Duty Report

Wednesday, July 25th 2018

Consultants on duty
dr. Vendry Rivaldy, SpB (K) V
Dr. dr. Yevri Zulfiqar, SpB, SpU
dr. Rizki Rahmadian, SpOT (K)
dr. Hesty Lidya Ningsih, Sp.BS

Residents on duty
Faris, Danus, Septry, Ishak, Iqbal, Eko, Meri, Deno, Leo,
Rama
• Total Patients : 3 Patients
 Patients underwent surgery : - Patient
 In Patients : 1 Patient
 Out Patient : 2 Patients
 Refused to treatment : - Patient

Ward report :
• CP : 29 Patients
• CW : 24 Patients
• CAA : 9 Patients
• TC : 27 Patients
• BR : 2 Patients
• RR : 11 Patients
 Patient
A male patient 20 years old was admitted to emergency
room with

Chief Complaint :
Headache 2 hours before admission after traffic accident

Primary Survey :
A : Clear
B : Spontan, RR 20x/minute
C : HR : 88 x/minute, BP: 110/70 mmHg
D: GCS 14 (E3M6V5), pupil isochor: 3 mm/3 mm,
light reflex +/+

3
Present Illness History :
• Headache for 2 hours before admission after traffic
accident
• Patient was riding a motorcycle then suddenly
strucked by another motorcycle from the opposite
direction. Patient was felt with the head bumped to the
asphalt
• Patient was unconscious after the accident
• Vomitus (+), Seizure (-)
• Trauma at the other part (-)
Physical examination

- General appereance : Moderately illness

- Conciousness : GCS 14 (E3M6V5)
- Blood pressure : 110/70 mmHg
- Heart rate : 88 x/minute
- Respiratory rate : 20 x/minute
- Temperature : 37,2 °C
- VAS :5

- Thorax and abdomen was normal

Locally state

Head Region :
Ins : Hematoma (+) at right temporoparietal
Pal : Sign of depress fracture (-)
Working Diagnose :
Traumatic Brain Injury GCS 14 (E3M6V5)

Laboratory Findings:
• Hb : 12,9 gr%
• Leukocyte : 13.700/ mm3
CT Scan
Diagnosis :
Traumatic Brain Injury GCS 14 (E3M6V5) + ICH

Planning:
Conservative
Condition patient this morning
Patient in TC
S : Conscious (+)
O : GCS 15
BP : 110/70 mmHg, HR : 82x/minute,
RR : 20 x/ minute
Pupil isochor 3mm/3mm, light reflex +/+

A : Traumatic Brain Injury +ICH

P : - Monitoring conciousness and haemodinamic