CASE REPORT

Tuesday, July 23th 2015

Team on duty
dr. M. Nazir Tambunan
dr. Tommy Rivelino
dr. Raja Raharja MP
dr. Bobby HE Fermi
dr. Andri Feisal Nst
dr. Herdi Gunanta S
dr. Ifani

(Jaga 1)
(Jaga 2)
(Jaga 3)
(Jaga 4)
(Jaga 4)
(Jaga 5)
(Jaga 5)

Patient identity
Name
: By. Muhammad Asysaf Al Hafis
Age
: 12 d.o
Sex
: Boy
Address
: Simpang kramat aceh utara
Phone
: 082364116687
CM
: 1059016
dy weigt
: 3500 gr
Admission time : 21.19 WIB
Chief complaint
Lump at the head region
Patient illnes history
Patient referred from Bunda Lhokseumawe district hospital to Zainoel Abidin
with a chief complaint Lump at the head region for 3 days . he was born with
normal pregnancy and helped by a midwive . History of antenatal care (+) by
midwife . History of vomit (-),history of trauma (-).
Physical examination
Vital Sign
Sucking reflex
: Good
Grasping reflex
: Good
Crying
: weakness
Pulse
: 120 beats/ min
Respiratory rates
: 30 breaths/min
Temperature
: 36,7oC
GCS E4M6V5=15, pupil isochoric
light reflect (+/+)
L/S at Cranial region :
Look : sweling (+), hiperemis (-)

Feel : Pain (-),

There was no abnormality at another part of body
Assessments:
Subgaleal Hematom
Management
Laboratory examination
Radiology Examination
Laboratory examination
Haemoglobin
White Blood Count
Platelets
Hematocrit
BT/CT

: 12,2 gr/dl
: 8.400 /ul
: 382.000/ul
: 36 %
: 7/3

Radiologi examination
Head CT Scan :
Scalp haematom a.r left temporoparieto occipital
Sulcus and gyrius was normal
Ventricle was normal
No mid line shift
Diagnose
Subgaleal Hematome at left temporoparieto occipital.
Consult to neuro surgery division
Insision evacuation subgaleal haematom urgency