Duty Report

th
Saturday, July19 2014
Resident in charge :
dr. Wahyu R Wibowo

Consultant in charge

Digestive surgery

Dr. Arief setiawan SpB(K)BD

Urology surgery :

Dr.Nindra P., SpU.

Neuro surgery :

Dr. Agus Aulia SpBS

Oncology surgery :

Dr.Ktristina Maria SpB

Orthopaedic surgery :

Dr. AB Mulyanto, SpOT

Pediatric surgery :

Dr. IrhamniSpBA
Plastic surgery :

Dr Asrofi,SpBP, MARS
Cardiothoracic surgery :

Dr. Dedi A Zaelani, SpB(K)BV

Resume

Outpatients : 2 patients
Operations : 0 patient
Hospitalized : 1 patient

Outpatient

Mr. Gerry, 35 y.o,

WD: Laceration wound of the right

lower leg region (ICD-10:S81.819)

Mr. Anton, 32 y.o,

WD: Laceration wound of the right

foot region.
(ICD-10:S81.819A)

Nn.Nurlaili/ 31 yo

Hispitalized

CC :
Patients felt pain on her head and vomite since 1 hour before
admission
HPI :
1 hour hours before admission, patien had a motor vehicle
accident while he was driving a motorcycle, she wore
helmet. The mechanism of trauma was unknown, she was
found by people arround and brought to GS Hospital.
History of fainted (+), vomite(+) more than 2x. Patients felt
pain on her head . There was hematoma wound on the right
parietal region, no bleeding from ear nor nose.
Patien is being pregnant 6 months (G3P1A1)

Primary Survey :

A : Clear
B : Spontaneous, RR : 20 x/mnts , O2 saturation
100 percent
C : BP : 100/70 mmHg, HR : 96 x/mnts
D : Alert with GCS = E4M6V4 : 14
Pain score VAS : 5

Secondary Survey :
General condition
Head: subgaleal hematome (+) at right parietooccipital
Eye: anemic -/-, icteric -/-, Isocore pupil with diameter 3 mm.
Chest: symmetric, vesicular +/+, rhonchi -/-, wheezing -/Heart: HS I-II normal, murmur (-), gallop (-)
Abdomen: flat, supple, tenderness (-), bowel sound (+)
Ekstremity: warm, CRT<2

Local status :

Head : There was hematoma

wound on the parietal region, no
bleeding from ear nor nose.
Face : No excoriation , no
laceration on hematom periorbita,
no diplopia.
No maloclutio, no floating maxilla.

Neurological state:

GCS E4M6V4=14

isochor pupil, diameter 3 mm, light reflex of eye +/ +

Motoric: 4 extremity are normaly active

Sensoric : within normal limits

Autonomic : within normal limits

(BP : 100/70 mmHg, HR : 96 x/mnts RR 20x/mnts)

Laboratory finding :

within normal limits

Chest and cevical X-ray finding :

within normal limits

Head CT-Scan

Sub Galleal hematom on the right

temporo-parietal region
Contucio cerebri on the left frontal
dan temporal pole.
No intra cerebral bleeding
No mid line reft,
Normal gyrus and sulcus
(No sing of Space Occpying P
rocess finding)

No Fracture of calvaria
No Fracture of bone face

Working Diagnosed:
Mild head injury
with Contucio cerebri on the left frontal and
temporal pole.
(ICD-10: S06.2X)
Sub Galleal hematom on the right temporoparietal region
(ICD-10: S00.T88)

Pregnant 6 months (G3P1A1)

(ICD-10: 000.09A)

Treatment

Antibiotic, Analgesic
Anti odema cerebri
Conserfative tratment of neuro Surgery
Obsevation, If decrease of consciousness evaluation
Re-Head CT Scan
(Z51.81)

Consultation to OBSGIN Depatement :

good condition of her prengnacy
(Z34.0)
Anti uterus contraction : Duvadilan 2x1/2 tabets

Today Condition :

Stable condition, no dizzy , no vomite

Pain score : 2

Plan:

Discharge to day

Thank you

GCS

Indication CT Scan in Head Injuries

Selection of adults for CT scan
(NICE Clinical guideline (Jan 2014))

CT scan of the brain within one hour (with a written radiology report
within one hour of the scan being undertaken):
Glasgow Coma Scale (GCS) <13 when first assessed or GCS <15 two
hours after injury Suspected open or depressed skull fracture
Signs of base of skull fracture*
Post-traumatic seizure
Focal neurological deficit
>1 episode of vomiting
All patients with a coagulopathy or on oral anticoagulants should have a
CT brain scan within eight hours of the injury, provided there are no other
identified risk factors, as listed above. Again, a written radiology report
should be available within one hour of the scan being undertaken.

Selection of children (under 16 years) for CT scan

CT scan of the brain within one hour (with a written radiology report within one hour of the scan being undertaken):
Clinical suspicion of non-accidental injury
Post-traumatic seizure (no past medical history of epilepsy)
GCS <14 on initial assessment or, if <1 year, GCS <15
GCS <15 two hours after injury
Suspected open or depressed skull fracture or tense fontanelle
Signs of base of skull fracture*
Focal neurological deficit
Aged <1 - bruise, swelling or laceration >5 cm on the head
If none of the above are present then CT brain scan within one hour if more than one of the following are present (with a written
radiology report within one hour of the scan being undertaken):
Witnessed loss of consciousness >5 minutes
Amnesia (antegrade or retrograde) >5 minutes
Abnormal drowsiness
3 Discrete episodes of vomiting
Dangerous mechanism of injury (high-speed RTA, fall from >3 m, high-speed projectile)
If only one of the aforementioned risk factors is present then observe for a minimum of four hours - CT scan of the brain within
one hour if any of the following occur (with a written radiology report within one hour of the scan being undertaken):
GCS <15
Further vomiting
Abnormal drowsiness