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Name : Ch. NJ
Age : 6 years old
Sex : Male
Address :Abelli- Kendari
Admission : Mei, 8th 2019
Doctor in charge : dr. Saktrio D Subarno, Sp. BP-RE
History Taking
Chief complain :
Pain at the mouth
Anamnesis :
Since ±2 minutes ago before admitted to Hospital due to traffic accident
Mechanism of trauma :
the patient was playing on the side of the road, when he heard the sound of firecrackers the
patient ran across the street, and passed and hit the patient's body so that he fell and the
patient's lips were exposed to the iron plate of the motor
C
Pulse = 108x/min, regular, strong, CRT <2 second
D
GCS 15 (E4M6V5), pupil isocord ø : 2,5 mm/2,5mm, light reflex +/+
E
T = 37.20 C (axillary)
SECONDARY SURVEY
Compos mentis
moderate illness
Normal nutritional status
GENERAL
STATE
Secondary Survey
Face:
Inspection : Deformity (-), hematoma (-), swelling (-), wound (+): Vulnus laceratum at regio labialis superior
with size 8 x 0,5 cm post hecting
Palpation : tenderness (+)
STEP OFF
rima orbitalis superior (-) Malocculis (-)
rima orbitalis inferior (-) Avulsion (-)
frontonasalis (-) Visus: 6/6
frontozygomaticum (-) Diplopia: -
Unstable os maxilla (-)
Unstable os mandibula (-)
Clinical Finding
Plan of Diagnostic
primary survey
A:Clear dengan C-spine control,
B: Bentuk dan gerak dada simetris
C: Tekanan darah
D:GCS
E: Temperatur.
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Thank You