A/M/13 yo

73.12.94
Chief complaint : Difficult to open mouth

It has been suffered by the patient since 6 hours

before admitted to the Adam Malik Hospital.
Initially the patient was fell from coconut tree
estimated about 5 meter height with head met
the ground first.
Shortness of breath, seizure, vomiting, and neck
pain (-). History of unconsciousness (-). Patient
was reffered from district hospital.
 PRIMARY SURVEY
• A : Clear, C-Spine Control
• B : Spontaneous, RR : 18x/i
• C : Warm acral, HR : 84x/I BP : 120/80 mmHg
• D : GCS 15 (E4M6V5)
• E : Logroll and undressed →bruise (-)
• VAS 6
 Secondary survey

Head : In localized state

Neck : No abnormalities was found
Chest : In localized state
Abdomen : No abnormalities was found
Extremity : No abnormalities was found
 Secondary Survey
Head : Eyes pupil isocor Ø 3mm/3mm, Light reflex (+)
Asymetric, Floating maxilla (-), maloclussion (+), swelling o/t (R)
maxilla, lacerated wound o/t chin size 2x1x1cm, subcutis based,
bleeding (-), moderate contamination.
• Chest : Symmetrical, bruise (+),
Vesicular on both hemithorax
Laboratory findings :

• Hb / Hct / WBC / PLT : 10.2 / 30.8 / 19790 / 351

Working Diagnosis :
HI GCS 15 + Segmental mandible fracture
Treatment at the ER :
• IVFD Crystalloid
• Inj. Antibiotic
• Inj. Analgetic
• Inj TT
• Inj ATS
• Barton’s Bandage
• Oral hygiene
• Plan :
– CT Scan 3D Midface
– ORIF Elective