MORNING REPORT

Sabtu 22-12-2012

BIODATA
Name : Jitron Nenotek Age : 18 years old Sex : Male Address : Job : Student Arrive to hospital : 13.30

Anamnesis
Chief Complaint :
Wound in chick

Mechanism of Injury
Patient fall from electric pole + 10meters. His position is facing to down and he rest on his arm. But his chin cras a box.

History
After this acident patien fell unusual in his teeth and hard to open because paint. No unconscious, vomit and nausea. The patien is refferenced from Bajawa Hospital.

Primari Survei
A: Clear, B : RR: 24 times in a minute, simetric C : Blodd preasure : 120/80mmHg, heart rate : 96 times/minute, reguler D : hard to open mouth E : vulnul laseratum et mandibula

Secondary Survei
GCS : E4 V5 M6 Eye : anemis (-), pupils refleks +/+, isocord Ear : otorhuoe (-/-) Nose : Rhinoroe (-/-) Jaw : vulnus laceratum at mandibula, clear, hacktinged, deformitiy (+),diameter 4cm, creepitation (-), paint (+),

Toraks
Inpeksi : cheest floating simetric, brush (-) Palpation : crepitation (-), paint (-) Auscultation : breath sound is vesicular

Abdoment
Inspektion : Brush (-) Auscultation : intestinal sound +, Palpation : tenderness paint no, Perkusion : normal

Extremitas
Look : vulnus laseratum at cubital regio sinistra, clear, hacktinged, size 3cm, deformity (-), shortening (-) Fell : paint (+), NAV normal, CRT <2 seconds, pultation arteri (+), crepitation (-), Move : Free moving

Radiologi
Linear fractur ini mandibula

Assesment
Fracture parasymphis mandibula dextra

Planning
IVFD RL 20 tpm Cafotaxim 2 x 1gr Ranitidin 2 x 1 amp Ketorolac 3% 2x 1 amp Wound toilet, hakting Fixtation

 THANK YOU