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Patient Identity

Name : Edi Sahputra


Age : 19 years old
Sex : Male
Address : Ule Gle ,Pidie
Jaya
CM : 1-09-78-79
Mobile Phone : 08116893575
Driving license : (-)
Admission time : 17.00
Date/h Examinati Laboratory Radiology Hour of Date/hou DPJP
our on hour Examination Examination Diagnost r patient
patient ics out from
came Send Result Send Result ER
to ER

July 31st 17.10 17.15 18.00 17.30 18.15 18.30 Hospitalize Dr.Armia
2016 SpOT
17.00
Chief Complaint:
Decrease of consciousness

Present illness history


The patient taken to
Emergency room with
decrease of consciousness,
initially the patient was riding
a bike with his friend, and
suddenly a car strucked him
from opposite,
history nausea & vomiting(+)
Physical examination
Primary Survey
Air Way : Clear C - spine control
Breathing : Spontaneous, 20
breaths/minute
Circulation : Blood Pressure: 110/70
mmHg ,
HR: 96 beats/minute
Disability : GCS 12 (E3 M5 V4) :
isochoric pupil (Right 3mm, Left 3mm),
lateralization (-), Light reflex (+/+)
Exposure :

L/S at the left eyebrow region


Look : lacerated wound 3 x 1 x 0,5 cm ,
irregular surface ,
hematoma (+)
Feel : pain (+),

L/S at the right tight region


Look : Swelling (+), deformity (+),
shortening (+)
Feel : Pain (+), NVD (-)
Move : ROM limited

L/S at the Pelvic Region


Look : Swelling (-), deformity (-),
wound (-)
Feel : Pain (+)
Move : ROM limited
Secondary Survey :
Head & Neck :
L/S at the left eyebrow region
Look : lacerated wound 3 x 1 x
0,5 cm , irregular
surface , hematoma (+)
Thorax : in normal limit
Abdomen : in normal limit

Pelvic
L/S at the Pelvic Region
Look : Swelling (-), deformity (-),
wound (-)
Feel : Pain (+)
Move : ROM limited
Extremity :
L/S at the right tight region
Look : Swelling (+), deformity (+),
shortening (+)
Feel : Pain (+), NVD (-)
Move : ROM limited
Assessment:
Moderate head injury
Lacerated wound at the left
eyebrow
Susp close fracture at the
right tight
Management
Immobilization
Stop oral intake
O2 4 L Nasal canule
IVFD NaCl 0,9 % 20 drips
macro/minute
Inj Cefazoline 1gr
Ketorolac inj.30 mg
Tetagam inj. 250 iu
Urinary catheter
Laboratory examination
Radiology examination
Laboratory examination
Hemoglobin :14,8
gr/dl
White Blood Count
:13.700 / ul
Platelets
:300.000/ul
Hematocrit :44 %
CT/BT :7/2
Radiology examination
Head CT Scan
SCALP Hematoma at the right
temporo-parietal
There was no fracture at the bone
windows
Sulcus & Gyrus was narrow
There was no hiperdens abnormal
There was no midline shift
Cervical Lat
lost of lordothic

Pelvic AP
There was discontinuity of bone
at the
upper & lower at the right & left
ramus pubic
Right Genue
There was discontinuity of bone at
the lower third of femur Communitive
Fracture

Right Femur AP/Lat :


There was discontinuity of bone at
the lower third of femur Communitive
Fracture
Diagnose
1. Moderate head injury (ICD 10 S09.90)
2. Brain edema (ICD 10 G93.6)
3. Lacerated wound at the left upper
palpebra (ICD 10 S14.2)
4. Close fracture lower third of the right
Femur (ICD 10 S72.0)
5. Close Fracture of the upper & lower at the
right & left Ramus Pubis (ICD 10 S32.9)

Consult to Neurosurgery division :


Conservative to Neurosurgery division

Consult to Orthopaedic division :


Performed Skin Traction
Performed pelvic bandage
ORIF elective
Follow Up
Date S O A P

August 1st Decrease of General Condition : 1.Moderate Diet 1800 kcal


2016 consciousness moderate head injury (ICD - IVFD Nacl
BP : 120/80 mmhg 10 S09.90) 0,9% 20 drip /
Pulse : 82x/minute 2.Brain edema minutes
RR : 20x/minute (ICD 10 G93.6) - Cefazoline Inj
GCS 12 (E3 M5 3.Lacerated 1gr/12 hours
V4) wound at the - Ketorolac inj 30
L/S at the right tight left upper mg 30mg/8
region palpebra (ICD hours
L : skin traction (+) 10 S14.2)
F : NVD (-) planing:
4.close fracture
M: Limited - Observation of
lower third of
consciousness
the right Femur - ORIF elective
(ICD 10 S72.0)
5.Close Fracture
of the upper &
lower at the
right & left
Ramus Pubis
(ICD 10 S32.9)