evaluated. There was
floating maksilla
 Localized Status
Zygoma region
There was no laceration, no
excoriation, no Crepitation, Mandible region
no edema, nor malar There was no
depress laceration, no
Right and Left Maxilla Region: excoriation, no
There was no laceration, no crepitation, no edema,
excoriation, no crepitation, nor malocclusion
no edema, nor floating
maxilla
Schedel Xray
(RSCM. March 15th 2017)

Expertise:
Internal fixation at
mandible was in good
position
Fracture line was seen at
right parasymphisis
mandible
There were no others
fracture visualized
Facial and cerebral CT Scan.
RSCM. March 15th 2017
Facial and cerebral CT Scan.
RSCM. March 15th 2017
Facial and cerebral CT Scan.
RSCM. March 15th 2017

Conclusion:
-Multiple facial fracture involving anterior-posterior
wall of left and right frontal sinuses, medial and
inferior wall of right orbita, nasal bone, anterior wall
right and left maxilla medial and right sphenoid wing
-Panhematosinus
-Pneumoencephalus at left frontal regio,
subcutaneous emphysema at bilateral periorbita and
mid nasal
-Internal Fixation (plate and screw) at right
symphysis-corpus mandible and left angulus
mandible
Working Diagnosis

Post epistaxis at bilateal nasal

cavity(S.02.2)
Multiple facial fracture
(S02.70)
 Management

Currently
there was no specific treatment from ENT
department
Multiple fracture management based on Plastic
surgeon
Thank You