Patient identity

• Name : Mamah
• Age : 49 years old
• Sex : Female
• Address : Cot Bayu, Aceh
Selatan
• Phone : 085361686899
• MR : 1-14-07-42
• Admission Time : 21.51 WIB
 Time Response
Date/hour Examination Laboratory Radiology Hour of Date/hour DPJP
patient came to hour Examination Examination Diagnos patient out
ER tics from ER
Send Result Send Result

30/08/2017 21.55 WIB 21.55 23.40 21.55 22.50 22.50 20.00 Dr.
ISKANDAR,
WIB WIB WIB WIB WIB WIB SpBS
21.51 WIB
Chief Complaint
• Decrease of consciousness

Patient illnes History

• The patient was referred from Aceh Selatan
district hospital to Zainoel Abidin emergency
room with chief complaint of decrease of
consciousness for one day.
• Initially the patient was riding a motorcycle
without helm and suddenly strucked by a car
from behind and he fell off to the ground.
• There was history of nausea and vomiting (+)
• History alert after trauma (-).
• Patient opened eyes to verbal command,
purposeful movement and confused
Physical examination
Primary Survey:
• A: Clear, C Spine control wit collar neck
• B: Spontaneous, RR: 20 breaths/ minutes

Right haemithorax Left haemithorax

Inspection symmetrical, trachea in the middle, JVP was normal

Palpation Stem fremitus normal Stem fremitus normal

Percution Sonor Sonor
Auscultation Vesiculer Vesiculer
C : BP:160/80 mmHg, Pulse : 88 beats/minute
D : GCS : E3 M5 V4 = 12, isochoric pupil(3mm/3
mm), light reflex (+/+)
E:
L/S at the facial region
• L : Symetrically, swelling (-), wound (-),
brill hematome (+), battle sign (+)
• F :Step off (-)
L/S at the parietal region
L : Haematome (+), lacerated wound (+), size
8x0,5x0,5 cm, irreguler, base of the
wound was bone
F : Discontiunity of bone (-)
Secondary Survey
Head
L/S at the facial region
• L : Symetrically, swelling (-), wound (-),
brill hematome (+), battle sign (+)
• F :Step off (-)

L/S at the parietal region

L : Haematome (+), lacerated wound (+), size
8x0,5x0,5 cm, irreguler, base of the
wound was bone
F : Discontiunity of bone (-)
Thorax
Right haemithorax Left haemithorax
Inspection symmetrical, trachea in the middle, JVP was normal

Palpation Stem fremitus normal Stem fremitus normal

Percution Sonor Sonor
Auscultation Vesiculer Vesiculer

Abdomen  in normal limit

Upper extremity  in normal limit
Lower extremity  in normal limit
Assessments:
1. Moderate head injury
2. Lacerated wound at the parietal
Management
• Stop Oral Intake
• Head up 30 0
• Oxygen 8 L/ min via face mask
• IVFD NaCl 0,9% 20 drips/minutes
• Ceftriaxon Inj. 1 g
• Metamizole Sodium 1 g
• Urinary catheter
• Laboratory examination
• Radiology examination
Laboratory result

•Hb : 6,5 gr/dl  transfusion

•WBC : 23.900/ul
•Platelet : 157.000 /ul
•Ht : 18 %
•CT : 9 minute
•BT : 3 minute
•Glucose ad random: 195 mg/dl
Radiology examination
Head CT-Scan :
• There was SCALP haematoma at left occipital region
• There was no fracture at the bone window
• Hyperdense biconvex appearence at the left
occipital region  EDH
• Hyperdense appearence at the right frontal region
 ICH
• Sulcy and gyrus were narrow
• Ventricle and cysterna were narrow
• There was midline shift to the left 5 mm
Cervical lateral
• In normal limit

Thorax
• In normal limit

Pelvic
• In normal limit
Diagnose:
1. Moderate head injury
2. EDH at the left occipital region
3. ICH at right frontal region
4. Lacerated wound at the parietal

Consult to Neurosurgery Division :

• Craniotomy decompression + EDH bore
hole drainase emergency
Operation report
• Lazy S incision at the parietooccipital region
• Performed debridement
• Performed 1 burehole
• Found epidural hematoma was about 25 cc
• Question mark incision at the right temporoparietal
region
• Performed 6 burrholes and the skull was sawed by gigli
• Performed dura hit stiches, evacuated ICH about 15 cc
and bleeding controlled
• Bone flap was returned
• Wound operation closed by primary sutured and
performed one tube drain
Post Operative Diagnose
1. Moderate head injury (ICD 10 CM S09.7)
2. EDH at the left occipital region (ICD 10 CM
S06.4)
3. ICH at right frontal region (ICD 10 CM S06.1)
4. Lacerated wound at the parietal (ICD 10 CM
S34.2)
 Follow up
Date S O A P
05/08/2017 Pain (-) General condition : Post craniotomy • IVFD NaCl 0,9% 20
Pod 5 severe decompression + drips/minutes
BP : 110/70 mmHg EDH bore hole • Ceftriaxon inj 1 g/ 12
drainase due to
HR : 82 beats/mnt hours
RR : 18 breaths/mnt 1. Moderate head • Metamizole Sodium
GCS : E4 M6 V5 injury (ICD 10 CM 1 g/8 hour
isochoric pupil S09.7) • Ranitidin inj 50 mg/
2. EDH at the left
Ø3mm/3mm occipital region 12 hours
(ICD 10 CM S06.4)
S/L at the right 3. ICH at right Wound care
temporoparietal frontal region
(ICD 10 CM S06.1)
region 4. Lacerated wound
L : gauze was dry at the parietal
P: pain decrease (ICD 10 CM S34.2)