2. Identity
● Name : Mr.N
● Age : 21 years old
● Gender : Male
● Address : Batu
● Arrival date : 02/07/2023 19.20 WIB
● Incident date : 02/07/2023 17.00 WIB
● Patient Type : Trauma
3. Incident date: 22 Juni 2023 at 09.00 WIB
Arrival Date: 22 Juni 2023, at 10.00 WIB
Anamnesis:
Main Complaint : Complaint of pain in left lip
The patient came to the ER with complaints of pain in the left lip with a VAS SCORE of 4-5 (mild) after falling from an ontel
bicycle. When the incident occurred, the patient was riding an ontel bicycle through a steep road, at high speed the patient finally
could no longer control his steering wheel and then fell with his mouth hitting the asphalt. Nausea (-), vomiting (-), syncope (-),
retrograde amnesia (-) seizures (-)
MOI: the patient fell from the ontel and the patient's mouth hit the asphalt
Examination Initial Diagnosis Action
Airway:
Patent, gargling (-), stridor (-)
Paten -
Breathing:
Look: symmetrical chest wall movement, lesion (-)
Feel: the patient breathes spontaneously, no additional breath
sounds, rib crepitations (-), step defect (-)
RR: 26x/minute
SpO2 : 100% on NRBM
Breathing spontaneusly NRBM 10 LPM
Circulation:
BP 136/78 mmHg
HR: 80x/m
CRT <2s, red warm dry acral
Resucitation Fluid IVFD RL Resucitation
EBV : 60x70= 4200 cc
EBL : 4200 x 15% = 630 cc
Volume resusitasi : 4200 x
PRIMARY SURVEY
4. PRIMARY SURVEY
Examination Initial
Diagnosis
Action
Disability :
GCS 456 Composmentis, Isochor pupil diameter 3mm/3mm, Light reflex direct and indirect +/+, cornea reflex +/+,
move the eyeball in all directions (+)
- -
Exposure:
Temperature: 36.6⁰C, CRT<2s
Localist status
-Oral cavity region
L: Vulnus laseratum measuring 1-2 cm on the inner upper lip, Vuln laseratum measuring 1-2 on the superior
gingiva, incisors 1-2-3 above are missing, incisors 1-2 below are rocking, deformity (+) bleeding active ( +)
F: Pain (+) VAS score 4-5, crepitus palate (-), step off palate (-)
-Region of the Labia oris (S)
L: vulnus laceratum with a size of 2x2 cm, the base of the muscle is red, the boundaries are not clear, bleeding is
active (+)
F: Pain (+) VAS score 4-5, crepitus (-), step off (-)
M: The patient can open and close his mouth normally
-Temporal Region (S)
L: vulnus abrasion with a size of 3x3 cm, the base of the dermis is red, the boundaries are not clear, bleeding is
active (-)
F: Pain (+) VAS score 2-3, crepitus (-), step off (-)
-Genu Region (D)
L: vulnus abrasion with a size of 2x2 cm, the base of the dermis is red, the boundaries are not clear, the bleeding
is active (-)
F: Pain (+) VAS score 1-2, crepitus (-), step off (-)
M: The patient can perform maximal flexion and extension of the genu joint
--Vulnus
laceration of
Region of Labia
Oris (S)
-Vuln laseratum
uk 1 cm on the
upper lip
-Vuln laseratum
uk 1-2 cm on the
inside of the
upper lip
-Vuln laseratum
uk 1-2 on the
superior gingiva
- Upper 1-2-3
incisors missing
- Incisors 1-2
under rocking
-Multiple vulnus
abrasions
- Inj.
Ketorolac
30 mg
- inj.
Ranitidine
50 mg
- Inj asam
traneksamat
500 mg
- IVFD RL
Resucitation
1890 cc
- Treat
wounds
- Fast 8
hours
6. SECONDARY SURVEY
ANAMNESIS
Allergy : -
Medication: -
Past illness : -
Last meal : 12.00 am (02/07/23)
Event : The patient fell from the
ontel and the patient's mouth hit the
asphalt
Nausea (-), vomiting (-), syncope (-),
retrograde amnesia (-) seizures (-)
7. PHYSICAL EXAMINATION
HEAD/NECK:
Head
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), Isochor
pupil diameter 3mm/3mm, Light reflex direct and indirect
+/+
Ears : bloody rhinorrhea (-/-)
Nose : epistaksis (-/-)
Neck :
Inspection: tracheal deviation (-)
Palpation: enlarged lymph nodes (-)
Auscultation : Bruits (-)
THORAX :
Cor:
Inspection: ictus cordis invisible
Palpation: ictus cordis palpable at ICS 5 MCL S
Percussion: Right heart border at PSL D ICS 4, heart
border Left at MCL S ICS 5
Auscultation: S1 S2 single, regular, murmur (-), gallop (-)
Pulmo:
Inspection: normal chest wall shape, retraction (-),
looks symmetrical (+/+)
Palpation: symmetrical D/S chest wall movement
Percussion: sonor all lung fields
Auscultation: Ves/Ves, rh (-/-), wh (-/-)
Abdomen:
Inspection : Flat, injury (-), surgical scar (-)
Auscultation : Bowel sound (+) 10x/minute
Percussion : Timpany all abdomen fields
Palpation : Flat, soft, superficial tenderness (-),
deep tenderness (-)
Extremities : Dry warm acral, CRT <2 s
8. PHYSICAL EXAMINATION
HEAD/NECK:
Head
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), Isochor
pupil diameter 3mm/3mm, Light reflex direct and indirect
+/+
Ears : bloody rhinorrhea (-/-)
Nose : epistaksis (-/-)
Neck :
Inspection: tracheal deviation (-)
Palpation: enlarged lymph nodes (-)
Auscultation : Bruits (-)
THORAX :
Cor:
Inspection: ictus cordis invisible
Palpation: ictus cordis palpable at ICS 5 MCL S
Percussion: Right heart border at PSL D ICS 4, heart
border Left at MCL S ICS 5
Auscultation: S1 S2 single, regular, murmur (-), gallop (-)
Localist status
-Oral cavity region
L: Vulnus laseratum measuring 1-2 cm on the inner upper lip, Vuln laseratum measuring 1-2 on the
superior gingiva, incisors 1-2-3 above are missing, incisors 1-2 below are rocking, deformity (+) bleeding
active ( +)
F: Pain (+) VAS score 4-5, crepitus palate (-), step off palate (-)
-Region of the Labia oris (S)
L: vulnus laceratum with a size of 2x2 cm, the base of the muscle is red, the boundaries are not clear,
bleeding is active (+)
F: Pain (+) VAS score 4-5, crepitus (-), step off (-)
M: The patient can open and close his mouth normally
-Temporal Region (S)
L: vulnus abrasion with a size of 3x3 cm, the base of the dermis is red, the boundaries are not clear,
bleeding is active (-)
F: Pain (+) VAS score 2-3, crepitus (-), step off (-)
-Genu Region (D)
L: vulnus abrasion with a size of 2x2 cm, the base of the dermis is red, the boundaries are not clear, the
bleeding is active (-)
F: Pain (+) VAS score 1-2, crepitus (-), step off (-)
M: The patient can perform maximal flexion and extension of the genu joint
10. PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning
Diagnosis
Planning Therapy &
Monitoring
Anamnesis:
• The patient came to the ER with complaints of pain
in the left lip with a VAS SCORE of 4-5 (mild) after
falling from an ontel bicycle
• the patient fell from the ontel and the patient's
mouth hit the asphalt
• Nausea (-), vomiting (-), syncope (+), retrograde
amnesia (-) seizures (-)
Localist status
-Oral cavity region
L: Vulnus laseratum measuring 1-2 cm on the inner
upper lip, Vuln laseratum measuring 1-2 on the superior
gingiva, incisors 1-2-3 above are missing, incisors 1-2
below are rocking, deformity (+) bleeding active ( +)
F: Pain (+) VAS score 4-5, crepitus palate (-), step off
palate (-)
-Region of the Labia oris (S)
L: vulnus laceratum with a size of 2x2 cm, the base of
the muscle is red, the boundaries are not clear,
bleeding is active (+)
F: Pain (+) VAS score 4-5, crepitus (-), step off (-)
M: The patient can open and close his mouth normally
--CKR 456
-Vulnus laceration of
Region of Labia Oris (S)
-Vuln laseratum uk 1 cm
on the upper lip
-Vuln laseratum uk 1-2
cm on the inside of the
upper lip
-Vuln laseratum uk 1-2
on the superior gingiva
-The upper incisors 1-2
are missing
- Incisors 1-2 under
rocking
-Multiple vulnus
abrasions
Xray Skull - IVFD RL 20 tpm
- ketorolac inj 30mg
- inj Ranitidine 50mg
- inj. Ceftriaxone 1 gram
- Inj asam traneksamat
500 mg
- Treat wounds
- Pro repair vulnus
- 8 hour fast
