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IDENTITY
C
BP = 100/60mmHg, HR = 75 x/min, regular, strong, CRT
< 2 minutes
D
GCS 7 (E2M5V1), pupil : Isokor : 2 mm/ 2mm,
E
T = 37,00C (axillary)
HISTORY TAKING
(ALLOANAMNESIS)
Chief complain :
• Patient with traffic accident
•Anamnesis :
the patient was admitted to the hospital with facial and head injuries. The incident
occurred at 00.00 p.m. shortly after the accident the patient was unconscious then the
patient regained consciousness. The patient also complained of headache and one of his
incisors was pulled out.
Mechanism of trauma : The patient rides his own motorcycle without using helmet at an unknown
speed. The accident occurred at 00.00 p.m. while driving, the patient crashed into a speed limiting
device and then fell. The left side of the patient body and face is exposed to a pile of stones.
History of trauma :
History of previous treatment: at Konawe hospital and was given IVFD, analgesic, proton pump inhibitor,
diuretic,antibiotic, neuroprotector.
GENERAL STATE (AT 04:00 PM)
Inspection :
Frontal Region : Wound (exist) Vulnus Ekskoriatum (exist)
Orbita Region : Swelling (exist), haematome (exist) wound (exist) vulnus
ekskoriatum (exist)
Zygomatica Region : Swelling (exist), wound (exist) vulnus ekskoriatum(exisit)
Buccal Region : Swelling (exist), wound (exist) vulnus ekskoriatum (exist)
Mentalis region : Swelling (exist), wound (exist) vulnus ekskoriatum (exist)
Neck Region
Inspection
Trigonum Caroticum Region : Wound (exist) vulnus ekskoriatum (exist)
Cervicalis Posterior Region : Wound(exist) vulnus ekskoriatum (exist)
LOCALIZE STATE
Palpation :
• Tenderness (+)
• Step Off :
Rima orbitalis superior (normal)
Rima orbitalis inferior (normal)
Frontonasalis (normal)
Frontozygoma (normal)
Zygomaticum (normal)
Maxilla (normal)
Mandible (normal)
Unstable maxilla (normal)
Unstable mandible (normal)
Intra oral : malocclusion (not exist), avulsion (exist), active bleeding (not
exist)
CLINICAL FINDING
Plan of Diagnostic
CT-SCAN SKULL
X-RAY SOULDER
CT-SCAN SKULL
X-RAY SHOULDER
DIAGNOSIS
Non-Pharmacology Pharmacology
IVFD
Rest
O2
Immobilisation
Antipiretic Injection
Wound Care Analgetic Injection
Education Antibiotic Injection
Antifibrinolitic Injection
Vitamin
Consult Surgeon
THANK YOU
GENERAL SURGERY
DEPARTMENT