Case Report

16-04-2017

LAKI-LAKI USIA 31 TAHUN DENGAN

CEDERA KEPALA RINGAN GCS 14 E3M6V5,
FRAKTUR MANDIBULA DAN VULNUS
LASERATUM MENTALIS
COASS JAGA: ANIN, FARDI, MADE, ANA, AMITA, ZAKI, FYAN,
NOVI, NIMAS, AYU
Identity
Name : Mr S
Gender : Male
Age : 31 years old
Adress : Jepara
No. CM : C632860
Primary Survey
Airway and C-spine control
gurgling (+) perdarahan dari mandibula suction,
snoring (-)
Airway clear post suction

Breathing and Ventilation

RR: 20x/mnts, (regular, adequate depth of breath)
Pergerakan dada simetris
Retraksi tidak ada
No tracheal deviation
JVP in normal range
 Circulation and control hemorrhage
HR: 82x/mnts regular, adequate tone and volume
BP: 120/70 mmHg
external bleeding (-),
Disability
GCS E3M6V5 = 15
Isocoric pupil 3 mm, LR +/+
Exposure
Jejas(+) pada regio mandibula
Log roll: external bleeding (-), vertebra jejas (-)
 Autoanamnesis
A 31 years old man presented with Nyeri pada dagu went to Emergency unit in
RSDK

Main complaint : Nyeri pada dagu

Chronology/ History of present illness :

15 minutes before hospitalized pasien mengendarai motor, menggunakan
helm. Pasien menghindar motor didepannya kemudian terjatuh, ketika jatuh
dagu pasien mengenai jalan, pasien tetap sadar, muntah (-), merasakan nyeri
pada dagu (+). Sesaat setelah itu pasien dibawa ke RSDK.
Past Illness:
DM (-), HT (-), trauma (-), past surgery (-)

Family history:
DM (-), HT (-)

Social economy:
A farmer
BPJS class III
Physical Examination :
General state : composmentis, moderate ill

Vital sign : RR : 20 x/mnt regular

Pulse : 82 x/mnt
BP : 120/70 mmHg
T : 36,8 C
VAS :4

Head /Neck :
- Mesocephal, benjolan (-), jejas pada regio mandibular
 Head : mesocephal, skin turgor in normal range, jejas pada regio
mandibular
Eyes : conjunctiva palpebral pale (-/-), sclera icteric (-/-)
Ears : discharge (-/-)
Nose : discharge (-/-)
Mouth : cyanosis (-/-)
Neck : enlargement of the lymph nodes (-/-), No tracheal deviation ,
JVP in normal range
Chest :
Heart :
I : IC cannot be seen
P : IC palpable on SIC IV, 2 cm medial LMCS
P : Configuration wnl
A : Basic sound wnl
Lungs :
I : Static : right hemithorax = left hemithorax
Dinamic : right hemithorax = left hemithorax
P : Tactile fremitus right = left
P : Sonor all around area
A : Vesikuler basic sound, additional sound (-)

Abdomen : I : Flat, bowel pattern/movement (-)

P: Tenderness (-), DM (-)
P: Tympanic, liver dullness (+), flank dullness (+) N, shifting dullness (-)
A: Bowel sound (+) normal, metallic sound (-)
External genitalia : Male, within normal limit

Extremities : Upper Lower

Cyanosis -/- -/-
Cold acral -/- -/-
Deformities -/- -/-
Motoric 555/555 555/555
Sensoric +/+ +/+
Status Lokalis
Regio Mandibula:
Inspeksi: Terlihat diskontinuitas kulit pada mandibula, angulasi (+)
Perdarahan dari gusi (+)
Palpasi : Krepitasi mandibula (+)Maksila(-)
ROM: Gerakan temporomandibular joint tidak terkunci

Masalah Aktif: Cedera Kepala Ringan

Patah tulang mandibula
Working Diagnosis:
Cedera Kepala ringan, GCS 14 E3M6V5, fraktur mandibula, Vulnus laseratum mentalis
Initial Plan
IpDx : S :-
O : Head MSCT without contrast, thoracic Spine X-ray (AP)
Panoramic dental X-Ray
IpTx : Head up 30
Oxygenation with oxygen mask 10 lpm
Cervical Collar Rigid
IVFD RL 20 dpm
Ketorolac inj. 30 mg/8 hours intravenous
Inj ceftriaxone 2g/24 h
Inj ranitidine 50 mg/12 h
IpMx : general condition, vital sign, GCS, neurologic deficit
IpEx : Current condition, Diagnosis, treatment plans, Prognosis
Clinical Photo
Subarachnoid haemorrhage
Tampak tanda-tanda peningkatan TIK
 Fraktur kominutif pada
simfisis os mandibula