CASE REPORT

Monday, October 13rd 2014

Team on duty:
dr. Fachrul Razi
dr. Nizarli
dr. Rynaldi Andriansya
dr. Lea Darman S. Husen
dr. Jauhari Deslo Angkasa Wijaya
dr. Sumrahadi Manurung
dr. Zumirda Zainal
dr. Muhammad Reza
dr. Yoki Oktadi
I.

Patient identity
Name
Age
Sex
Address
MR
Phone
Patient came at
Driving license

:
:
:
:
:

Sofyan
35 years old
Male
Ds.Tuwi Kareung , Kec. Panga, Aceh Jaya
1-02-25-72
: 085358750221
: 10.30 PM
: (+)

II.

Chief complain
Headache after trauma

III.

Patient illnes history

The patient came to Zainoel Abidin emergency room with a chief
complain headache after trauma since 13 hours ago. He was
riding motorcycle without helmet and suddenly headlong by
buffalo rampage on its head. History of nausea and vomit (-),
history of decrease of consciousness (-)

IV.

Physical Examination
Primary Survey :
A : Clear
B : Spontaneous, RR: 20 breaths/ minute
C : Pulse: 85 beats/minute, Blood Pressure: 120/80 mmHg
D : GCS : E4M6V5 : 15; isochoric pupil, 3mm/ 3mm no
lateralization,
light reflex (+/+)

E : L/S ar left temporal region :

L : hematoma (+), oedema (+), sutured wound (+) size 8 x 1
cm
F : Pain (-)
Visus : in normal limit
Secondary survey
Head
:
L/S ar left temporal region :

L : hematoma (+), oedema (+), wound (+)

F : Pain (-)
Visus : in normal limit
Neck
: In normal limited
Thorax
: In normal limited
Abdomen
: In normal limited
Pelvis
: In normal limited
Lower limb
: In normal limited
V.

Assessment :
1. Mild head injury
2. Excoriated wound at the left temporoparietal region

VI.

Management
Stop oral intake
Head up 30
Oxygen 7 litre via facemask
IVFD NaCl 0,9% 20 drips/minutes
Urinary catheter
Ceftriaxone inj. 1 gr
Ketorolac inj. 30 mg
Laboratory examination
Radiology examination

VII.

Laboratory result
Hb
: 15,3 gr/dl
White blood count : 14.500 /ul
Platelet
: 178.000 /ul
CT
: 7 minute
BT
: 2 minute
Ht
: 45 %
Ureum
: 23 mg/dl
Creatinin
: 0,90 mg/dl

VIII.

Radiology result
Head CT-Scan :
There was SCALP hematoma at left temporoparietal
There was depressed fracture at the left temporal region
Sulcus and gyrus was narrow
There was hypodense/ hyperdense area
Ventricle and cysterna system normal
There was no midline shift.

IX.
1.
2.
3.

Diagnose
Mild head injury
Excoriated wound at the left temporoparietal region
Open depressed fracture at the left temporal region

X.

Consult to Neurosurgery Division

Craniotomy elevation depressed fracture

XI. Operative Report

Patient was supine position, extended to the right side, head up 300,
with general anesthesia
Performed horse shoe incision at the left temporoparietal region,
incision layer by layer until bone
Identified depressed fracture at the left temporal region
Performed one burr hole
Performed elevation depressed fracture
Performed one tube drain
XII. Diagnose
1. Mild head injury (ICD 10 CM S.06)
2. Excoriated wound at the left temporoparietal region
3. Open depressed fracture at the left temporal region
S.02)

XIII. Follow up

(ICD 10 CM

Date
15/10/2014
POD II

S
O
A
P
Pain (-)Vital sign
1. Mild head injuryHead up 30
GCS
(ICD 10 CM S.06) Oxygen 7 litre
BP
: 120/80 mmHg
2. Excoriated woundvia facemask
HR
: 80 beats/minute
at
the
rightIVFD NaCl 0,9%
RR
: 20 breaths/minute
20 drips/minutes
temporoparietal
Temp : oC
Ceftriaxone inj.
region
L/S left temporal region : 3. Open
depressed1 gr
Drain
fracture at the leftKetorolac inj. 30
L : hematoma (+), gauze
temporal
regionmg
F : Pain (-)
(ICD 10 CM S.02)
Urin output
Post Elevation
depressed fracture