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    Fracture Mandibula

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    Myra Miera
    This document details a medical case report of a 19-year-old male patient who was in a motorcycle accident and sustained a lacerated wound on his chin and a mandible fracture. The document provides information on the patient's history, examination findings, test results, diagnosis, treatment which included surgery, and prognosis.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd

    Fracture Mandibula

    Uploaded by

    Myra Miera
    22 views13 pages
    This document details a medical case report of a 19-year-old male patient who was in a motorcycle accident and sustained a lacerated wound on his chin and a mandible fracture. The document provides information on the patient's history, examination findings, test results, diagnosis, treatment which included surgery, and prognosis.

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    Fracture Mandibula

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    This document details a medical case report of a 19-year-old male patient who was in a motorcycle accident and sustained a lacerated wound on his chin and a mandible fracture. The document provides information on the patient's history, examination findings, test results, diagnosis, treatment which included surgery, and prognosis.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    22 views13 pages

    Fracture Mandibula

    Uploaded by

    Myra Miera
    This document details a medical case report of a 19-year-old male patient who was in a motorcycle accident and sustained a lacerated wound on his chin and a mandible fracture. The document provides information on the patient's history, examination findings, test results, diagnosis, treatment which included surgery, and prognosis.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 13

    No.

    Nam
    : Mr. R
    Sex
    : Male
    e
    19 years
    No.
    Age :
    : 630475
    old
    Reg
    Main complaint : Lacerated wound at mentale
    Condition
    : The condition had suffered for 4 hours due to traffic
    accident before the patient was taken to the hospital.
    There were no events of vomiting and unconsciousness.
    Mechanism of
    injury

    : The patient was riding a motorcycle when accidentally


    struck another vehicle. He was thrown from the
    motorcycle with his head landed first
    Sustained Injury : Mandible
    Symptom & sign : Headache
    Examination
    : Physical examination, Laboratory examination, Head CT
    Done
    Scan, skull X-Ray

    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear
    B: RR: 22x/minutes, spontaneous, symmetric,
    thoraco abdominal type
    C: BP: 110/70 mmHg, PR: 90 x/minute, regular,
    adequate
    D: GCS 15 (E4M6V5), pupil equal 3 mm/3 mm,
    Light Reflex +/+
    E: T (ax): 36,7 oC

    Secondary Survey
    Mandibular Region :
    I : Seen stitched wound size 4 cm.
    Hematome (-), wound (+)
    P : Tenderness (+), Crepitation (+)

    Laboratory Result
    WBC

    16,83 x 103 / L

    RBC

    5,05 x 106 / L

    HGB

    14,5 g/dL

    HCT

    42,6 %

    PLT

    279 x 103/ L

    CT / BT

    730/300

    Blood Sugar

    91 mg/dl

    Ureum

    13 mg/dl

    Creatinin

    0,8 mg/dl

    GOT / GPT

    32/31 /L

    Head CT scan

    Skull X-Ray

    WORKING
    DIAGNOSIS

    : - Mild head injury GCS 15

    MANAGEMENT

    : Apply IVFD

    (E4M6V5)
    - Mandibular fracture

    Medicaments
    Consult to senior plastic
    surgeon
    Advice: immediate ORIF

    OPERATION PROCEDURE
    Laid patient down onto supine position under
    GA
    Disinfection and draping procedure
    Proceed incision mucous on the mandibular
    Seen fracture line on mandibular parasimfisis
    Applied 2 plate, 5 burr hole with 4 screw and 3
    burr hole with 3 screw
    Rinse the wound by NaCl and betadine
    Stitch the wound layer by layer
    Done

    POST OP
    DIAGNOSIS

    : - Mild head injury GCS 15

    PROGNOSIS

    : Good

    FOLLOW UP

    : Vital sign

    (E4M6V5)
    - Mandibular fracture

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