Emergency Report NS 2-8 Oct

Emergency Report
Neuro Surgeon
October 2nd 8th October
2016
Co ass:
Desy Puspita Sari
General Surgery
Digestive Surgery
Thorax Cardiovascular Surgery :

Plastic Surgery
Urology Surgery
Neuro Surgery
Pediatric Surgery
Total
:
:
Oncology Surgery
Orthopaedy
Patient List
No
Identity
Admission to
ER
1.
Mrs. Siti
Fatimah/ 27 y.o./
1-22-70-09
October, 02th
2016/
11.00
am
Diagnose
Mild Head Injury
GCS 14
+
Vulnus Laserated
a.r left cruris
medial + left
parietal + right
manus
+
Multiple
excoriated a.r
abdomen
Treatment
VS + GCS obs
Head Up 30
O2 2 lpm
IVFD NS
Analgetic
Antibiotic
H2 Blocker
Consult to Neuro
Surgery:
- Head CT Scan
- Hospilalized
Patient List
No
2.
Identity
Ch. Alfia Nazwa/
6 y.o./
1-22-70.10
Admission to
ER
Diagnose
October, 02th Mild Head Injury

2016/11.20
GCS 15
am
+
Subgaleal
haemoatoma at
Left parietal
+
excoriated at
right zygoma
Treatment
VS + GCS obs
Head Up 30
O2 2 lpm
IVFD NS
Analgetic
Antibiotic
H2 Blocker
Consult to Neuro
Surgery:
- Head CT Scan
- Discharged to
permision
Patient List
No
3.
Identity
Mrs. Mariatul/
60 y.o./
1-22-70-14
Admission to
ER
Diagnose
October,
02th Mild Head Injury
2016/12.47 am
GCS 15
+
Subgaleal
Haematoma at
right parietal
Treatment
VS + GCS obs
Head Up 30
O2 2 lpm
IVFD NS
Analgetic
H2 Blocker
Calcium channel
Blocker
Consult to Neuro
Surgery:
-Head CT Scan
-Hospitalized
Patient List
No
Identity
4.
Mis. Nida
Wati/21y.o./
1-22-70-00
Admission to
ER
Diagnose
Treatment
October,
02th Mild Head Injury VS + GCS obs
2016/ 08.00 m
GCS 15
Head Up 30
IVFD NS
Analgetic
H2 Blocker
Antibiotic
Head CT Scan
Consult to Neuro
Surgery:
-Hospitalized
Patient List
No
5.
Identity
Admission to ER
Tn. Rudiansyah/ October 3rd 2016

22 y.o./
05.40 a.m
Diagnose
Multiple vulnus
ictum a.r. upper
extrimity D/S,
back+ zygoma
S+open fracture of
sinistra parietal of
calvaria + susp.
internal bleeding
Treatment
Oxygenation
2 IV ine
Catheter
Observation
Co. Digestive-thorax
cardiovascular surgery :
Not suggestif of internal bleeding,
pro USG abdomen
Co. Orthopaedi :
Bilateral x ray elbow, evaluated
active bleeding
Co. neurosurgery:
Colloid + transfusion
Co. Plastic surgery:
Debridement + wound haecting
Patient List
No
6.
Identity
Admission to
ER
Mr. M. Hidayatul/23 October 4th

y.o/ 1.21.87.26
2016
Diagnose
Treatment
Post op VP Shunt
ai hydrocephalus
obstruktif ec
infratentorial
tumor
Head up 30 degree
VS obs
IVFD Nacl
Antibiotic
Analgetic
Manitol
dexametason
H2 Blocker
Complete blood
count
Co.to. Neuro
surgery:
Hospitalized
Patient List
No
7.
Identity
Mr. M. Agung/18
y.o/ 1.22.71.76
Admission to
ER
October 4th
2016
Diagnose
Severe head
injury GCS 6 +
susp fraktur basis
cranii + ICH
temporalis dextra
Treatment
Head up 30derajat
VS obs
IVFD Nacl
Antibiotic
Analgetic
H2 Blocker
Complete blood
count
Co.to.
Neurosurgery:
Pro OP Cito
craniotomi
evakuasi
Patient List
No
8.
Identity
Ch. Noorjanah/17
y.o/ 1.22.71.47
Admission to
ER
October 4th
2016
Diagnose
Mild Head injury
+ SAH + ICH
temporalis D +
fraktur
temporoparietal
D
Treatment
Head up 30derajat
VS obs
IVFD Nacl
Antibiotic
Analgetic
H2 Blocker
Complete blood
count
Co.to. Neurosurgery
surgery:
Conservative
Hospitalized
Patient List
No
9.
Identity
Mrs. Rusniah/ 51 yo
1-22-72-83
Admission to ER
oct, 4th 2016
06.00 pm
Diagnose
Mild head injury
+
Laceratum wound of
left temporoparietal
Treatment
Obs GCS, VS
IVFD NS
Head up 30
O2
Analgetic
H2 Blocker
Antiemetic
Co neurosurgery
observation
Patient discharge by
permission
Patient List
No
No
2.
10.
Identity
Identity
Mr.
Mr. Iduar/
Iduar/ 44
44 yo
yo
1-22-72-94
1-22-72-94
Admission
Admission to
to ER
ER
th
oct,
oct, 4
4th 2016
2016
09.00
09.00 pm
pm
Diagnose
Diagnose
Moderate
Moderate head
head injury
injury
+
+
Contusio
Contusio cerebri
cerebri ar
ar
right
right and
and left
left of
of FTP
FTP
+
+
Edema cerebri
cerebri
Edema
+
+
Fracture
Fracture liner
liner lef
lef of
of
occipital
occipital
+
+
SDH
SDH ar
ar left
left of
of occipital
occipital
+
+
EDH
ar
right
EDH ar right of
of occipital
occipital
Treatment
Treatment
Obs
Obs GCS,
GCS, VS
VS
IVFD
IVFD NS
NS
Head
Head up
up 30
30
Oksigenasi
Oksigenasi
antibiotic
antibiotic
Analgetic
Analgetic
H2
H2 Blocker
Blocker
Co
Co neurosurgery
neurosurgery
manitol
manitol 3
3x
x 150
150 mg,
mg,
hospitalazed
hospitalazed
Patient List
No
No
2.
11.
Identity
Identity
Mr.
4464
yo yo
Mr. Iduar/
parnoto/
1-22-72-94
1-22-72-94
Admission
Admission to
to ER
ER
th
oct,
oct, 4
5th 2016
2016
09.00
00.10 pm
pm
Diagnose
Diagnose
Moderate
Moderate head
head injury
injury
+
+
Contusio
cerebri
ar
Corpus alineum
wood
right
left of FTP
untiland
intracranial
+
+
Edema cerebri
cerebri
Edema
+
Fracture liner lef of
occipital
+
SDH ar left of occipital
+
EDH ar right of occipital
Treatment
Treatment
Obs
Obs GCS,
GCS, VS
VS
IVFD
IVFD NS
NS
Head
Head up
up 30
30
Oksigenasi
Oksigenasi
antibiotic
antibiotic
Analgetic
Analgetic
H2
H2 Blocker
Blocker
Co
Co neurosurgery
neurosurgery
manitol
3 x 150 mg,
craniotomi
hospitalazed
debridement, post op
ICU
Patient List
No
No
2.
12.
Identity
Identity
Mr.
44yo
yo
Mr. Iduar/
dudi/ 16
1-22-72-94
1-22-72-98
Admission
Admission to
to ER
ER
th
oct,
oct, 4
5th 2016
2016
09.00
01.00 pm
pm
Diagnose
Diagnose
Moderate
Moderate head
head injury
injury
+
+
Contusio
EDH arcerebri
left of ar
right
and left of FTP
temporoparietal
+
+
Edema cerebri
cerebri
Edema
+
+
Fracture
liner
of
Midline
shift
> lef
5mm
occipital
+
+
Treatment
Treatment
Obs
Obs GCS,
GCS, VS
VS
IVFD
IVFD NS
NS
Head
Head up
up 30
30
Oksigenasi
Oksigenasi
antibiotic
antibiotic
Analgetic
Analgetic
H2
H2 Blocker
Blocker
Co
Co neurosurgery
neurosurgery
manitol
3 x 150 mg,
CITO craniotomi
hospitalazed
evakuasi
Patient List
No
13.
Identity
mr. M Amin/ 25 yo
1-22-76-25
Admission to ER
oct, 6th 2016
05.30 pm
Diagnose
Mild head injury
+
EDH ar left
temporoparietal
Treatment
Obs GCS, VS
IVFD NS
Head up 30
Oksigenasi
Analgetic
H2 Blocker
Antibiotik
Co neurosurgery
ranioyomi evakuasi
CITO
Patient List
No
No
2.
14.
Identity
Identity
Mr.
Ch. Iduar/
rifai/ 344
yoyo
1-22-72-94
1-22-76-10
Admission
Admission to
to ER
ER
th
oct,
oct, 4
7th 2016
2016
09.00
04.30 pm
pm
Diagnose
Diagnose
Moderate
head
injury
mild head
injury
+
+
Contusio
Laserationcerebri
woundar
ar
rightleft
and
left of FTP
parietal
+
Edema cerebri
+
Fracture liner lef of
occipital
+
+
Treatment
Treatment
Obs
Obs GCS,
GCS, VS
VS
IVFD
IVFD NS
NS
Head
Head up
up 30
30
Oksigenasi
Oksigenasi
antibiotic
Hecting
Analgetic
Wound toilet
H2
Blocker
Analgetic
Antibiotik
Co
H2 neurosurgery
blocker
manitol 3 x 150 mg,
hospitalazed
Co
neurosurgery
observation
Patient discharge by
permission
1. Mrs. Siti Fatimah/ 27 y.o/ 1-22-70-09

Chief Complain:
Decreased of consciousness
History of Current Disease:
Since 1 hour before admission, patient got
decreased of consciousness after an accident.
She fell from the motorcycle and her dress
twisted on the chain of the motorcycle . Her head
hit the road and her body dragged for about 10
meters. Helmet(-). History of unconsciousness
(+). History of vomiting (-). History of bleeding in
nose (-), mouth (-) ear (-) convulsion (-). After the
accident, he brought to Ulin General Hospital for
Primary survey :
A : Clear, without c-spine control
B : Spontaneous, RR 20 x/m, regular, Rh (-/-), Wh (-/-)
C : HR: 82 x/m, BP 110/80 mmHg
D : GCS 14: E3V5M6, pupil round 3mm/3mm, light reflex +/+, Lateralization (-/-) , BH
(-/-), BS (-/-), BR (-/-), BO (-/-)
Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 3 hours before accident
E = Environtment on the road
Physical
Head examination
Clinical Picture
Excoriated at left parietal, size

3x2x0,5 cm, bleeding (+) minimal
active
Clinical Picture
Multiple excoriated at abdomen
Vulnus lacerated at left cruris,

size 6x2,5 cm
Laboratory
Examination
Result
Normal value
Hemoglobin
13.4
11.00-16.00
g/dl
Leucosit
10.5
4.0-10.5
103 /ul
Eritrosit
4.46
4.50-6.00
106/ul
Hematocrit
40.4
42.00-52.00
Vol%
Trombocit
246
150-450
106 /ul
Random Blood
Glucose
150
<200
Mg/dL
SGOT
31
0-46
U/I
SGPT
24
0-45
U/I
Urea
18
10-50
Mg/dL
Creatinine
0.7
0.7-1.4
Mg/dL
Laboratory
Examination
Result
Normal value
Natrium
138
135-146
Mmol/l
Kalium
3.4
3.4-5.4
Mmol/L
Chlorida
108
95-100
Mmol/L
PT
9.7
9.9-13,5
second
APTT
22.3
22,2- 37
second
INR
0.85
Head CT Scan
X-Ray Thorax
Working Diagnosis
Mild Head Injury GCS 14
+
Vulnus Laserated a.r. Left cruris medial + Left parietal +
Right manus
+
Multiple excoriated a.r abdomen
Management
VS + GCS obs
Head Up 30
O2 2 lpm
IVFD NS
Analgetic
Antibiotic
H2 Blocker
Consult to Neuro Surgery:
Head CT Scan
Hospitalized
2. Ch. Alfia Nazwa/ 6 y.o/ 1-22-70-10

Chief Complain:
Headache
Since 1 hour before admission, patient got
headache after an accident. She carried by her
father, and she fell after her mothers dress
twisted on the chain of the motorcycle . Her head
hit the road when she fell. Helmet(-). History of
unconsciousness (-). History of vomiting (1x) at
location and (2x) at her way to ulin Hospital. The
material of vomiting is her last meal. History of
bleeding in nose (-), mouth (-) ear (-) convulsion
Primary survey :
C : HR : 105 x/m
D : GCS 15: E4V5M6, pupil round 3mm/3mm, light reflex +/+, Lateralization (-/-) , BH
(-/-), BS (-/-), BR (-/-), BO (-/-)
Secondary survey
A = Allergy (-)
M = Medication (-)
Head
Physical
examination
General Status
Clinical picture
haematom at left parietal
excoriated at right
zygoma
Laboratory
Examination
Result
Normal value
Hemoglobin
13.1
11.00-16.00
g/dl
Leucosit
18.5
4.0-10.5
103/ul
Eritrosit
4.93
4.50-6.00
106 /ul
Hematocrit
39.9
42.00-52.00
Vol%
Trombocit
349
150-450
Thousand /ul
X-Ray Skull AP/Lat
Working Diagnosis
+
Subgaleal haematom at left parietal
+
Excoriated at right zygoma
Management
VS + GCS obs
Head Up 30
O2 2 lpm
IVFD NS
Analgetic
Antibiotic
H2 Blocker
Head CT Scen
Discharge by permision
3. Mrs. Mariatul/ 60 y.o./ 1-22-70-14

Chief Complain:
Vomiting
Patient complaint about vomiting since 3 hour before
admission, after patient got an accident. He rode the
motorcycle and he got a single accident. She also complaint
about headache since 3 hours before admission. He fell on
the road and his head hit the street. Helmet (+). History of
unconsciousness (-). Nausea (-). History of bleeding in nose
(-) mouth (-), and ear (-), convulsion (-). After the accident,
she brought to Bayangkara Hospital and she got an
injection of keterolac and ondancetron, she discharged by
permission. After she was home, she vomitted again and
Primary survey :
C : BP: 180/110, HR :84 x/m
D : GCS 15, pupil round 3mm/3mm, light reflex +/+, Lateralization (-/-) , BH (-/-), BS (-/-),
BR (-/-), BO (-/-), parese (-)
Secondary survey
A = Allergy (-)
M = Medication (-)
Head
Physical
examination
General Status
Clinical Picture
X-Ray Thorax
Head CT Scan
Laboratory
Examination
Result
Normal value
Hemoglobin
13.4
11.00-16.00
g/dl
Leucosit
9.3
4.0-10.5
103 /ul
Eritrosit
4.39
4.50-6.00
106 /ul
Hematocrit
39.7
42.00-52.00
Vol%
Trombocit
232
150-450
103 /ul
Random Blood
Glucose
270
<200
Mg/dL
SGOT
48
0-46
U/I
SGPT
29
0-45
U/I
Urea
17
10-50
Mg/dL
Creatinine
0.7
0.7-1.4
Mg/dL
Laboratory
Examination
Result
Normal value
Natrium
130.7
135-146
Mmol/l
Kalium
3.5
3.4-5.4
Mmol/L
Chlorida
102
95-100
Mmol/L
Working Diagnosis
+
Subgaleal Haematoma at right parietal
Management
VS + GCS obs
Head Up 30
O2 2 lpm
IVFD NS
Analgetic
H2 Blocker
Calcium channel Blocker
-Head CT Scan
-Hospitalized
4. Miss. Nida Wati/ 21 y.o./ 1-22-70-00

Chief Complain:
Unconsciousness
Patient was unconscious 5 minutes before admission.
Unconscious for about 2 minuts. History of unconsciousness
(+). Since 1 day before admission, patient got an accident.
She rode the motorcycle and he got a single accident. She
fell on the road and his head hit the street. Helmet (+).
Nausea (-). History of bleeding in nose (-) mouth (-), and ear
(-), convulsion (-). After the accident, she brought to Ulin
Hospital and she got observation until 6 hours. After
observation until 6 hours, she discharged by permission.
After she was home, she was unconsciousness again and
Primary survey :
C : BP: 100/70, HR :96 x/m
D : GCS 15, pupil round 3mm/3mm, light reflex +/+, Lateralization (-/-) , BH (-/-), BS (-/-),
BR (-/-), BO (-/-), parese (-)
Secondary survey
A = Allergy (-)
M = Medication (-)
Head
Physical
examination
General Status
Clinical Picture
Head CT Scan
Laboratory
Examination
Result
Normal value
Hemoglobin
11.7
11.00-16.00
g/dl
Leucosit
6.1
4.0-10.5
103 /ul
Eritrosit
4.29
4.50-6.00
106 /ul
Hematocrit
36.8
42.00-52.00
Vol%
Trombocit
218
150-450
103 /ul
Random Blood
Glucose
115
<200
Mg/dL
Natrium
133
135-146
Mmol/l
Kalium
3.3
3.4-5.4
Mmol/L
Chlorida
97
95-100
Mmol/L
Working Diagnosis
Management
VS + GCS obs
Head Up 30
IVFD NS
Analgetic
H2 Blocker
Antibiotic
Head CT Scan
Hospitalized
5. Mr. Rudiansyah / 22 y.o.

Chief Complain:
Multiple wound
The patient has multiple wound after he got fight
with his friend using big knife. Based of an info,
he got this fight at 09.00 pm and found in
Mosque. He brought to Binuang hospital and
referred to Ulin Hospital.
Primary survey:
B : Spontaneous, RR 24x/m, regular, Rh (-/-), Wh (-/-)
C : HR :114x/m,regular,BP 80/60 mmHg
D : GCS : E3V5M6, pupil isokhor, round 3mm/3mm, light reflex +/+, Lateralization
(-/-) , BH (-/-), BS (-/-), BR (-/-), BO (-/-)
Secondary survey:
A = Allergy (-)
M = Medication (-)
L = Last meal unknown
E = Environment on the road
Head
Physical
Examination
General Status
Clinical Picture
a.r. zygoma D:
Open wound (+), bone as
its base, active bleeding (-)
Clinical Pictures
right upper extremity :
a.r. humerus D : open
wound 13x5x 2 cm, active
bleeding (-), muscle as its
base
a.r. antebrachii D:
Open wound (+) 15x7x2
cm, active bleeding (-),
muscle as its base
Clinical Pictures
Parietal S
Open wound (+) 18x2 cm,
active bleeding (+), open
fracture
Clinical Pictures
Left upper extremity :
a.r. humerus S : open
wound 10x5x 2 cm, active
bleeding (+), muscle as
its base
a.r. antebrachii S:
Open wound (+) 9x5x1
cm, active bleeding (-),
muscle as its base
Clinical Pictures
a.r. Back:
Open wound (+) 15x8 cm,
active bleeding (+), bone
as its base
Clinical Pictures
I : Distention (-)
A : bowel sound (+)
P : Tenderness (+) hyphocondriaca Dextra, defans muscular (-)
P : tympani all region
Working Diagnosis
Multiple vulnus ictum a.r. upper extrimity D/S, back+

zygoma S+open fracture of sinistra parietal of calvaria +
susp. internal bleeding
Management
Oxygenation
2 IV ine
Catheter
Observation
Co. Digestive-thorax cardiovascular surgery :
Not suggestif of internal bleeding, pro USG abdomen
Co. Orthopaedi :
Bilateral x ray elbow, evaluated active bleeding
Co. neurosurgery:
Colloid + transfusion
Co. Plastic surgery:
Debridement + wound haecting
6. Mr. M. Agung 18 y.o/1.22.71.76

Chief Complain:
Decrease of conciousness
patient was riding motorcycle and got accident at
Gambut. There is no witness so the mechanism was
unclear.
Primary survey :
A : Clear without c spine control
B : RR 20 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP:100/60 mmhg HR: 98x/m;
D : GCS 6 E1V2M3, pupil round equal 3 mm, light reflex +/+
lateralization (-) , BH(-/-) BS(-) BO(-/-) BR (-)
Secondary survey
A = Allergy (-)
M = Medication
L = Last meal Unclear
E = Environment on the street
Head
Physic
Diagnostic
Clinical picture
Working Diagnosis
Severe head injury GCS 6 + susp fraktur basis
cranii + ICH temporalis dextra
Management
Head up 30derajat
VS obs
IVFD Nacl
Antibiotic
Analgetic
H2 Blocker
Complete blood count
Co.to. Neurosurgery:
Pro OP Cito craniotomi evakuasi
7. Ms. Noorjannah 17 y.o/1.22.71.47

Chief Complain:
Decrease of conciousness
Patient got accident 15 hours before admission. She
rode a motorcycle and hitted by other motorcycle from
side when she wanted to turnaround. Unconciousness
(+) bloody discharge from mouth/ear/nose (+/+/+).
Nausea/vomite (-/-). Seizure (-)
Primary survey :
A : Clear without c spine control
B : RR 22 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP:90/70 mmhg HR: 108x/m;
D : GCS 14E3V5M6, light reflex sde/+
lateralization (-) , BH(-/-) BS(-) BO(-/+) BR (-)
Secondary survey
A = Allergy (-)
M = Medication
L = Last meal 15 hour ago
E = Environment on the street
Head
Physic
Diagnostic
Clinical picture
Working Diagnosis
Mild Head injury + SAH + ICH temporalis D +
fraktur temporoparietal D
Management
Head up 30derajat
VS obs
IVFD Nacl
Antibiotic
Analgetic
H2 Blocker
Co.to. Neurosurgery surgery:
Conservative
Hospitalized
8. Mr. Hidayatullah 23 y.o/1.21.87.26

Chief Complain:
Vomite
Patient referred from Rantau Hospital with susp increase
of intracranial pressure due to SOL. He complained
vomite since 1 month before admission. He has
undergo VP Shunt operation at RSUD Ulin 1 month
ago.
Vital sign
BP : 100 / 70 mmhg
HR : 72 Bpm
RR : 20 tpm
T : 36,4 0C
GCS 15 E4V5M6
Head
Physic
Diagnostic
Clinical Picture
Clinical picture
Working Diagnosis
Post op VP Shunt ai hydrocephalus obstruktif ec
infratentorial tumor
Management
Head up 30 degree
VS obs
IVFD Nacl
Antibiotic
Analgetic
Manitol
dexametason
H2 Blocker
Co.to. Neuro surgery:
Hospitalized
9. Mrs. Rusniah/51 yo
1-22-72-83
CC : Headache
Since two hours before admission, patient got accident when

he was ride a motorcycle suddenly she fell by herself and his
head hit the road. Helmet (+) History of unconsciousness (+).
History of vomiting (+) two times. History of bleeding in ear (-),
nose (-), mouth (-). After the accident patient complained
headache. Because of his complained, he brought to gambut
health center and then referred to Ulin Hospital for further
treatment
Primary survey :
A : Clear
B : RR 24 x/m, symmetrical shape and movement, VBS equal
C : HR :80 x/m, BP: 110/80
D : GCS 15: pupil round equal 3mm, light reflex +/+, Lateralization (-/-) ,
Secondary survey
A = Allergy (-)
M = Medication (-)
L = Last meal 1 hour before accident
Physical examination
Head
General Status
Clinical picture
localized status
At left of temporoparietal
I: Wound(+) 2x2 cm, reguler, suture(+)

F: tenderness(+), bleeding(-)
M:-
Skull AP LAT
Working Diagnosis
Mild head injury

+
Laseratum wound of left
temporoparietal
Management
Obs GCS, VS
IVFD NS
Head up 30
O2
Analgetic
H2 Blocker
Antiemetic
Co neurosurgery observation
Patient discharge by permission
10. Mr. iduar/44 yo

1-22-72-94
Chief Complain:
Decreased of unconsciousness
7 hours prior to admission, patient got accident when he was riding a
motorcycle with medium speed and got hit by another motorcycle from the
front. Helm (+), history of seizure (-), history of fainted (+) more than 15
minutes, history of vomiting (-), Bleeding from ear (+) nose (+) mouth (-).
Because of his complain,the patient brought to public health centre of
kintapura and reffered to boejasin hospital for observation until 3 hours
and then reffered to Ulin general hospital for further treatment.
Primary survey :
A : Clear
C : HR :90 x/m, BP: 160/100
D : GCS 12, E3V4M5 pupil round equal 3mm, light reflex +/+, Lateralization (-/-) ,
Secondary survey
A = Allergy (-)
M = Medication (-)
Head
General Status
Clinical picture
Head ct scan
Working Diagnosis
Moderate head injury
+
Contusio cerebri ar right and left of FTP
+
Edema cerebri
+
Fracture liner lef of occipital
+
+
Management
Obs GCS, VS
IVFD NS
Head up 30
Oksigenasi
antibiotic
Analgetic
H2 Blocker
Co neurosurgery manitol 3 x 150 mg, hospitalazed
11. Mr. Parnoto/64 yo

1-22-72-94
Chief Complain:
Since 1 day before admission, patient got accident when he ride a
motorcycle, he felt down himself and his nose got stabbed wood. Helm (+),
history of seizure (-), history of fainted (+), history of vomiting (-), Bleeding
from ear (-) nose (+) mouth (-). Because of his complained patient brought
to palangkaraya hospital and reffered to Ulin general hospital for further
treatment.
Primary survey :
A : Clear
C : HR :90 x/m, BP: 160/100
Secondary survey
A = Allergy (-)
M = Medication (-)
Head
General Status
Clinical picture
Laboratory
Examination
Result
Normal value
hemoglobin
13,7
11.00-16.00
g/dl
Leucosit
13,5
4.0-10.5
Thousand /ul
eritrosit
4,41
4.50-6.00
milion /ul
hematocrit
40,7
42.00-52.00
Vol%
trombocit
239
150-450
Thousand /ul
Random Blood
Glucose
164
<200
Mg/dL
SGOT
193
0-46
U/I
SGPT
60
0-45
U/I
Urea
44
10-50
Mg/dL
Creatinine
1,2
0.7-1.4
Mg/dL
Laboratory
Examination
Result
Normal value
PT
10,1
9.9-13,5
secon
APTT
25
22,2- 37
secon
INR
0,89
Head ct scan
Working Diagnosis
+
Corpus alineum wood until
intracranial
+
Edema cerebri
Management
Obs GCS, VS
IVFD NS
Head up 30
Oksigenasi
antibiotic
Analgetic
H2 Blocker
Co neurosurgery craniotomi debridement, post op ICU
12. Mr. Dudi/16 yo

1-22-72-98
Chief Complain:
Since 5 hours before admission, patient got accident when he ride a
motorcycle with medium speed, he got hit by other motorcycle from the
front. History of seizure (-), history of fainted (+), history of vomiting (+),
Bleeding from ear (-) nose (-) mouth (-). Because of his complained patient
brought to damanhuri hospital and hospitalazed 1 day in damanhuri
hospital but not progress and then reffered to Ulin general hospital for
further treatment.
Primary survey :
A : Clear
C : HR :83 x/m, BP: 120/100
Secondary survey
A = Allergy (-)
M = Medication (-)
Head
General Status
Clinical picture
Head ct scan
Working Diagnosis
+
EDH ar left of temporoparietal
+
Edema cerebri
+
Midline shift > 5mm
Management
Obs GCS, VS
IVFD NS
Head up 30
Oksigenasi
antibiotic
Analgetic
H2 Blocker
Co neurosurgery CITO craniotomi evakuasi
13. Mr. M. amin/25 yo

1-22-76-25
Since 7 hours before admission, patient got accident when he ride a
motorcycle with medium speed, he got hit by other motorcycle from the
behind. Helm (+), history of seizure (-), history of fainted (+) more than 15
minutes, history of vomiting (-), Bleeding from ear (-) nose (+) mouth (+).
Because of his complained patient brought to ansari saleh hospital and
then reffered to Ulin general hospital for further treatment.
Primary survey :
A : Clear
C : HR :85 x/m, BP: 130/90
D : GCS 14, E3V5M5: pupil round equal 3mm, light reflex +/+, Lateralization (-/-) ,
Secondary survey
A = Allergy (-)
M = Medication (-)
Head
General Status
Status localized
Ar left frontal
L: Hecting (+)
F: swelling(+),
tenderness(+), crepotasi(-)
Laboratory
Examination
Result
Normal value
hemoglobin
15,1
11.00-16.00
g/dl
Leucosit
15,2
4.0-10.5
Thousand /ul
eritrosit
5,21
4.50-6.00
milion /ul
hematocrit
45,1
42.00-52.00
Vol%
trombocit
188
150-450
Thousand /ul
Random Blood
Glucose
192
<200
Mg/dL
SGOT
78
0-46
U/I
SGPT
61
0-45
U/I
Urea
27
10-50
Mg/dL
Creatinine
1,5
0.7-1.4
Mg/dL
Laboratory
Examination
Result
Normal value
PT
10,5
9.9-13,5
secon
APTT
22,8
22,2- 37
secon
INR
0,92
Head CT- Scan
Working Diagnosis
Mild head injury

+
EDH ar left temporoparietal
Management
Obs GCS, VS
IVFD NS
Head up 30
Oksigenasi
Analgetic
H2 Blocker
Antibiotik
Co neurosurgery ranioyomi evakuasi CITO
14. Ch. Rifai/3 yo

1-22-76-10
CC : Headache
Since three hours before admission, patient got accident

when he was walking beside the road, he got hit by motorcycle
from the behind. History of unconsciousness (-). History of
vomiting (-). History of bleeding in ear (-), nose (-), mouth (-).
Bleeding at head.
After the accident patient complained
headache. Because of his complained, he brought to marabahan
health center and then referred to Ulin Hospital for further
treatment.
Primary survey :
A : Clear
C : HR :90 x/m,
D : GCS 15. pupil round equal 3mm, light reflex +/+, Lateralization (-/-) ,
Secondary survey
A = Allergy (-)
M = Medication (-)
Head
General Status
Clinical picture
Status localized
Ar left parietal
L: suture(+), bleeding(-)
F: tenderness(+).
Head ct scan
Thorax x-ray
Working Diagnosis
mild head injury

+
Laseration wound ar left parietal
Management
Obs GCS, VS
IVFD NS
Head up 30
Oksigenasi
Hecting
Wound toilet
Analgetic
Antibiotik
H2 blocker
Co neurosurgery observation
Patient discharge by permission

Emergency Report NS 2-8 Oct

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Emergency Report NS 2-8 Oct

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Emergency Report

Thorax Cardiovascular Surgery :

October, 02th Mild Head Injury

Tn. Rudiansyah/ October 3rd 2016

Mr. M. Hidayatul/23 October 4th

1. Mrs. Siti Fatimah/ 27 y.o/ 1-22-70-09

Excoriated at left parietal, size

Multiple excoriated at abdomen

Vulnus lacerated at left cruris,

2. Ch. Alfia Nazwa/ 6 y.o/ 1-22-70-10

haematom at left parietal

X-Ray Skull AP/Lat

3. Mrs. Mariatul/ 60 y.o./ 1-22-70-14

4. Miss. Nida Wati/ 21 y.o./ 1-22-70-00

Mild Head Injury GCS 15

5. Mr. Rudiansyah / 22 y.o.

Multiple vulnus ictum a.r. upper extrimity D/S, back+

6. Mr. M. Agung 18 y.o/1.22.71.76

7. Ms. Noorjannah 17 y.o/1.22.71.47

8. Mr. Hidayatullah 23 y.o/1.21.87.26

Since two hours before admission, patient got accident when

I: Wound(+) 2x2 cm, reguler, suture(+)

Mild head injury

10. Mr. iduar/44 yo

11. Mr. Parnoto/64 yo

12. Mr. Dudi/16 yo

13. Mr. M. amin/25 yo

Head CT- Scan

Mild head injury

14. Ch. Rifai/3 yo

Since three hours before admission, patient got accident

mild head injury

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