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No
Distribution of surgery
patient
Room
1 /961912
Emergency room patient
15 Patients
2 Hospitalize
9 Patients
3 Out of clinic
5 Patients
1 Patient
5 Passed away
6 Hospitalize room
Jeumpa 1
28/28 bed
Jeumpa 2
28/28 bed
Jeumpa 3
28/28 bed
Jeumpa 4
26/26 bed
ICU
2 Patients
ICUC
1 Patients
PICU
1 Patients
NICU
2 Patients
ICU
Usman/M/51 yo/Post VP shunt ai Stroke
ADULT
Haemoraghic + IVH/POD 28
Farhan Andika/M/17 yo/Poost Craniectomy ai
evakuasi ICH/POD 17
NICU
ICU
Nurjannah/F/5 yo/Effusi pleura bilateral ec Ca
Cardia
Mamae post VATS/POD 5
c
PICU
Patient identity
Name
: Yandika
Age
: 34 years old
Sex
Address
Simeuleu
: Male
: Ds. Tran Meutiara, Kab
MR
: 1082207
HP
: 082370587868
Driving licence
: (+)
Admission time
: at 1:55 PM
Time Response
Date/ Exam Laborator Radiology
hour inati
y
Examinati
patie
on
Examinati
on
nt
hour
on
came
Sen Res Send Res
to ER
d
ult
ult
28-22016
01.55
PM
28-22016
04.00
PM
OR
dr.
Bustami
SpBS
Chief complaint
Decrease of consciousness
Patient illnes History
The patient reffered from Simeuleu
distric hospital
to Zainoel Abidin
emergency room with chief complaint
decrease of consciousness for 3 days.
The complaint started when the
patient was riding motorcycle without
helmet, suddenly strucked a cow. He
felt down to the street and his head hit
Physical examination
Primary survey
A : Clear, C-spine control
B : Spontaneous, RR : 22 breaths/min
C : BP : 146/86 mmHg, Pulse : 78
beats/min
D : GCS : 9 : E2 M5 V2 , pupil 3mm/3mm,
light reflex (+/+), no lateralization
E:
Secondary survey
Head region :
L/S at the right parietal region
I : hematome (+), wound (-)
Neck region
: in normal limit
Thorax region
: in normal limit
Abdominal region : in normal limit
Pelvic region
: in normal limit
Upper extremity
: in normal limit
Lower extremity
: in normal limit
Assessments:
Moderate head injury
Management
Stop oral intake
Head up 30
Urine catheter clear (initial 50 cc)
O2 8 L/minutes via facemask
IVFD NaCl 0,9% 20 drips/minutes
Inj. Ceftriaxone 1 gram
Inj. Ketorolac 30 mg
Laboratory examination
Radiology examination
Laboratory result
Hb
: 13,8 gr/dl
: 12.400 /ul
: 112.000 /ul
CT
: 9 minute
BT
: 3 minute
Ht
: 42 %
Diagnose
1. Moderate head injury (ICD 10 CM S06.0)
2. SDH at the right fronto-temporo-parietal
region (ICD 10 CM I62.1)
3. ICH at the right fronto-temporo-parietal
region (ICD 10 CM I61.1)
4. SAH at the right fronto-temporo-parietal
region (ICD 10 CM I60.0)
Operative report :
Performed temporo-frontal extended incision
layer by layer
Made 5 burr holes, the skull was sawed and
pull out.
The dura looked bluewish and tension
Performed dura stiches
Duramater was incision sharply.
Evacuated SDH with thick about 1 cm
Bleeding control and perform duraplasty
Bone flap to subgaleal
Performed one tube drain
Follow up
Dat
S
O
e
29/2/ Decreas Vital Sign :
2016
BP : 140/90
e of
POD conscio mmhg
1
usness HR : 67
beats/min
RR: 20
breaths/min
with ventilator
IPPV
TV : 450
PEEP : 5
Temp : 37,2 0 C
Post craniotomy
decompression
(SDH evacuation)
Head Up 30o
IVFD NaCl
0,9% 20
drips/min
Inj.Ceftriaxon
2 gr/24 hours
Inj.Metamizol
e Sodium 1 gr
/ 8 hours
Inj.Ranitidin
50 mg/12
hours
Inj. Phenitoin
100 mg/ 8
hours
Piracetam 1
gr/8 hours
1.Moderate head
injury (ICD 10 CM
S06.0)
2.SDH at the right
fronto-temporoparietal region
(ICD 10 CM I62.1)
3.ICH at the right
fronto-temporoGCS : on
parietal region
ventilator
(ICD 10 CM I61.1)
4.SAH at the right
S/L at the
fronto-tempororight temporoparietal region
parietal :
(ICD 10 CM I60.0)
I : wound
Liquid diet
6x100