CASE REPORT

Friday, December 5th 2014

Team on duty :
Dr. Nizarli
Dr. Haji Ifradin Pinim
Dr. Aswad Affandi
Dr. Fauzan Hafizar
Dr. M.Saidi
Dr. Andri Faisal N
I.

Patient identity
Name
Age
Sex
Address
Phone
MR
Driving licence
Patient came at

(Chief)
(Case report)
(Medical record)
(Medical record)
(Documentation)
(Documentation)

: Usna
: 28 years old
: Female
: Desa Lolo, Pasie Raja, Kab.Aceh Selatan
: 085262346280
: 1031099
: (-)
: 19.27PM

II.

Chief complaint
Headache after trauma

III.

Patient illnes History

The patient came to RSUDZA emergency room with chief complain headache after
trauma for 3 day ago. Initially, the patient was driving motorcycle without helmet
and suddenly strucked with pig from beside of her.She felt to the asphalt with her
head hit the asphalt.History of nausea and vomiting (+).History of lucid interval (-).

IV.

Physical examination
Primary Survey
A: Clear
B: Spontaneous, RR: 20 breaths/ minute
C: Blood Presure : 130/90 mmHg, Pulse : 92 beats/minute
D: GCS : 15 (E4 M6 V5) ,isochoric pupil (Right 3 mm,Left 3 mm),
no lateralization, Light reflex (+/+)
E:
S/L a.r Right occipital region
Look : Wound (-).
Feel : pain (+)
Thorax Normal

Abdominal Normal

Pelvic region in normal limit

L/S at the extremitas superior Normal
L/S at the extremitas inferior Normal

Secondary survey :
S/L a.r Right occipital region
Look : Wound (-).
Feel : pain (+)
Thorax Normal
Abdominal Normal
Pelvic region in normal limit
L/S at the extremitas superior - Normal
L/S at the extremitas inferior Normal
V.

Assessments:
Mild Head Injury

VI.
Management
Stop Oral Intake
O2 4 liters/minutes
IVFD NaCl 0,9% 20 drips/minutes
Inj. Ketorolac 30 mg
Drip Tramadol 80 mg
Laboratory examination
Radiology examination
VII.
Laboratory result
Hb
White blood count
Platelet
Ht
CT
BT
Blood Glucose ad Random

:
:
:
:
:
:
:

13,2 gr/dl
5.300/ul
178.000 /ul
37 %
8 minute
3 minute
98 mg/dl

VIII. Radiology examination

Head CT-Scan:
NO SCALP hematoma at the left occipital region
There was no fracture at the bone window
Hyperdens abnormal (biconvex) at the right occipital region EDH
Sulcus and gyrus was narrow
Ventricle and cysterna system normal
There was no midline shift

IX. Diagnose:
1. Mild Head Injury
2. EDH at the the right occipital region
Consult to Neurosurgery Division :
Craniotomy EDH evacuation emergency
IX.
Operative report
Lazy S incision at the occipital region until bone
There was linier fracture at the right occiptal region
Performed 1 burr hole, bone was sawed with canable and pulled out
There was found blood with volume 35 cc
Perform blood (EDH) evacuated
Bleeding control
Closure the operation wound by primary suture with one tube drain
XII. Post Op Diagnosed
1.Mild Head Injury (ICD 10 CM S09.9)
2.EDH at the right occipital region (ICD-10 S02.2)
3.Linear fracture at the right occipital (ICD-10 S03.7)
XIII. Follow up
Date
8-12-2014
POD III

S
Pain (-)

BP : 120/70 mmHg
Pulse : 80 beats/mnt
RR : 22 breaths/mnt
GCS : E4 V5 M6 =
15
Isochoric pupil
3mm/3mm

1. Mild Head Injury

(ICD 10 CM S09.9)
2.EDH at the right
occipital region
(ICD-10 S02.2)
3.Linear fracture at
the right occipital
(ICD 10 CM S03.7)

IVFD NaCl 0,9 % 20

drip/minute
Inj. Ceftriaxone 1
gr/12 hour
Inj. Ketorolac 30mg/8
hours

Drain : 20 cc/24
hours
.