CASE REPORT

Friday, July 17th 2015

Team on duty
dr. M. Nazir Tambunan
dr. Tommy Rivelino
dr. Raja Raharja MP
dr. Bobby HE Fermi
dr. Herdi Gunanta S
dr. Syahmardani Ibnu
Patient identity
Name
Age
Sex
Address
CM
Phone
Driving license
Addmision time

(Jaga 1)
(Jaga 2)
(Jaga 3)
(Jaga 4)
(Jaga 5)
(Jaga 5)

: Raihana
: 34 years old
: Female
: Cot Bayu Aceh Selatan
: 1-05-85-37
: 085277176118
: (-)
: 18/07/15 at 04.22 AM

Date/h Examinati Laboratory

Radiology
Hour of
our
on hour
Examination Examination Diagno
patien
stics
t came
Sen Result Send Result
to ER
d

Date/ho DPJP
ur
patient
out from
ER

18 July
2015/
04:22
AM

12:00 AM Dr
Bustami
SpBS

04:30 AM

04:50 06:00
AM
AM

05:10 06:00 06;20

AM
AM
AM

Chief complaint
Headache after trauma
Patient illnes history
The patient come to the emergency with a chief complaint Headache after
trauma for 18 hours. The patient was riding motorcycle without helmet and
suddenly lose of control and hit a bridge. History of lucid interval (-). Nausea and
vomiting(-)vomitting (-).

Physical examination
Primary Survey
A: Clear
B: Spontaneous, RR: 20 breaths/ minute
C: Blood Pressure: 150/70 mmHg Pulse 90 beats/minute,
D: GCS: 15 (E4 M6 V5); isochoric pupil (L/R) 3mm/3mm,lateralization(-)
E:
L/S Frontal region
L: Lacerated wound 10 cm x 2 cm, pulp cerebri (-)
F: Base Bone discountinity (+)
L/S Oris region
L: laceration at superiol labia 3cmx1,5 cm, and laceratum at inferior labia
3cmx1,5 cm
L/S Right fore arm
L: wound (-) deformity (+)
F: pain (+) NVD (-)
M : ROM limited
Secondary Survey :
Head and neck
:
L/S Frontal region
L: Lacerated wound 10 cm x 2 cm, pulp cerebri (-)
F: Base Bone discountinity (+)
L/S Oris region
L: laceration at superior labia 3cmx1,5 cm, and laceratum at inferior labia
3cmx1,5 cm
Thorax region
: in normal limit
Abdominal region
: in normal limit
Upper extremity :
L/S Right fore arm
L: wound (-) deformity (+)
F: pain (+) NVD (-)
M : ROM limited
Lower extremity : in normal limit

VAS : Mild

Mild 1-3

Moderate 4-6

Non opioid +
Opioid +
adjuvant
adjuvant
COX-2
Ibuprofen
Aspirin
Acetaminoph
en

nonopioid +

Severe 7-10

Opioid +
adjuvant
Codein
Propoxyphene
Hydrocodone
Tramadol
-

Assessments:
1. Mild head injury
2. Open depress fracture at the right frontal region
3. Lacerated wound at Oral region
Management

Head up 30 0

Oxygen 3 L/i via nasal canule

IVFD NaCl 0,9 % 20 drips/minute

Ceftriaxone inj 1 gr

Ketorolac inj 30 mg

Tetagam 250 iu

Blood routine laboratory

Radiology examination

nonopioid +
Oxycodone
Morphine
Hydromorphon
e
Fentanyl

Laboratory examination
Hb
White blood count
Platelet
CT
BT
Ht

: 10.2 gr/dl
: 13.200 /ul
: 251.000 /ul
: 7 minute
: 2 minute
: 31 %

Radiologi examination
Head CT Scan :
SCALP hematome of the right frontal region
There was depress fracture of the frontal region > 1 tabule
There was hiperdens area at the right frontal region surely ICH
Sulcus and gyrus was narrow
Ventricle and systerna system was normal
No mid line shift
Right fore arm
Discountuinity at distal of the right radius
Cervical Lat
Loose lordotic
Diagnose
1. Mild head injury (ICD-10-CM S09.90)
2. Open depress fracture at the frontal region (ICD-10 CM S02.91)
3. ICH at the frontal region (ICD 10 CM)
4. Close fracture at the distal of the right radius (ICD 10 CM S52.381)
Consult to neurosurgery division
Debridement +craniotomy elevation depress fracture and evacuation ICH
Consult to Orthopedic division
ORIF patient refuse medical advice Fore slab
Consult to plastic surgery
Primary heacting
Operative Report Neurosurgery
Performed debridement
Performed horse shoe incision at the old wound
There was depress fracture 4x2 cm
Performe Elevation fracture depressed
Found ruptured duramater about 1 cm
Evacuation ICH about 5cc at frontal region

Plastic surgery
Performed debridement
Primery suture
Post Operation Diagnose
1. Mild head injury (ICD10 CM S09.90)
2. Open depress fracture at the frontal region (ICD10 CM S02.91)
3. ICH at the frontal region (ICD10 CM I61.065)
4. Close fracture at the distal of the right radius (ICD10 CM S52.381)
Follow up
Date
22-7-2015
POD IV

O
(-)

General condition : good

HR: 80 beats/minute
BP : 120/80 mmHg
RR:
20 breath/minute
T:37,0 0C
GCS 15

P
1. Mild head injury
(ICD-10-CM
S09.90)
2. Open depress
fracture at the
frontal region
(ICD-10 CM
S02.91)
3. ICH at the frontal
region (ICD 10
CM I61.065)
4. Close fracture at
the distal of the
right radius(ICD
10 CM S52.381)

IVFD NaCl 0,9 % 20

drips/minute
Ceftriaxone inj. 1 gr
Ketorolac inj 30 mg
Diet 1800 kkal