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8/12/2019 Case Report Hakim

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CASE REPORT

Friday, January 03 th 2014

Team on duty : dr. Safwan Azhari

dr. Joko Siswanto

dr. Guruh L.S.

dr. Lea Darman

dr. Zumirda

dr. Andri Mulia

dr. Mohan

I. Patient identity Name : Hakim Age : 23 years old Sex : Male Address : Desa Matang Kec Bandar Baru Kab Pidie Jaya CM : 98 52 20 Phone : 085314684808 Patient came : at 16.05 PM

II. Chief complain Decrease of consciousness

III. Patient illnes history The patient come to Zainoel Abidin emergency room with a chief complaint

decrease of consciousness for 4 hours ago. The complaint started when thepatient was repaired of the roof suddenly he fell down to the floor. History ofnausea and vomiting (+). History alert after trauma (+).

IV. Physical examination Primary survey :

A: ClearB: Spontaneous, RR: 22 breaths/ minute

C: Pulse: 98 beats/minute, BP : 99/61 mmHgD: GCS: E2 M5 V3 isochoric pupil (Right 3mm, Left 3mm), lateralization (-),


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Light reflex (+/+)

Secondary survey :There was no trauma at the other part of body

V. Assessments:Moderate Head Injury

VI. ManagementHead up 30 o IVFD NaCl 0,9 % 20 drips/mntCeftriaxone Inj. 1 grKetorolac Inj. 30 mgCatheter urineLaboratory examinationRadiology examination

VII. Laboratory examinationHemoglobin : 13.3 gr/dlWhite blood count : 6,800 /ulPlatelet : 216.000 /ul

Ht : 39 %CT : 7 minuteBT : 2 minuteGlucose ad random : 101 gr/dl

VIII. Radiology examination Head CT-Scan : Scalp hematome at the right temporo-parietal region There was fracture of the bone window ( Parieto-occipital) Linier

fracture Sulcus and gyrus in normal limit There was hiperdense area at the ganglia basal sinistra Ventricle and Cysterna system in normal limit No Midline shift


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IX. Diagnose: Moderate Head Injury (ICD X : S.06.2 ) + Close Linier fracture of the leftparietooccipital region

Planning: Consult to Neurosurgery Division :

Concervative to Neurology division

XII. Follow up

Date S O A P

7/1/2014 VS/

BP : 100/80 mmHg

HR : 124 x/mnt

RR : 22 x/mnt

GCS; E3 M6 V4

Isochoric pupil

3mm/3mm

ModerateHead Injury(ICD X :S.06.2 ) +Close Linierfracture of theleftparietooccipital

region

IVFD NaCl 20drips/minutes

Head up 30

O2 2l/ viacanule

Ceftriaxone 1

g/ 12 hoursKetorolac 3%Inj 1 amp/ 8hours

Phenytoin 1amp /12hr

Ranitidine inj1 amp /12 hr