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8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
1/22
Patient identity• Name : Zulfkar• Age : 17 years old• Sex : Male• Address : Matang Kumbang, Kec.
Gandaura
Kab. !"reuen• #$one : %&'()')(7'&'
• M* : 1 %1 + &%• -r""ng l"cense : /0• 2"me Arr"ed : 1:( AM
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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Chief complaint
• -ecrease o3 consc"ousness
Patient Illnes History
• 2$e at"ent re3erred 3rom !"reuen d"str"c$os"tal 5"t$ c$"e3 comla"n decrease o3
consc"ousness 3or 1' $our. 2$e comla"ntstarted 5$en $e r"de a motorcycle 5"t$out$elmet and strucked anot$er motorcycle t$atsuddenly came out 3rom t$e alley. 2$ere 5as$"story o3 nausea and om"t"ng /0. 2$ere5as no $"story o3 alert a3ter trauma.
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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Physical examination
• A : 6lear
• ! : Sontaneous, **: ' breat$s8 m"nute
• 6 : !# : 1(%8+% mm9g, #ulse: &% beats8m"nute
• - : G6S 1% /( M ;' < "soc$or"c u"l/(mm8(mm
l"g$t re=ex /080
• : >8S a.r 3ac"al"s
?er @ace / at t$e 3rontal
> : Symetr"c, ound /0 s"Be cm 5as sutured
•
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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M"d @ace :
> : Symetr"c, excor"ated 5ound /0, s5ell"ng /C
>o5er @ace :> : Asymetr"c, ound /C, s5ell"ng /0 de3orm"ty
/0,
$ematoma /C
Dntra Eral :• Malocclus"on /0• Mand"bular =oat"ng /0• Aleolar =oat"ng /C• Max"lla =oat"ng /C
>8S at t$e neck reg"on
D : 9aematoma /0, excor"ated 5ound /0
#: #a"n /C
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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Assessments:
1.Moderate 9ead DnFury
'.Mand"ble @racture
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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Management
• 9ead u (%
• Neck collar• D;@- Na6l %,+H '% dr"s8m"nutes
• E' & l8m"nutes "a 3acemask
• ?r"ne cat$eter
• DnF.6e3tr"axone 1 gr
• DnF. Ketorolac (% mg
• DnF. 2etagam '% D?
• >aboratory exam"nat"on• *ad"ology exam"nat"on
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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Laboratory result
• 9b : 11,& gr8dl
• $"te blood count : 17.1%%8ul• #latelet : 1)%.%%% 8ul
• 9t : () H
• 62 : 7 m"nute
• !2 : ' m"nute
• !lood Glucose ad random : 1' gr8>
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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Radiology examination
9ead 62CScan :
• Subgaleal $ematoma at le3t occ""tal reg"on
• >"near 3racture at t$e le3t 3rontal bone
• 2$ere 5as $"erdens abnormal area at t$er"g$t temoral reg"on surely S-9
• 2$ere 5as $"erdens abnormal area at t$e3alx cerebr" surely SA9
• ;entr"cle system 5as narro5
• Sulcus and gyrus narro5.
• M"d l"ne s$"3t to t$e le3t I %, cm
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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2$orax A# :
Dn normal l"m"t
Sc$edell A#8>at
Segmental 3racture o3 t$e mand"ble
6er"cal :
>oss o3 lordot"c aereance
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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Diagnose
1.Moderate $ead "nFury
'.>"n"er 3racture o3 t$e le3t 3rontal reg"on
(.S-9 at t$e r"g$t temoro ar"etal reg"on.Segmental 3racture o3 t$e mand"ble
Consult to eurosurgery Di!ision :
• 6ran"otomy S-9 eacuat"on emergency
Consult to Plastic "urgery Di!ision :
• 9os"tal"Be
• E*D@ elect"e
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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Intra #perati!e
• #at"ent "n su"ne os"t"on, extended to t$e le3ts"de, $ead u (% %, 5"t$ general anest$es"a.
• Aset"c and Ant"set"c rocedure, dra"ngrocedure
• *eerse Juest"on mark "nc"s"on at t$e r"g$t
temoro ar"etal reg"on, deeer layer by layerunt"l bone
• Made !urr $oles, t$e skull 5as sa5ed 5"t$g"gly and t$e 3ragment 5as ulled out.
• 2$e dura looked tens"on and blue"s$.• #er3ormed dura $"t st"c$es
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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• -uramater oened 5"t$ s$ar rocedure
• #er3orm S-9 eacuated 5"t$ olume about
) cc.• @ounded bleed"ng 3rom lacerated cortex at
seeral o"nt and er3ormed bleed"ng control
• #er3ormed dura 3ac"al gra3t
• !one =a 5as kee at subgaleal
• #er3ormed one tube dra"n
• ound oerat"on closed by r"mary sutured
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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#otoCoto "ntra oerat"3
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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Post #perati!e Diagnose
1.Moderate $ead "nFury
'.>"n"er 3racture o3 t$e le3t 3rontal reg"on(.S-9 at t$e r"g$t temoro ar"etal reg"on
.Segmental 3racture o3 t$e mand"ble
8/18/2019 Moderate head injury + SDH at the right temporo parietal ZULFIKAR
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Date S O A P
22/9/2014POD I
VS/BP : 120/70 mmHg
HR : 90 x/mntRR : 22 x/mntGCS 12; E2M4 V3Is!"#$! %&%$'
(3mm/3mm
1. Moderate$ead "nFury
'. >"n"er 3ractureo3 t$e le3t3rontal reg"on
(. S-9 at t$er"g$t temoroar"etal reg"on
. Segmental3racture o3 t$emand"ble
IV)D *+C' 20,#$%s/m$n&t-s
H-+, &% 30O2 4'/m$n&t-.$+C-t#$+xn- 1 g/12 "s-t#'+! 3
In 1 +m%/ "s$5&$, ,$-t6x100 !!