FR MAXILLA RADIUS PATELLA

ENGLISH
NAME : Mr. Y
AGE : 51 y.o
MR : 01172127
Chief Complaint :
Pain at face, right hand,and left knee after MVA

Present Illness :
Four hours prior to admission, while the patient was ride
a motorcycle, he was hit by another motorcycle from
behind. The patient felt down then he complained pain at
his face, right hand, and left knee. Uncounciusness (-),
vomit (-). The patient was brought to the PKU
Muhamadiyah Hospital of Delanggu and was performed
suture. Due to health goverment insurance finance
reason, the patient was referred to Moewardi Hospital
with Fracture of Maxilla.
 Primary Survey

A : Clear
B : I : Thoracoabdominal, RR : 20 x/mnt
P : Crepitation (-/-)
P : sonor/sonor
A : Vesiculer sound (+/+), Additional sound (-/-)
C : BP : 120/80 mmHg, HR : 88 x/mnt
D : GCS E4V5M6, Pupile isocore (3mm/3mm), Light reflexes
(+ /+)
E : t : 36,7C, Lesion (+) look at physical examination
 Secondary Survey
Head : No abnormality
Eyes : palpebra inferior edema (+/+), telecanthus(+),
diplopia(-), distopia(-),movement of orbita N
Ears : No abnormality
Nose : saddle nose (+), epistaxis (+/+)
Mouth : malocclusion (+) : cross bite, mucogingival
laceration (-), mobile teeth (+) 1
floating of maxilla (+)
Neck : No abnormality
Chest : No abnormality
Abdomen : No abnormality
Extremity : Lesion (+) look at physical examination
 Local Examination
Mid Facial region :
I : Edema (+/+), malar flattening (+/+)
P : infraorbital nerve paresthesis (+/+)

Right Wrist Region :

L : Wound (-), edema (+), deformity (+) : dorsal angulation
F : NVD (-)
M : ROM limited due to pain

Left Genu Region :

L : Edema (+), Wound 10 cm :sutured with silk 11 stitch
F : NVD (-)
M : ROM limited due to pain
ASS I :
Fracture of Maxilla Lefort II
Right Radius distal Closed Fracture
Suspicion Left Patella Open Fracture

PLAN I:
- IVFD RL 20 dpm
- Inj. Ceftaxidime 1 gr/12 hrs
- Inj. Metamizol 1 g/8 hrs
- Inj ATS 1500 IU
- Blood examination
- Waters X-rays, Wrist AP/Lat X-rays, Genu AP/Lat X-rays,
Thoraks AP X-rays
lab
Genu (S)
Kepala ap/ waters
Thorak ap
ASS II :
Fracture of Maxilla Lefort II
Right Radius distal Closed Fracture Frykman IV
Left Patella Abration

PLAN II :
Plastic Surgery :
In ward
Oral Higiene
Liquid diet
ORIF elective miniplate
Orthopaedic :
Right Radius distal Closed Fracture Frykman IV ORIF
elective (Pinning)
Left Patella AbrationDebridemant
 Arrival 00.05

Triage 00.05

Surgery 00.10

Radiology 00.10 01.10

Laboratory 00.10 01.10

Diagnose 01.10

Inward 02.00