Morning Report

7th September 2017

Primary Survey
 A : clear
 B : RR 20x/m adecuate, simetris D/S
 C : HR 90x/m reguler, adecuate
 D : Pain respone
 E : Head
 History Taking
 A woman, 41 years old, admitted to hospital with a chief
complaint: unconsciousness after an accident.
 5 hours before admission, the patient was sitting on a motorcycle
rode by the driver and she was not wearing a helmet. The rider
loses control in downhill and the patient fell down on the rocky
road.
 There was vomiting about 3 times of the patient, no seizure,
temporarily loss of consciousness that the patient didn’t know how
long it is.
 Blood from nose (-), blood from ears(-),
 Seizure (-),Fever(-), Slurred Speech(-), Weakness of one side of
the body(-), alcohol (-)
 After that, she was taken to Kandou Hospital for the first aid and
treatment
History of Past Illness
Hypertension (-)
Cholesterol (-)
Heart Disease (-)
DM (-)
Kidney (-)
 Physical Examination
 General examination:
 General condition: Severe, Consciousness : Sopor
 BP: 100/70 mmHg, MABP: 80, HR: 90 times per minute reg, RR: 20
times per minute , T: 36,5 °C, SaO2 : 97%
 Conjunctiva: pale (-/-), sclera ikteric (-/-)
 JVP : normal
 Thorax : Rale -/-, Wh -/-, heart sound I/II normal, gallop -, murmur –
 Abdomen : Flat, normal turgor, peristaltic normal
 Extremities : warm acral
 Neurological Examination
 GCS E2M5V2. Pupil round ø 2/2 mm. Direct light Reflex +/+
Indirect Light Reflex +/+
 Meningeal Sign: nuchal rigidity not evaluated. Lasegue (>70/>70)
Kernig (>135/>135)
 Cranial Nerves: impression of paresis (-).
 Motoric examination : hemiparesis impression (-).
MT : N N PhyR : ++/++/++ ++/++/++ PathR : - -
N N ++/++ ++/++ - -
 Sensoric exam : can’t be evaluated
 Autonomic state : urination via catheter
Localized Examination
 Otorrhea - / -
 Rhinorrhea - / -
 Racoon eye - / -
 Battle sign - / -
 Brill Hematoma (-)
 Subgaleal hematoma regio temporoparietal dextra and regio
frontoparietal sinistra
WDx
Moderate head injury
 Planning
 Bed rest + C Spine control
 Family CIE
 Pro NGT+catheter ( family approval)
 O2 nasal canule 2-4 lpm
 IVFD NaCl 0,9% 500 cc 20gtt /m
 Paracetamol 3x500mg NGT
 Vitamin C 2x200mg NGT
 Zink 2x20mg NGT
 Observe GCS/Pupil/O2 per hour.
Diagnostic Planning
 Blood exam: hematology, blood sugar, electrolyte, renal
function, liver function.
 Brain CtScan + BW
 Cervical X-ray AP/lat.
 ECG
Laboratory Examination 8 September 2017
 Hb : 12.7
 Ht : 37.8%
 WBC : 18.500
 PLT : 179.000
 RBC : 4.940 x 10^6
 SGOT : 20
 SGPT : 12
 Ureum : 18
 Creatinine : 0.6
 Blood sugar : 116
 Na : 139
 K : 4.10
 Cl : 108.0
 OSM : 285 mOsm/L
Cervical X-ray AP/ Lat
Brain CT
Brain CT Scan (zoomed)
Bone
Window
WDx
ICH r/ temporal sinistra vol 7.6cc
SDH r/ frontoparietal sinistra
SAH traumatical
edema cerebri
Additional Therapy
 Tranexamat acid 4x1gr IV
 Nimodipin 4x60 mg via NGT if BP>130/80
 Paracetamol 1gr drips/8 hour
 Manitol loading dose 300cc, next 4x 150 cc 6
hours after loading if BP> 110/80
THANK YOU