CASE REPORT

Monday, August 11th 2015

Team on duty
dr. M. Nazir Tambunan
dr. Tommy Rivelino
dr. Andri Mulia
dr. Raja Raharja M
dr. Bobby HE Fermi
dr. Herdi Gunanta S
dr. Syahmardani Ibnu
Patient identity
Name
Age
Sex
Address

MR
HP
Driving licence
Patient admission

(Jaga 1)
(Jaga 2)
(Jaga 3)
(jaga 3)
(Jaga 4)
(Jaga 5)
(Jaga 6)

: Syaripudin
: 50 years old
: Male
: Ds Bahagia pantonmakmur Kec
Manggeng Aceh Barat Daya
: 1-06-08-14
: 085276361674
: (-)
: 11/8/2015 07:10

Date/h Examinati Laboratory

Radiology
Hour of
our
on hour
Examination Examination Diagno
patien
stics
t came
Sen Result Send Result
to ER
d
11
07.20
Agustus
2015/
07:10

07.20 09.10

08.15 08.55 09.10

Date/ho DPJP
ur
patient
out
from ER
Dr. Imam
SpBS

Chief complaint
Decrease of consciousness
Patient illnes history
The patient referred from Abdya district hospital to Zaenoel Abidin Hospital with
decrease of consciousness for 12 hours. The complaint started when the patient
was riding motorcycle without helmet, suddenly he struck by others motorcycle
from biside him and he felt down to the asphalt. Nause and vomiting (+)

.
Physical examination
Primary Survey :
A: Clear, C Spine control
B: Spontaneous, RR: 22 breaths/ minutes
C: Blood pressure : 180/90 mmHg ,
Pulse 101 beats/minutes
D: GCS: (E2M5V3) =10 pupil 3mm/3mm, light reflex (+/+)
no lateralization
E:
L/S at right frontal
L : haematom (+), excoriated wound (+)
L/S right orbita
L: Monocele (+), wound (-)
S/L ar thorax :
Thorax examination
Inspection
Palpation
Percussion
Auscultation

Right hemithorax

Symmetrically, trachea in the middle, JVP was normal

Strem fremitus decreased

Strem fremitus normal

Hypersonor

Sonor

Vesiculer decreased, wheezing (-), Vesiculer decreased, wheezing (-),

Rhonki (-)
Rhonki (-)

L/S Right shoulder

L: Deformity (+) sweling (+)
M : ROM Limited
Secondary survey :
L/S at right frontal
L : haematom (+), excoriated wound (+)
L/S right orbita

Thorax

Left hemithorax

Thorax examination

Strem fremitus decreased

Palpation

Hypersonor

Percussion

Strem fremitus normal

Sonor

Vesiculer decreased, wheezing Vesiculer normal, wheezing (-),

(-), Rhonki (-)
Rhonki (-)

Auscultation

Left hemithorax

Symmetrically, trachea in the middle, JVP was normal

Inspection

Right hemithorax

Abdominal
: in normal limit
Upper extremity
:
L/S Right shoulder
L: Deformity (+) sweling (+)
M : ROM Limited
Lower extremity : in normal limit
VAS : Moderate

Assessments:
1. Moderate head injury
2. Pneumothorax at the right hemithorax
3. Susp fracture right clavicle

Management

Stop oral intake

Head up 30
Neck Collar
Urine catheter initial urine 90 cc (clear)
O2 6 L/minutes via face mask
IVFD NaCl 0,9% 20 drips/minutes
Inj. Ceftriaxone 1 gram
Inj. Ketorolac 30 mg
Laboratory examination
Radiology examination

Laboratory examination
Hb
: 16,5 gr/dl
White blood count : 20.300 /ul
Platelet
: 271.000 /ul
CT
: 7 minute
BT
: 2 minute
Ht
: 46 %
Glucose ad randome: 165 mg/dL
Radiologi examination
Head CT-Scan:
SCALP hematoma at the right temporo parietal region
There was no fracture at the bone window
Hyperdens area at the right temporoparietal region ICH
Hyperdens area at the left temporoparietal region ICH contusional
Sulcus and gyrus was narrow
Ventricle and cysterna system was narrow
There was midline shif to the left more than + 0,5 cm
Cervical lat
in normal limit
Thorax AP
Trachea in line position
Discountuinity at the middle of the right clavicle
Right bronchovascular was not until lateral pneumothorax at the right
hemithorax
Diagnose
1. Moderate head injury
2. ICH at the right temporopariatal region
3. ICH contusional At the left temporoparietal region
4. Pneumothorax at the right hemithorax
5. Close fracture at the middle of the right clavicle
Consult to Neurosurgery Division

Craniotomy
ICH evacuation emergency
Consult to Orthopedic division
Conservative (ARM Sling)
Consult to TCV Surgery
Perform WSD

Operative Report (WSD)

Chest tube was inserted and connected to water seal drainage
Air buble (+) and undulation (+), Fluid (-)

Operative Report (Craniotomy)

Incision question mark at the left temporoparietal layer by layer
Made 7 burr holes, the skull was sawed and pull out.
The dura looked bluewish and tension
Bleeding control and perform duraplasty
Bone flap was not return

1.
2.
3.
4.
5.

Post Operative Diagnosed

Moderate head injury (ICD 10 CM S06.0)
ICH at the right temporal region (ICD 10 CM I62.1)
ICH contusional at the left temporoparietal region (ICD 10 CM I62.1)
Pneumothorax at the right hemithorax (ICD X CM J39.9)
Close fracture at the middle of the right clavicle (ICD 10 CM :S 42)

Follow up

Date
12/8/15
POD 1

O
Pain ( - ) General condition :
Blood pressure : 114/85
mmhg
Pulse : 90 beats/minute
on ventilator mode
(S)CMV
Temp : 37,0 0 C
GCS on sedative
L/S at the head
I : wound dry (+), drain :
60 cc serous
hemorrhagic
L/S thorax
WSD : undulasi (+),air
bubble (+), fluid (-)

Post craniectomy
decompression
due to
Moderate head
injury (ICD 10 CM
S06.0)
ICH at the right
temporal region
(ICD 10 CM I62.1)
ICH contusional at
the left
temporoparietal
region (ICD 10 CM
I62.1)
Post WSD due to
Pneumothorax at the
right hemithorax
(ICD X CM J39.9)
Close fracture at the
middle of the right
clavicle (ICD 10
CM :S 42)

Head Up 30o
IVFD NaCl 0,9% 20
drips/minutes
Inj.Ceftriaxon
1gr/12hours
Inj. Ketorolac 30mg
/ 8hours
Fentanyl 3mq
Propofol 3 mq
Liquid diet 6x100
Planing
ORIF clavicle
elective