HTWU/URP/06

Laporan Perubatan ( Medical Report )

Kementerian Kesihatan Malaysia

Butiran Pesakit (Patient Parlticulars) :

Nama Pesakit ( Name of Patient ) : Masriyanto Bin Jaling

No. K/P (I/C No): Baru (new) 830919-12-5865 Lama (Old) : -

No. Passport (Passport No): MRN: -

Umur (Age) 33YR Jantina (Sex): X Lelaki (Male) Perempuan (Female)

Tarikh masuk wad atau menerima rawatan buat kali pertama (Date of admission or receiving
treatment for the first time): 3/5/2016 @ 1500 H

Tempat menerima rawatan (Place where patient received treatment):

X
X Jabatan Kecemasan ( Emergency Department ) Klinik Pakar (Specialist
Clinic)

Jabatan Pesakit Luar ( Out patient Department ) X Wad (Ward) : Male Surgical
Ward

Tarikh discaj dari wad atau meninggal dunia ( Date of discharge or death ) : 14 / 5 /2016

Disiplin ( Discipline ) : OTORHINOLARYNGOLOGY

Sejarah ( History ): Patient was alleged MVA on 3/5/2016 at about 10.15am. Patient was a driver of mini bus
who alleged collision in between sedan car with his mini bus. There was uncertainty of mechanism of injury since
there was no eye witness. Patient was brought to Hospital Kunak Emergency Department. From the referral letter,
noted patient unconscious with GCS 7/15 hence intubation made for airway protection. On examination in
Hospital Kunak, noted big laceration wound at right parietal region (ragged wound with actively bleeds). Also
noted having ear and nose bleeding. Transferred to Hospital Tawau for To Rule Out Intracranial Bleeding (ICB). In
Hospital Tawau, patient admitted to ICU for critical ill care and ventilator support. CT Scan Brain & Cervical done
on 3/5/2016, it showed
i. Small pneumocephalus at right temporal region with adjacent temporal bone fracture
ii. No acute intracranial haemorrhage or any focal lesion
iii. Horizontal fracture of left temporal bone extending to sphenoid sinus
iv. Right lateral pterygoid plate fracture
v. Walls of right maxillary sinus fracture
vi. Right basisphenoid and greater wing of sphenoid fracture
vii. Cervical spine intact

Impression:
1)multifocal base of skull and facial bone fracture
2)fracture right temporal bone with a small pneumocephalus

On examination at ICU, patient intubated and sedated. BP 119/71 , Heart rate 109, noted extensive subcutaneous
emphysema at upper thorax / chest. Case then was referred to Otorhinolaryngology (ORL) team to rule out any
laryngeal trauma. Upon ORL assessment on 4/5/2016, we cannot exclude any laryngeal trauma, suggested to not
for extubation first in view of extensive subcutaneous emphysema (treat conservatively). CT Thorax done on
5/5/2016 to showed
i. Larynx is oedematous and collapse with ET tube
ii. Extensive subcutaneous emphysema over the anterior chest wall and bilateral neck
iii. Horizontal fracture of temporal bone
iv. Fracture lateral wall of both sphenoid sinuses
v. Fracture right lateral pterygoid plate
vi. Fracture right maxillary sinus wall
vii. Fracture right basisphenoid and greater wing of sphenoid

Impression:
Extensive surgical emphysema with pneumodiastinum indicate airway injury

Initially, ORL team suggested for tracheostomy in view of evidence of laryngeal trauma, however, Anaest team
opted for trial of extubation first. On 11/5/2016, patient was extubated well. No desaturation since then. Patient
was discharged then by surgical Team.

PAST MEDICAL HISTORY :Nil

PAST SURGICAL HISTORY : Nil

FAMILY HISTORY : NO HISTORY OF HEARING PROBLEMS OR MALIGNANCY RUN IN PATIENT'S FAMILY TREE

MEDICATION / ALLERGY HISTORY : NO KNOWN ALLERGIES TO ANY DRUGS / FOOD

Pemeriksaan Fisikal (Physical Examination) :

Alert, conscious
Good pulse volume, regular, CRT <2secs

BP :125 / 85

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HR :88

LUNGS:CLEAR
CVS:DUAL RYTHYM, NO MURMUR
PER ABDOMEN: SOFT, NON TENDER

Facial nerve palsy grade III-IV

RIGHT EAR
TYMPANIC MEMBRANE INTACT
EXTERNAL AUDITORY CANAL INTACT, NO LACERATION
NO EAR DISCHARGE
MINIMAL WAX BUT NOT OCCLUDED THE CANAL

LEFT EAR
HEALED PERFORATED TYMPANIC MEMBRANE
EXTERNAL AUDITORY CANAL NORMAL
NO EAR DISCHARGE
CLEAR CANAL

RIGID NASOPHARYNGOSCOPY
NOSE CLEAR
NO POLPYS / NO MASS
NORMAL FINDINGS

PURE TONE AUDITORY (PTA) TEST DONE ON 1/6/2016

RIGHT EAR : Mix Mild to Moderate MHL air conduction more than bone conduction, noted dip notch at 2k Hz ?
Cahart notch
LEFT EAR : Mild Sensorineural Hearing loss at mid frequency

Diagnosis (Diagnosis)
1) Left facial nerve palsy secondary to horizontal fracture of temporal bone
2) Right mix hearing loss ? otosclerosis ? ossicular discontinuity secondary to trauma

Perkembangan keadaan pesakit sepanjang di bawah penjagaan doktor termasuk rawatan

susulan (progress of patient while under the care of the doctor including follow-up):

During our first appointment in ORL clinic on 1/6/2016, noted patient developed grade IV left
facial paresis late onset post trauma. HRCT temporal requested , it showed (27/6/2016) :

Left ear
i. Horizontal fracture of temporal bone
ii. Ossicles patent

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 iii. No dislocation incudomalleolar complex
iv. Inner ear intact

Right ear
i. Fluid within middle ear
ii. Mastoid air cells fills with fluid
iii. Ossicles patent
iv. Inner ear patent

IMP : Right ear acute otomastoiditis

Hearing test result as mention above.

Keadaan pesakit ketika berjumpa kali terakhir dengan doktor (condition of patient last seen by
the
doctor
Stable, alert. Still have left facial nerve palsy grade III-IV. Still under ORL follow up for his both
diagnosis. We plan to repeat hearing test next visit.

Tarikh (date): (Medical certificate/school leave): Tiada

Dari(From) : TIADA Hingga (to):

Surat kerja ringan yang diberikan (light duty given): Tiada

Dari (From) : TIADA Hingga (to):

Laporan disediakan oleh (Report prepared by):

Nama (Name): DR.MOHD HADZRIE BIN MOHD HAMDAN

No K/P ( I/C No ) :880717-56-5905 Jawatan (Designation) : PEGAWAI PERUBATAN UD44

Kelulusan (Qualification) : MBBS Jabatan (Department): ORL

Tandatangan (Signature): Tarikh ( Date )27/3/2017 Masa ( Time )1530H

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Cop Rasmi Hospital ( Official Hospital Stamp )