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77.38.04
Chief Complain : Swelling on the Mouth
It had been suffered by patient since 6 hours
before admission to Adam Malik Hospital.
Previously the patient was riding motorcycle and
the patient fell off the motorcycle while avoiding
another motorcycle. Patient’s face bump to the
road. Patient was not wearing helmet. History of
vomiting (-), unconsciousness (+), and seizure
(-). Patient was refered from district hospital.
PRIMARY SURVEY
A : Clear
B : Spontan, RR : 20 times/minute
C : Warm acral, CRT <2”, HR : 88
beats/minute, BP : 110/70 mmHg
D : GCS 15 (E4V5M6)
E : Logroll and undressed → lacerated
wound o/t upper lips, upper gum rupture
VAS : 4
AMPLE
A : No history of Allergy
M : No history of Medication
P : No history of Past Illness
L : Last meal 4 hours before accident
E : Street
SECONDARY SURVEY
• Head : In localized state
• Neck : No abnormality was found
• Chest : No abnormality was found
• Abdomen : No abnormality was found
• Genitalia : Male, no abnormality was found
• Extremities : No abnormality was found
Localized State
Head :
• Eye : equal pupil’s diameter 3mm/3mm, light
reflex +/+, diplopia (-), visus (+) normal.
Hematom (-), eye ball movement (+) normal