7/27/2019 Fracture Maxilla
1/28
Morning Report
ISMAYUNI SUMIRA
0908120524
7/27/2019 Fracture Maxilla
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.
7/27/2019 Fracture Maxilla
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.
7/27/2019 Fracture Maxilla
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.
7/27/2019 Fracture Maxilla
5/28
Recent Illness History
The patient then brought up toIS Hospital and got initialtreatment before the patient
sent to AA General Hospital.
7/27/2019 Fracture Maxilla
6/28
Past Illness History
No history of trauma before
Family Illness HistoryNo family Illness relate with
recent patients symptom
7/27/2019 Fracture Maxilla
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
7/27/2019 Fracture Maxilla
8/28
Head and neck : Localized status
Thorax : Normal
Abdomen : NormalExtremity : Normal
7/27/2019 Fracture Maxilla
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 (-)
7/27/2019 Fracture Maxilla
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 (+)
7/27/2019 Fracture Maxilla
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 (-)
7/27/2019 Fracture Maxilla
12/28
Locallized status
8. Temporomandibulajoint(TMJ)
Deformity (-), tenderness (-) whenpatient open and close the mouth
- Intraoral :
Laceration mucosa (-), stepping (-),
gapping (-), malocclusion (+),floating maxilla (-), trismus (+)
7/27/2019 Fracture Maxilla
13/28
7/27/2019 Fracture Maxilla
14/28
7/27/2019 Fracture Maxilla
15/28
Working diagnosis
nasale bone fracture + left andright maxilla bone fracture + left
zygoma bone fracture
7/27/2019 Fracture Maxilla
16/28
Suggestive Examination
Head CT Scan 3D
Head X-Ray AP Lateral
X-Ray Waters
7/27/2019 Fracture Maxilla
17/28
Head CT Scan3D
7/27/2019 Fracture Maxilla
18/28
7/27/2019 Fracture Maxilla
19/28
7/27/2019 Fracture Maxilla
20/28
HeadBone
Scan
7/27/2019 Fracture Maxilla
21/28
Diagnosisnasale bone fracture + left and
right maxilla bone fracture + leftzygoma bone fracture + left
corpus mandibular bone fracture
7/27/2019 Fracture Maxilla
22/28
Treatment
IVFD Ringer Lactat 20 gtt/min
Ketorolac injection 2x30 mg
Ceftriaxone injection 2x1 grOral Hygiene
Liquid Diets
Operation => ORIF
7/27/2019 Fracture Maxilla
23/28
7/27/2019 Fracture Maxilla
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
7/27/2019 Fracture Maxilla
25/28
Follow Up June 11th 2013
S : Pain around nose, cheeks and lipO:
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, deformity onnose, vulnus excoriatumaround lip, maloclution
Palpation : tenderness (+)A :
nasale bone fracture +left and right maxilla bonefracture + left zygoma bonefracture + left corpusmandibular bone fracture
P : Continous therapy
7/27/2019 Fracture Maxilla
26/28
Follow Up
June 12th 2013S : Pain around nose, cheeks and lipO:
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, deformity onnose, vulnus excoriatumaround lip, maloclution
Palpation : tenderness (+)A :
nasale bone fracture +left and right maxilla bonefracture + left zygoma bonefracture + left corpusmandibular bone fracture
P : Continous therapy
7/27/2019 Fracture Maxilla
27/28
Follow Up
June 13th 2013
S : Pain around nose, cheeks and lip
O:
General condition : mild illness
Counsiousness : Composmentis
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
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
P : Continous therapy
7/27/2019 Fracture Maxilla
28/28
Thank You