Morning Report

Saturday, October 28th 2017

Team on duty

dr. Andri Feisal Nasution ( Chief )

dr. Nasrul Haidi ( Chief )

dr. Reza Furqon ( jaga 1 )

dr. Adang Sunandar ( Jaga 1 )

dr. Muhammad Taqwa ( Jaga 2 )

dr. Ahmad Muhtadi ( Jaga 2 )

dr. Syahmardani Ibnu ( Jaga 3 )

dr. Marshal Agreno ( Jaga 4 )

dr. Yudi Nugraha ( Jaga 5 )

Patient Identity

Name : Sayed Miftahul Fahmi

Age : 13 years

Sex : Male

Address : Neuhen, Aceh Besar

CM : 1148131

Phone : 082339333032

Admission time : 16.40 WIB

Time Response
Chief Complaint:

Pain at nasal region

Present illness history

The patient came to emergency room Zainoel Abidin Hospital with a chief complaint pain at the
nasal region for 3 hours.

Initially the patient was passenger when riding a motorcycle without helmet suddenly his motorcycle
struck by the other motorcycle and his nose hit the handle of the motorcycle

History of decrease of consciousness (-), nausea and vomiting (-).

He was spontaneously opened his eyes, obey commands, oriented to time, place and person

Physical examination

Primary survey:

A : Clear,

B : Spontaneous, 21 breaths/min

C : Pulse: 100 beats/min

D : GCS (E4M6V5): 15, isochoric pupil 3mm/3mm,

E:

L/S at the facial region

Upper Face

L : Symmetrical (+), swelling (-), excoriated wound (-)

F : Pain (+), step off (-) , hipoesthesia (-)

Visus examination : 6/6

Movement of eye examination
Middle face

L : Asymmetrical (+) , swelling (+) at the nasal region, lacerated wound (-), nasal deviation (+),
nasal flattening (+)

F : Pain (+), step off (-), hipoesthesia (-)

Lower Face

L : Symmetrical , swelling (-), lacerated wound (-).

F : Pain (-), step off (-), hipoesthesia (-)

Intra Oral

Open bite (-)

Cross bite (-)

Maxilla floating (-)

Alveolar floating (-)

Malocclusion (-)

Secondary survey :

Head and neck

L/S at the facial region

Upper Face

L : Symmetrical (+), swelling (-), excoriated wound (-)

F : Pain (+), step off (+) , hipoesthesia (-)

Visus examination : 6/6

Movement of eye examination

Middle face

L : Asymmetrical (+) , swelling (+) at the nasal region, lacerated wound (-), nasal
deviation (-), nasal flattening (+)

F : Pain (+), step off (-), hipoesthesia (-)

Lower Face

L : Symmetrical , swelling (-), lacerated wound (-).

F : Pain (-), step off (-), hipoesthesia (-)

Intra Oral

Open bite (-)

Cross bite (-)

Maxilla floating (-)

Alveolar floating (-)

Malocclusion (-)

Thorax :

Abdominal : in normal limit

Pelvic : in normal limit

Upper extremity : in normal limit

Lower extremity : in normal limit

Vas : 3

Assessment:

Suspect Nasal fracture

Management

Stop oral intake

IVFD RL 1860cc / 24 hours

Ceftriaxone inj. 1 g/ 12 hours

Metamizole sodium inj 500 mg

Laboratory examination

Radiology examination

Laboratory result

Hemoglobin : 13,2 gr/dl

White Blood Count : 9.900/ul

Platelets : 278.000 /ul

Hematocrit : 41 %

CT/BT : 7/2

Radiology result :

Schedle AP/Lateral

Discontinuity of bone at the nassal region

Diagnose

Nasal fracture with septal deviation (ICD 10 S02.401)

Consult to Plastic surgery Division :

Nasal reconstruction emergency

Operative report

Performed nasal elevated and reconstruction by using klemp until form a straight line between nasal
tip with nasal cantus left and right, and glabella left and right

Nasal fixated with butterfly gips

Nostril is corked using sufratule

Post operative Diagnosed

Nassal fracture with septal deviation (ICD 10 S02.401)

Follow up