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