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Duty ReportSaturday, January 30th 2016Resident: dr. Diana Fitria
Intern: Dody, Sevy, Fani
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Rekapitulation
Outpatient : 5 Inpatient: 0
Operation :3
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Ms, 20 years old
Chief complaint : Head injury withunconsciousness post traumatic
History of present illness :
5 hours before the hospital admission of patientfalling rocks hit by landslides !atient come withattached gudle mouth" and a bandage on herhead #fter it opened bandage look the part lefttemple was torn head and brain e$pose %here&soedem on eyes" bleeding from the nose
History of past illness : '( )*+" H% )*+
History of #lergy : )*+
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Primary survey
# : clear
, : takipnoe" --$.min"
C : ,! /.10 mmHg" H2 $.min" C2%4-
' : unconsciousness" 6C7: 89 (- 9
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Resutitation
#: attached 8%% ,: takipnoe" -1$.min
C: ,! 991.3" H2 /$.min" C2% 4 -
': 6C7: 8:9 (:- : on tube
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7econdary 7ur;ey6eneral status
67 : se;ere pain" unconsciousness" 6C7 1%% : ,! 9-0." < =0$.m" ! -0$.m"% 3/">c
Head : there&s rips up the left parietal brain ;isible
(ata : oedem on palpebra sinistra" pupillary
re?e$es @.@ isokhor%H% : bleeding from nose
%hora$:
Cor : Cor sound I*II normal" murmur )*+" gallop )*+
!ulmo: ;esicular @.@" rhonchy *.*" wheeAing *.*
#bdomen : no abnormality detected
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Localy State
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DIAGNOSIS
7e;ere head injury @ ,rain8$pose
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Treatment
!ro Craniotomy 'ebridement
!rimary suture
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Surgical Report, 31 -1-2016 !re*surgical diagnosis: Craniocerebral injury
Operation action : 'ecompression craniotomy anddebridement
!ost surgical diagnosis: Craniocerebral injury
Braian:
!atient on supine position on general anasthesia" headturn to the right" debridement with
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%hank Eou
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