Mr. N, a 21-year-old male, arrived at the emergency room complaining of mild pain in his left lip after falling from his bicycle. On examination, he had lacerations to his upper lip, gums, and inside of his mouth. He was alert and oriented, and examination of his breathing, circulation, and other systems were normal. The clinical impression was multiple oral cavity injuries from the bicycle fall, including laceration of the upper lip. The treatment plan included X-rays of the skull, IV fluids, antibiotics, pain medications, and wound treatment.

1. MORNING
REPORT
Juli 2023

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

5. SECONDARY SURVEY
GENERALIST STATUS
GCS: 456
BP : 136/78
HR: 80 /menit
RR: 26x/menit
T: 36,5 C
SpO2 : 100% on NRBM

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

9. CLINICAL PICTURE

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

11. Xray SKULL

12. THANK YOU