ER Trauma 190915 Cecep 190915 Final Leidya
-
Upload
dwi-sastrawan -
Category
Documents
-
view
223 -
download
2
description
Transcript of ER Trauma 190915 Cecep 190915 Final Leidya
Emergency Report
Saturday, September 19th 2015
Name : Cecep Andrian
Sex : MaleAge : 25 y.oAddress : Kp. Cibodas, Kabupaten Bandung
Religion : MoslemStatus : Not MarriedMedical Rec No. : 0001480088
Time of admission : 9.30 PM
Referred from Majalaya Hospital
PS: Bleeding From Mouth
S: A 25 y.o male patient referred from Majalaya Hospital with bleeding from mouth. ± 4 hours prior to admission, when the patient was riding a motorcycle in medium speed under alcohol influenced at Majalaya area, suddenly the patient lost his balance then hit a tree and fell down with mechanism his mouth hit the asphalt first. History using helmet (+) half face, history of unconciousness (-), nausea and vomiting(-), bleeding from mouth (+), bleeding from ear and nose (-). The patient was taken to Majalaya Hospital but no treatment was received. Then the patient was referred to Hasan Sadikin Hospital Emergency Department.
O : Primary Survey
A: ClearB: Symmetrical shape and movement , VBS right=left, RR= 20x/minutes, Ronkhi -/-, Wheezing -/- C: BP = 120/80mmHg, Pulse= 76 x/minutesD: GCS 15 (E4M6V5), pupil : round equal ODS ϕ 3mm, Light reflex +/+, Parese-/-,
Secondary Survey : Within normal limit
General status :
• Skin : Turgor (+)• Head : Symmetrical face
Eyes : non anemic conjunctiva, non icteric sclera• Neck : JVP not increased
Submandible lymph nodes : not palpable, no pain
• Thorax : Symmetrical shape and movement Pulmo : VBS right=left, Rh -/-, Wh-/-
Cor : Regular pure heart sounds• Abdomen : Soft, flat, bowel sound (+) N Hepatic & Lien : not palpable • Extremity : Warm, cyanosis -/-, oedema -/-, CRT < 2”
Local status :
Extra Oral : • Symmetrical face
Intra Oral :
• Lips : Oedem at upper and lower lips, punctured wound at upper lip, with 2x1 cm in size irregular edge
Punctured wound at lower lip with 2x2 cm in size and 3x2 cm in size irregular edge
• Gingiva : Lacerated wound at gingiva of teeth 12-22 with 2x0,5x1 cm in size irregular edge, bone based
Lacerated wound at gingiva of teeth 32-42 with 2x0,5x1 cm in size irregular edge, bone based
• Vestibule : Within Normal limit• Tongue : Within normal limit• Floor of the mouth : Within normal limit• Buccal mucosa : Within normal limit• Palate : within normal limit• Tonsils : T1-T1
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Odontogram
Open Bite anterior (+)
#
# segmented dentoalveolar
avulsion avulsion
XVV
Mob °3Mob °3
Laboratory finding :• PT : 9.9
(9-13) second• INR : 0.92 (0,84-
1,16) second• APTT : 23.1 (14.6-34.6)
second• Hb : 15.8 (13.5-
17.5) g/dL• Ht : 45
(35- 45) %• WBC : 10900 (4400-11300)
/mm3
• RBC : 5.35 (4.5-6.5) /uL
• Platelet : 193.000 (150.000-450.000)/mm3
• AST (SGOT) : 15 (U/L <37 C) <37
• ALT (SGPT) : 9 ( U/L <37 C) <41
• Ureum : 24 (15-50) mg/dL
• Creatinine : 0.78 (M: 0.7-1.2 )mg/dL
• Random blood glucose : 110 (<140) mg/dL
• Alfa Amilase : 92 26-100U/L 37oC
• Lipase : 20.2 13-60U/L 37oC
• Sodium (Na) : 134 (135-145) mEg/L
• Potassium (K) : 3.5 (3.6- 5.5) mEg/L
Chest X-Ray
Impression :• No visible of traumatic wet lung or lung contusion• No visible of fracture on the costae, scapulae, clavicle• No visible of cardiomegaly
Skull PA-Lateral X-Ray
Impression :
Segmented Dentoalveolar fracture of teeth 32-42
#
Cervical X-Ray
Impression :
Within normal limit
FAST USG
Impression :• No sign of fluid collection at hepatorenal space• No sign of fluid collection at splenorenal space• No sign of fluid collection at vesikaurinaria space
Neurosurgery Department StatusA:
Mild HI + Alcohol Intoxication
Suggestion
• Complete Blood count, PT-APTT
• Observation of GCS
• Head up 30°
• IVFD NaCl 0,9% 2000 cc/day
• R/ Ceftriaxone inj 1 gram IV
Ranitidine inj 50 mg IV
Ketorolac inj 30 mg IV
• O2 2 litre/minute via nasal canul
• Thorax, Schedel AP-Lateral, cervical X-Ray
Respectfully
dr. MZ Arifin , Sp.BS
General Surgery Department Status
A:• Mild HI + Alcohol Intoxication• Fracture dentoalveolar of teeth 12-22 with avulsion of teeth 11, 21,
mobility grade 3 of teeth 12, 22 + Fracture of segmented dentoalveolar of teeth 32-42
• Punctured wounds at upper and lower lip • Lacerated wounds at gingiva of teeth 12-22 and gingiva of teeth 32-42
There is no sign of abnormalities on thorax and abdomen, no special treatment from our department
Thank you
dr. Bobby Eko /dr. Irene
A:• Mild HI + Alcohol Intoxication• Fracture dentoalveolar of teeth 12-22 with avulsion of
teeth 11, 21, mobility grade 3 of teeth 12, 22 + Fracture of segmented dentoalveolar of teeth 32-42
• Punctured wounds at upper and lower lip • Lacerated wounds at gingiva of teeth 12-22 and gingiva
of teeth 32-42
P : Treatment :• Injection of ATS and TT • Necrotomy debridement • Alveolectomy of alveolar bone at teeth region 11-21• Suturing at lacerated wounds IO• Interdental wiring at upper jaw (14-24) and lower jaw (35-45)
Suggestions :• Plan to perform Panoramic X-Ray• Oral Hygiene instruction• Soft diet • R/ Cefadroxil caps 2x500 mg PO
Ibuprofen tab 3x400 mg PO
Ranitidine tab 2x150 mg PO• Mouth rinse with Povidone iodine gargle after every meal• Application of Hyaluronic acid gel at post suturing IO• Application of chloramphenicol zalf at post suturing EO• Control to OMFS on Monday September 21th 2015 on office hours• Suture removal at POD VII (September 26th 2015)• Plan to perform selective grinding of teeth 42 at OMFS dept. on office hours• Plan to perform tooth extraction of teeth 46,47 at OMFS dept. on office hours• Another therapy according our fellow Neurosurgery dept.
Discharged
Nurul drg./ Prof.Dr.Harmas Yazid Yusuf,drg.,SpBM
Post Debridement
Post Treatment