fracture maxilla

7/27/2019 Fracture Maxilla

1/28

Morning Report

ISMAYUNI SUMIRA

0908120524


2/28

Anamnesis

Patient Identity

Male, 29 years old, came to AA

Hospital on June 8th 2013

Chief Complain

Pain around nose, cheeks and lipsince 4 hours before admitted tothe hospital.


3/28

Recent illness History

Patient described a continousand pulsating pain. There was

bulging around the eyes, cheeksand lip. There was scratched onthe lip.

Patients complained difficultyon opening the mouth widely.


4/28

Recent Illness History

4 hours before admitted to thehospital, patient got an accident.Patient ride motorcycle with the

speed was 40 km/hour and usedhelmet. The motor cycle crashed fromthe left side by a car. Patient fell tothe right side and the face hit the

trotoar. There was no blackout,headache, nauseous and vomit.Bleeding only came out from nose. Noteeth detached.


5/28

Recent Illness History

The patient then brought up toIS Hospital and got initialtreatment before the patient

sent to AA General Hospital.


6/28

Past Illness History

No history of trauma before

Family Illness HistoryNo family Illness relate with

recent patients symptom


7/28

Physical Examination

General condition : Mild illness

Awareness : Alert

Vital sign: BP = 120/80 mmHg

HR = 84 x/minute

RR = 20 x/minute

T = 36,8 C


8/28

Head and neck : Localized status

Thorax : Normal

Abdomen : NormalExtremity : Normal


9/28

Locallized status (Headand Neck )

Maxillofascial status :Inspection :Periorbital edema left and rightSubconjunctiva bleeding (+) on left ocular

Conjunctiva not anemis (-)Edema on cheeksDeformity on noseVulnus excoriatum around lip

Diplopia (-)


10/28

Locallized status

Palpation :

1. Rima superior orbita D and S :

Crepitation (-), discontinuitas (-),

tenderness (+)2. Rima lateral orbita D and S :

Crepitation (-), discontinuitas (-),tenderness (+)

3. Rima inferior orbita D and S :

Crepitation (-), discontinuitas (-),tenderness (+)


11/28

Locallized status

4. Os nasale :Crepitation (-), discontinuitas (-), tenderness

(+)

5.Os zygoma D and S:

Syimmetric malar imminent D and S (+)Tenderness (+) on zygomaticum S

6.Os maxilla D and S:

Crepitation (-), discontinuitas (-), tenderness (+)

7. Margo inferior mandibula D and S :Crepitation (-), discontinuitas (-), tenderness (-)


12/28

Locallized status

8. Temporomandibulajoint(TMJ)

Deformity (-), tenderness (-) whenpatient open and close the mouth

- Intraoral :

Laceration mucosa (-), stepping (-),

gapping (-), malocclusion (+),floating maxilla (-), trismus (+)


13/28


14/28


15/28

Working diagnosis

nasale bone fracture + left andright maxilla bone fracture + left

zygoma bone fracture


16/28

Suggestive Examination

Head CT Scan 3D

Head X-Ray AP Lateral

X-Ray Waters


17/28

Head CT Scan3D


18/28


19/28


20/28

HeadBone

Scan


21/28

Diagnosisnasale bone fracture + left and

right maxilla bone fracture + leftzygoma bone fracture + left

corpus mandibular bone fracture


22/28

Treatment

IVFD Ringer Lactat 20 gtt/min

Ketorolac injection 2x30 mg

Ceftriaxone injection 2x1 grOral Hygiene

Liquid Diets

Operation => ORIF


23/28


24/28

Follow Up

June 10th 2013S : Pain around nose, cheeks and lip

O:

General condition : mild illness

Counsiousness : Composmentis

Vital sign

BP = 120/80 mmHg HR = 82 x/minute

RR =18 x/minute

T = 36,8 C

Locallized status :

Head an neckInspection : Edema periorbital,

subconjungtiva bleeding on

ocular sinistra, edema oncheeks, deformity on nose,vulnus excoriatum around lip,maloclution

Palpation : tenderness (+)

A :nasale bone fracture + left

and right maxilla bonefracture + left zygoma bonefracture + left corpusmandibular bone fracture

P : Continous therapy


25/28

Follow Up June 11th 2013

S : Pain around nose, cheeks and lipO:



Vital sign


RR = 18 x/minute

T = 36,8 C

Locallized status :

Head an neckInspection : Edema periorbital,subconjungtiva bleeding on

ocular sinistra, deformity onnose, vulnus excoriatumaround lip, maloclution

Palpation : tenderness (+)A :

nasale bone fracture +left and right maxilla bonefracture + left zygoma bonefracture + left corpusmandibular bone fracture



26/28

Follow Up

June 12th 2013S : Pain around nose, cheeks and lipO:



Vital sign


RR = 18 x/minute

T = 36,8 C

Locallized status :

Head an neckInspection : Edema periorbital,

subconjungtiva bleeding on






27/28

Follow Up

June 13th 2013

S : Pain around nose, cheeks and lip

O:



Vital signBP = 120/80 mmHg HR = 80 x/minute

RR = 20 x/minute

T = 36,5 C

Locallized status :

Head an neckInspection : Edema

periorbital, subconjungtivableeding on






28/28

Thank You

fracture maxilla

Documents