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MORNING REPORT
MANDIBLE FRACTURE
Nurmuthmainnah0908120468
Level of om!etene " #$
%i&no'e( earl) thera!)( re*erin&
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+i'tor) ta,in&
I-entit)
Name " Tn. /
&e " 16 )o
-mitte- to the ho'!ital on " %e 1th201#
hief om!laintthe !atient oul-n3t he foo- 'ine &otai-ent 1
-a)' 5efore a-mitte- to the
ho'!ital
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Primar) urve)
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ira) an- ervial ontrol
a. Objective: Patient oul- an'er 7ue'tion' 5ut he '!o,e
unuentl)
hen a',e- 5eau'e he a' -iult to o!en hi' mouth.
There a' no a--itional 5reath 'oun-' :&ur&lin&(
'norin&(
'ti-or;.
b. Assessment: No aira)3' o5'trution :5) 'oli-'( li7ui-';
Patent airway
c. Action: O
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a. Objective No le'ion or oun- on he't all( ')mmetrial
he't all movement(fre7uen) of 5reathin& 22 t!m
re&ularl).
b. Assessment
>entilation an- lun& e
L=m
$reathin&
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irulation
a. Objective ?arm aral( capillary refll time:RT; @2 '.
Pul'e a' !al!a5le( 82 t!m re&ularl)
5loo- !re''ure a' 120=0 mm+&
b. Assessment
Circulation was good
c. Action I>/% RL :NalA; 20 -!m
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%i'a5ilit)
a. Objective Patient awake
Glasglow coma scale :G;"
Eyes" o!ene- '!ontanou'l) :E4; erbal" oriente- :>B;
Motori," oul- follo in'trution :M6;
G 1B :E4>BM6;
Pu!il i'ohor C 2 mm=2 mm( li&ht ree< :D=D;
Motori' B B
B B
+em)!are'i' :;
b. Assessment Mini neurolo&i
te't " &oo-
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E
Patient3' lothe' 'houl- 5e o!ene- thenovere-
. There a' e
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eon-ar) urve)
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1 -a) 5efore a-mitte- to the ho'!ital( the !atient
&ot ai-enthen ri-e motor)le :ithouthelmet;( u--enl)( he a'
ru'he- 5) anothermotor)le from ri&ht 'i-e. Then( hi'
motor)le fell -on to the left. There a'e
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Pa't illne'' hi'tor)
No -i'ea'erelate- to thi' om!laint.
/amil) illne'' hi'tor)
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Ph)'ial eital 'i&n' " $loo- !re''ure " 120=0 mm+&
Pul'e " 82 t!m
RR " 22 t!m
T " #6(#
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+ea- an- ne, " +ea- " e
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+ea-
Man-i5le re&ion " Loo, "
E
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/eel
Ten-erne'' :D; on ri&ht an- left man-i5le
re!itation :;en'i5ilit) of loer li! :;
Move"
Patient an o!en hi' mouth 5ut re'trite-5eau'e of !ain( -i'tane
5eteen u!!er li!to loer li! "
Patient -iult to he foo-
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?or,in& -ia&no'e
frature man-i5le 5one' D 'omee
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u&&e'tion E
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+ea-T 'an#%
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/inal -ia&no'e
frature at the 5o-) an- an&le ofman-i5le 5one
$aa la&i re&io man-i5ula( -ia&no'i'a,hir 'e'uai
-en&an re&io
man-i5ula( 5u,an nama tulan&n)a
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thera!)
excoriation wound cleaned povidon iodine
Maloclution Fixation with
interdental wire, or Repoition and open !xation
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Than, )ou
