Day/ date: Sunday Morning / Dec 18th 2016

Doctors on duty: Arfiza, MD / Robert, MD / Dewi, MD/ Ayi, MD -

Iman, MD/ Tara, MD

Consultant on duty:

Harim Priyono, MD, ORL-HNS

Plastic Reconstruction Division Consultant on Duty

Dini Widiarni W., MD, ORL-HNS, PhD

Casualty Report

Identity

Male, 38 years old

Consult from Neurology Department with

suspected Os Tympanic fracture and Otalgia

Medical History • History of fell off from the house roof with a height of

approximately 4 meters.• He was unconscious and didn’t remember the

mechanism of how he fell. • He had clear watery discharge from his right ear around

2 table spoon and stopped spontaneously. History of ears discharge before the accident was denied. There was pain on the right ear (VAS 3-4)

• There was blood mix with stickie mucus discharge from his nose about 1 table spoon and stopped spontaneously. History of nasal congestion, decrease of smelling, and epistaxis before the accident were denied.

• There was no difficulty in opening his mouth.• There was no discharge from mouth, no dyspnea

• There was no history of runny nose, and sneezing. • There was no pain when swallowing, difficulty

swallowing, and chocking

General condition: moderately ill Compos Mentis Dyspnoe (-) Stridor (-) inspiration and retraction (-). BP : 110/70mmHg RR: 20x/min T : 36,5 HR: 88 x/min O2 Sat : 99%

Medical History

Physical Examination

General condition: moderately ill

There was dyspnea, no stridor and no retraction

Vital sign:• BP : 110/70mmH• RR : 20x/min • T : 36,5 • HR : 88 x/min• O2 Sat : 99%

ENT Examination

• Right ear:• wide ear canal, there was laseration on one

third posterior of the ear canal at quarter right area with central perforation of the tympanic membrane with uneven borderline

• Left ear:• wide ear canal, no discharge, no cerumen,

intact tympanic membrane

Ear

ENT Examination

•Right nostril: wide nasal cavity, inferior turbinate hypertrophy, there were clotting, there were no discharge nor active bleeding•Left nostril: wide nasal cavity, inferior turbinate hypertrophy, no secretion, right deviated septum

Nose

• Pharyngeal arch was symmetric, not hyperemic, uvula in the middle, tonsil T1-T1 not hyperemic, posterior pharyngeal wall not hyperemic, wide oropharyngeal space

Throat

ENT Examination

HALO TES : Negative

• Tuning Fork Test :• Rinne Test :

• Right ear : Negative• Left ear : Positive

• Weber Test : Lateralisation to the right ear

Local Examination

Frontal region: lacerations -, excoriation -, hematoma -, edema -, deformity -, crepitation –

Right Orbital region : excoriation -, hematome + at right inferior palpebarae, edema -, deformity -, crepitation - intercanthal distance 1,5 cm -1,5 cm

Left Orbital region: laceration -, excoriation -, hematome -, edema -, deformity -, crepitation -, intercanthal distance 1,5 cm -1,5 cm

Nasal region: laceration -, excoriation -, hematome -, edema -, crepitation -, deformity -,

Local Examination

Left Zygomatic region: laceration -, excoriation -, hematome -, edema -, deformity -, crepitation -, malar depression –

Right Zygomatic region: laceration -, excoriation -, hematome -, edema +, deformity +, crepitation +, malar depression -

Right Maxillary region: laceration 2 x 1 cm, excoriation -, hematoma -, edema +, deformity -, crepitation - , floating maxilla -

Left Maxillary region: laceration -, excoriation -, hematome -, edema -, deformity -, crepitation -, floating maxilla -

Mandible region: laceration -, excoriation -, hematoma -, edema -, deformity -, crepitation -, malocclusion -

ENT Examination

Working Diagnosis

Multiple fracture of facial bones (S02.92)

Post bloody discharge from the right ear (388.69)

Laseration of the right ear (S01.311A)

Management

Reported to Dini Widiarni, MD, ORL-HN, PhD:

1. Plastic reconstruction division of ENT Department will follow up

2. Suggestion: 3D CT Scan of the facial bones and CT scan of mastoid without contrast

3. Avamys nasal spray 2x2 puff4. Dexamethasone 3 x 5 mg po5. Kemicetin applied on the right ear canal

CT Scan of the MastoidOctober 18th 2016

CT Scan of the MastoidOctober 18th 2016

CT Scan of the MastoidOctober 18th 2016

- Right os temporal fracture- Multiple fracture of the Anterior et lateral wall of the right maxilla- Multiple fracture of the anterior wall of the external acustic canal with postero-

inferior dislocation of the fracture fragment- Suspected of maleo-incudo junction dislocation dd/ fracture- Konsolodation on the external acustic canal and tympanic cavity of the right

ear dd/ Bleeding, fluid collection- Hematosinus of the right maxilla and right ethmoid- Minimal thickening of the mucosa of the left maxilla sinus

Chest X-Ray ExaminationOctober 18th 2016

- Lung and Heart within normal limit

- No Fracture at costae

Cervical X-Ray ExaminationOctober 18th 2016

- Straight cervical- Osteophyt on the

anterior C5 apex- No fracture at

cervical vertebrae

CT Scan of the brain October 18th 2016

CT Scan of the brain October 18th 2016

-Right zygomaticus fracture, infero-latero-antero wall fracture of the right orbita, comminutive fracture at the postero-latero-inferior right maxilla sinus wall, right maxilla lateral wall and tympanic part of the right temporal

-Bilateral haematosinus especially at the right ethmoid

-Bleeding at the right external acoustic canal -No subdural/ epidural/ subarachnoid bleeding and intra parenchimal cerebri / cerebelli

-Soft tissue swelling at the right face region

(October 18th , 2016 06.00 AM)Neurology Department

S : Adequate contact. There was pain on the right ear

O : BP : 110/70 HR : 70x/minRR : 18 x/min T : 36.6O2 saturation: 98% Eyes: normal shape and size of the pupil Cranial nerve : No sign of Paresis Motoric: 55555 I 55555Sensory: within normal limitAutonomy: within normal limit

A : - Comossio cerebri - Os Tympanic fracture- Multiple fracture of facial bone- Elevation of liver function test

P:-Consult to Plastic Surgery department -Consult to ENT-HNS department -IVFD NaCL 0,9 % 500 cc / 12 hours -Ketorolac 3 x 30mg -Ranitidine 2 x 50 mg -Extrace 1 x 400 mg

(October 18th , 2016 09.15 AM)Plastic Surgery Department

S : Right facial swollen since 22 Hours before admission, there was history of fell off from the house roof with unknown mechanism of how he fell. There was history of unconsiousness after the accident, there was history of ear and nose discharge,

O :A: clear, C spine under controledB: Spontaneous breathing (20 x/minutes) C: TD 110/70 mmHg, HR : 88 x/ minutesD: GCS 15

A : - Right zygoma bone fracture- Comossio Cerebri

P:-Hospitalized by the Plastic Surgery department-Plan for elective ORIF -Ceftriaxon 2 x 1 gr IV -ketorolac 3 x 30mg stopped and changed into oral form : Mefinal 3 x 500 mg po

(October 18th , 2016 16.15 PM)Neurology Department

S : Adequate contact.

O : BP : 110/70 HR : 76x/minRR : 20 x/min T : 37O2 saturation: 98% Eyes: normal shape and size of the pupil Cranial nerve : No sign of Paresis Motoric: 55555 I 55555Sensory: within normal limitAutonomy: within normal limit

A : - Commosio cerebri - Right Os Tympanic fracture- Multiple fracture of facial bone- Elevation of liver function test

P:-Round with Tirza A, Neurologist, PhD: There was no indication for hospitalizing the patient in neurology department. If ENT-HNS department or Plastic Surgery department will hospitalize the patient, ENT-HNS / Plastic surgery department can take over as a captain and neuro-trauma division will follow up-17.15 PM Plastic surgery department as a captain

(October 19th , 2016 16.15 PM)Neuro-trauma division

S : Adequate contact.

O : BP : 130/80 HR : 78x/minRR : 18 x/min T : 36.7O2 saturation: 99% Eyes: normal shape and size of the pupil (3mm/3mm)Cranial nerve : No sign of Paresis Motoric: 55555 I 55555Sensory: within normal limitAutonomy: within normal limit

A : - Commosio cerebri - Right Os Tympanic fracture- Multiple fracture of facial bone- Elevation of liver function test

P:-Ceftriaxone 2 x 1 gr IV -Mefinal 3 x 500mg po-Ranitidine 2 x 50 mg IV -Extrace 1 x 400 mg IV

(October 20th , 2016 08.00 AM)Neuro-trauma division

S : Adequate contact.

O : BP : 130/80 HR : 78x/minRR : 18 x/min T : 36.7O2 saturation: 99% Eyes: normal shape and size of the pupil (3mm/3mm)Cranial nerve : No sign of Paresis Motoric: 55555 I 55555Sensory: within normal limitAutonomy: within normal limit

A : - Commosio cerebri - Right Os Tympanic fracture- Multiple fracture of facial bone- Elevation of liver function test

P:-Ceftriaxone 2 x 1 gr IV -Mefinal 3 x 500mg po-Ranitidine 2 x 50 mg IV -Extrace 1 x 400 mg IVRound with Yetti Ramli, Neurologist, PhD: - Neuro-trauma division will not need further follow up

(October 20th , 2016 07.00 AM)Plastic Surgery Department

S : there was pain ( VAS 1-2)

O :A: clear, C spine under controledB: Spontaneous breathing (18 x/minutes) C: TD 120/80 mmHg, HR : 85 x/ minutesD: GCS 15

A : - Right zygoma bone fracture

without any functional lesion

P:-Plan for elective ORIF -Ceftriaxon 2 x 1 gr IV -Mefinal 3 x 500 mg po-Ranitidine 2 x 50 mg IV -Extrace 1 x 400 mg IV-Operation tolerance

(December 20th, 2016 07.00 AM)

Plastic Reconstruction Division , ENT Dept

S : Pain VAS (1),

O : CM, there were no dyspnea, stridor and retraction BP : 120/80 HR : 78x/minRR : 24 x/min T : 36.7O2 saturation: 99% Local examination : Zygoma Region : There was malar depression, oedema +, pain on palpation +, deformity +

A : • Multiple fracture of facial bones

(S02.92)P: • Plan for ORIF according to

Plastic Surgery Department

Thank You