Lapjag Ckb English

7/24/2019 Lapjag Ckb English

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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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