Emergency Case Report

July 11-12th 2015

Resident on Duty:
dr. Zacky Fauzie
Chief :
Evi Febriana Hafisah
Co-ass:
Rasdita Nurhidayati
Miranti Rahmi Aprilia
Jefry Albari Tribowo
Alvita Fani Yulita

Patients List
N
o

1.

2.

Identity

Mrs.
Ernawati/4
0 y.o

Mr.Supriya
nto/23 y.o

Admissio
n to E.R.

July 11th
2015 at
15.50
WITA

July 11th
2015 at
22.00
WITA

Diagnosis

Treatment
Obs. Vital sign
Oxygenation
Head up 30
Antibiotic
Analgetic
H2 Blocker

Hidrocephalus
Acute +
Meningoencephalit
Consult to neurosurgery :
is
Pro PV Shunt
Patient discharged by
request

Obs. Vital sign

Oxygenation
Moderate head
Head up 30
injury E3V4M5 + Antibiotic
EDH 60 cc + closed Analgetic
fr frontalis dex + H2 Blocker
closed fr Zygoma X ray thorax
CT Scan
dex + closed fr

zygomatic process
Consult to neurosurgery :
dex

Patients List
N
o

3.

Identity

Admissio
n to E.R.

July 12th
Mrs.
2015 at
Saugiah/47
01.10
y.o
WITA

Diagnosis

Treatment

Obs. Vital sign

Oxygenation
Mild head injury
Head up 30
GCS E3V5M6 +
Antibiotic
Cerebral Edema + Analgetic
Lefort I & II + CF H2 Blocker
Zygomatic Process CT Scan, Xray
Consult to Neuro surgery :
Sinistra + CF
Sphenoid Sinistra pro conservative
Consult to Plastic surgery :
pro ORIF

Mrs. Ernawati/ 40 y.o/

July 11th 2015/ 15.50 WITA
Chief Complain : decrease of consciousness
History:
The patient has decreased her consciousness about 1 wee ago.
About 1 month before, she complained about headache with
vomitus and nausea. The headache worsen by the time. Headache
didnt decrease by analgetic. About 2 weeks ago she looked for
medication to Kotabaru Hosp but then she dismissed after
decreasing of consciousness 1 week ago. She was brought to
Millenia Clinic at Banjarmasin. She was getting better and
conscious in Millenia Clinic for 2 days but getting decreased her
conciousness back. Because of that, she was referred to Suaka Insan
and warded at ICU for 3 days. After that she treated at Woman
ward for 4 days then referred to Ulin hosp for further treatment.
History of fever 2 weeks before headache. History of seizure (-).
History of hypertension (+).

Vital Sign

General Status

Neurological status
Patological reflects :
Brudzinskis signs (-)

Cornea reflects : (-/-)

Babinskis signs (+/+)

Pupil size (5mm/5mm)

Chaddocks signs (+/+)

Pupil reflects (-/-)

Hoffmans signs (-/-)

Tromners signs (-/-)
Gordons signs (+/+)
Rossolimos signs (+/+)
Schaffers signs (+/+)

Motoric

+3 +3
+3 +3
Sensoric +
+
+
+
Tonus
<
<
<
<
Clonus
-

APR
KPR
BPR
TPR

+1
+1 +1
+1 +1
+1 +1
+1 +1
+1 +1
+1 +1
+1 +1

+1

Clinical Picture

X ray Thorax June 27th 2015

CT scan June 27th 2015 at Sari Mulia Hosp

CT scan July 8th 2015 at Suaka Insan Hosp

CT scan July 8th 2015 at Suaka Insan Hosp

Laboratory finding July 11th 2015

Working Diagnosis
Hydrocephalus Acute +
Meningoencephalitis

Management
Obs. Vital sign
Oxygenation
Head up 30
Antibiotic
Analgetic
H2 Blocker
Consult to neurosurgery :
Pro PV Shunt
Patient discharged by request

Mr.Supriyanto/23 y.o
July 11th 2015/22.00 WITA
Chief Complain : open wound at head
History:
+ 4 hours before admission patient had an
accident at Tanah Bumbu area, he rode a
motorcycle and hited by another motorcycle
from behind. He fell and got an open wound at
head. Helmet (-). History of nausea and
vomitting (-/-). Bleeding from ear/nose/mouth
(+/+/-). History of fainted (-). History of seizure
(-). Patient from Tanah Bumbu hosp and patient
was referred to Ulin Hospital for further
treatment.

Primary Survey

Ceftriaxone,
Piracetam,
Ketorolac,
Ranitidin,

1 hours before
admission

Tanah Bumbu
area

Secondary Survey

Clinical Picture

Clinical Picture

X-Ray July 11th 2015

X-Ray July 11th 2015

Head CT Scan July 11th 2015

Laboratory finding July 11th 2015

Laboratory finding July 11th 2015

Working Diagnosis
Moderate head injury E3V4M5 + EDH 60
cc + closed fr frontalis dex + closed fr
Zygoma dex + closed fr zygomatic
process dex

Management
Obs. Vital sign
IVFD NS
Antibiotic
Analgetic
H2 Blocker
Head CT-Scan, xray thorax,
complete blood count
Consult to Neurosurgery :
Craniotomy evacuation

Mrs. Saugiah/47 y.o

July 12th 2015/01.10 WITA
Chief Complain : decrease of consciousness
History:
+ 14 hours before admission patient had an accident
at Martapura, she rode a motorcycle and hit by
another motorcycle from opposite. She rode a
motorcycle with his son rode the motorcycle and she
was on passanger seat. Helmet (+). Suddenly she
hitted from behind. She thrown away to the ground.
History of nausea and vomitting (-). Bleeding from
ear/nose/mouth (-/-/-). History of fainted (+) 1o
minutes. Patient from Ansari Saleh hosp and patient
was referred to Ulin Hospital for further treatment.

Primary Survey

Ceftriaxone,
Ketorolac,
Ranitidin,

7 hours before
admission

Martapura area

General Status

Local Status
a/r kepala :
rima orbita :Step off defect (-/-)
Os. Zygomaticum : step off defectt (+/+)
Os. Nasalis : step off defect (+/+)
Os. Maxillaris : step off defect (+/+) floating maxilla

(+)
Visus (N)
Maloklusi (-)

Clinical Picture

X-Ray July 11th 2015

Head CT Scan July 12th 2015

Laboratory finding July 12th 2015

Laboratory finding July 12th 2015

Working Diagnosis
Mild head injury GCS E3V5M6 +
Cerebral Edema + Lefort I & II + CF
Zygomatic Process Sinistra + CF
Sphenoid Sinistra

Management
Obs. Vital sign
Oxygenation
Head up 30
Antibiotic
Analgetic
H2 Blocker
CT Scan, Xray
Consult to Neuro surgery : pro
conservative
Consult to Plastic surgery : pro ORIF

THANK YOU