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Fracture Mandibula
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No. Name : Mr. R Sex : Male
Age : 19 years old No. Reg : 630475
Main complaint : Lacerated wound at mentaleCondition : The condition had suffered for 4 hours due to traffic
accident before the patient was taken to the hospital. There were no events of vomiting and unconsciousness.
Mechanism of injury
: The patient was riding a motorcycle when accidentally struck another vehicle. He was thrown from the motorcycle with his head landed first
Sustained Injury : Mandible Symptom & sign : HeadacheExamination Done
: Physical examination, Laboratory examination, Head CT Scan, skull X-Ray
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
Primary SurveyPrimary Survey
A: Clear
B: RR: 22x/minutes, spontaneous, symmetric, thoraco abdominal type
C: BP: 110/70 mmHg, PR: 90 x/minute, regular, adequate
D: GCS 15 (E4M6V5), pupil equal Ø 3 mm/3 mm, Light Reflex +/+
E: T (ax): 36,7 oC
Secondary SurveySecondary Survey
Mandibular Region :I : Seen stitched wound size 4 cm. Hematome (-), wound (+)P : Tenderness (+), Crepitation (+)
Laboratory ResultLaboratory Result
WBC : 16,83 x 103 / μL
RBC : 5,05 x 106 / μL
HGB : 14,5 g/dL
HCT : 42,6 %
PLT : 279 x 103/ μL
CT / BT : 7‘30”/3’00”
Blood Sugar : 91 mg/dl
Ureum : 13 mg/dl
Creatinin : 0,8 mg/dl
GOT / GPT : 32/31 μ/L
WORKING DIAGNOSIS : - Mild head injury GCS 15 (E4M6V5)- Mandibular fracture
MANAGEMENT : • Apply IVFD• Medicaments• Consult to senior plastic surgeon Advice: immediate ORIF
OPERATION PROCEDURE• Laid patient down onto supine position under GA• Disinfection and draping procedure• Proceed incision mucous on the mandibular• Seen fracture line on mandibular parasimfisis• Applied 2 plate, 5 burr hole with 4 screw and 3 burr
hole with 3 screw• Rinse the wound by NaCl and betadine• Stitch the wound layer by layer• Done