Professional Documents
Culture Documents
MR
HP
Driving licence
Patient admission
(Jaga 1)
(Jaga 2)
(Jaga 3)
(jaga 3)
(Jaga 4)
(Jaga 5)
(Jaga 6)
: Syaripudin
: 50 years old
: Male
: Ds Bahagia pantonmakmur Kec
Manggeng Aceh Barat Daya
: 1-06-08-14
: 085276361674
: (-)
: 11/8/2015 07:10
07.20 09.10
Date/ho DPJP
ur
patient
out
from ER
Dr. Imam
SpBS
Chief complaint
Decrease of consciousness
Patient illnes history
The patient referred from Abdya district hospital to Zaenoel Abidin Hospital with
decrease of consciousness for 12 hours. The complaint started when the patient
was riding motorcycle without helmet, suddenly he struck by others motorcycle
from biside him and he felt down to the asphalt. Nause and vomiting (+)
.
Physical examination
Primary Survey :
A: Clear, C Spine control
B: Spontaneous, RR: 22 breaths/ minutes
C: Blood pressure : 180/90 mmHg ,
Pulse 101 beats/minutes
D: GCS: (E2M5V3) =10 pupil 3mm/3mm, light reflex (+/+)
no lateralization
E:
L/S at right frontal
L : haematom (+), excoriated wound (+)
L/S right orbita
L: Monocele (+), wound (-)
S/L ar thorax :
Thorax examination
Inspection
Palpation
Percussion
Auscultation
Right hemithorax
Hypersonor
Sonor
Thorax
Left hemithorax
Thorax examination
Palpation
Hypersonor
Percussion
Auscultation
Left hemithorax
Inspection
Right hemithorax
Abdominal
: in normal limit
Upper extremity
:
L/S Right shoulder
L: Deformity (+) sweling (+)
M : ROM Limited
Lower extremity : in normal limit
VAS : Moderate
Assessments:
1. Moderate head injury
2. Pneumothorax at the right hemithorax
3. Susp fracture right clavicle
Management
Laboratory examination
Hb
: 16,5 gr/dl
White blood count : 20.300 /ul
Platelet
: 271.000 /ul
CT
: 7 minute
BT
: 2 minute
Ht
: 46 %
Glucose ad randome: 165 mg/dL
Radiologi examination
Head CT-Scan:
SCALP hematoma at the right temporo parietal region
There was no fracture at the bone window
Hyperdens area at the right temporoparietal region ICH
Hyperdens area at the left temporoparietal region ICH contusional
Sulcus and gyrus was narrow
Ventricle and cysterna system was narrow
There was midline shif to the left more than + 0,5 cm
Cervical lat
in normal limit
Thorax AP
Trachea in line position
Discountuinity at the middle of the right clavicle
Right bronchovascular was not until lateral pneumothorax at the right
hemithorax
Diagnose
1. Moderate head injury
2. ICH at the right temporopariatal region
3. ICH contusional At the left temporoparietal region
4. Pneumothorax at the right hemithorax
5. Close fracture at the middle of the right clavicle
Consult to Neurosurgery Division
Craniotomy
ICH evacuation emergency
Consult to Orthopedic division
Conservative (ARM Sling)
Consult to TCV Surgery
Perform WSD
1.
2.
3.
4.
5.
Follow up
Date
12/8/15
POD 1
O
Pain ( - ) General condition :
Blood pressure : 114/85
mmhg
Pulse : 90 beats/minute
on ventilator mode
(S)CMV
Temp : 37,0 0 C
GCS on sedative
L/S at the head
I : wound dry (+), drain :
60 cc serous
hemorrhagic
L/S thorax
WSD : undulasi (+),air
bubble (+), fluid (-)
Post craniectomy
decompression
due to
Moderate head
injury (ICD 10 CM
S06.0)
ICH at the right
temporal region
(ICD 10 CM I62.1)
ICH contusional at
the left
temporoparietal
region (ICD 10 CM
I62.1)
Post WSD due to
Pneumothorax at the
right hemithorax
(ICD X CM J39.9)
Close fracture at the
middle of the right
clavicle (ICD 10
CM :S 42)
Head Up 30o
IVFD NaCl 0,9% 20
drips/minutes
Inj.Ceftriaxon
1gr/12hours
Inj. Ketorolac 30mg
/ 8hours
Fentanyl 3mq
Propofol 3 mq
Liquid diet 6x100
Planing
ORIF clavicle
elective