MILD HEAD INJURY

Conselor : Antonius Kurniawan.,dr Sp. B, FINACS, FICS

Department of Surgery Sekar Kamulyan Hospital

2012

PATIENTS IDENTITY
Name : Mr. M Age : 65 years Sex : Male Address : Bandorasakulon Cilimus Religion : Islam Nationality : Indonesian Admission Date : May 4th 2012 Room : Elisa RM : 136269 Diagnosis : Mild Head Injury

PRESENT MEDICAL STATUS

History of Present Illness History was taken by autoanamnesis and heteroanamnesis from his wife as informant on May 5th 2012 with main complaint dizziness. In further anamnesis, patient felt dizziness after fall accidentally in bathroom 1 hour before go to hospital. His family say that his head was hit the wall. He also complaint about nausea and vomiting 3 times about a half of glass, the contents was food and no blood. Syncope (+) about 15 minutes and have found by his family in front of refrigerator in sit positition, retrograde amnesia(+), seizures ().

History of Past Illness Hipertensive disease (-), Diabetes mellitus (-)

Allergic History Blood Disorder

: (-) : (-)

GENERAL

EXAMINATION

General Appearance : Moderate Consciousness : Compos Mentis GCS : 15 Blood pressure : 160/100 mmHg Pulse : 80 x/minute Respiration : 20x/minute Temperature : 36,7 0C

PHYSICHAL

EXAMINATION

Skin : Anemis (-), Icteric (-), Cyanosis (-), normal turgor Head :Exscoriation 3 x 1 cm Battles sign (-) Eyes : Anemic Conjunctiva -/Icteric Sclera -/-, Pupil round, isokor, Light reflex +/+ reactive Raccoons eye -/-

CONT

Nose Neck

Chest
Cor

Pulmo

: No abnormalities epistaxis -/: No lymph node enlargement, mass (-) Meningeal Reflex : Shape and movement simetric in both sides : Nomal heart sound, reguler, shuffle (-) : VBS +/+, rales -/-, wheezing -/-

CONT
Abdomen Inspection Auscultation Palpation

: Flat : Bowel sound (+) normal : Soepel Tenderness (-)

Anus-Rectum : Normal Inguinal and Genital : not examined Extremities : Acral warm +/+

LABORATORY FINDINGS
May 4th 2012 Hb : 13,1 g/dl Ht : 38 % WBC : 11.400/mm3 RBC : 4,57 million/mm3 Trombocyt : 223.000/mm3 MCV : 84 fl MCH : 29 pg MCHC : 34%

CONT
Sodium : 144,5 mmol/dl Pottasium : 3,83 mmol/dl Chloride : 102,5 mmol/dl

CT SCAN IMAGING

TREATMENT
Inpatient O2 via nasal canule Intravenous fluid Ringer Lactate 1000cc/24 hour Metampiron and Diazepam 3 times a day Multivitamins 3 times a day p.o Beta histine 3 times a day p.o Ranitidine 3 times a day p.o Ketorolac twice a day p.o Citicholine 3 times a day p.o Metochlorpamide 3 times a day i.v Mannitol 125 cc 4 times i.v Peptisol 150 mg 6 times a day

PROGNOSE
Quo ad vitam Quo ad functionam Quo ad sanationam

: ad bonam : ad bonam : ad bonam

THEORY
HEAD INJURY

DEFINITION Head injury is both directly and indirectly head mechanical trauma that cause neurological function disturbance that is include physical disturbance, cognitive and physcosocial function that temporaly and permanently.

EPIDEMIOLOGY

Head injuries are among the most common types of trauma seen in NOrth American emergency departments (EDs), with an estimated 1 million cases seen annually. Many patients with severe brain injuries die before reaching a hospital , and almost 90% of prehospital trauma-related deaths involve brain injury.

ETIOLOGY

EPIDURAL HEMATOMA
Epidural hematomas typically become biconvex in shape as they push the adherent dura away from the inner table of the skull. Massive hematome >> caused by A.meningea media or sinus venosus that perforate

SUBDURAL HEMATOMA
Subdural hematomas appear to conform to the contours of the brain. Subdural hematomas may grow to cover the entire surface of the hemisphere. Furthermore, the brain damage underlying an acute subdural hematoma is typically much more severe that with the epidural hematomas.

INTRACERECRAL HAEMORRHAGE
Is brain parenchim bleeding, caused by intracerebral arterial rupture In period of hours or days, evolve to form an intracerebral hematoma or a coalescent contusion with enough mass effect to require immediately surgical evaluation For this reason, patients with contusions should undergo repeat CT scanning to evaluate for changes in the pattern of contusion 12 to 24 hours after the initial scanerebral arterial leakage

MILD HEAD INJURY

From interview From theory

Dizziness (+) Vomiting (+) Syncope (+) Retrograde Amnesia (+)

Syncope (-) Retrograde amnesia (-)

MILD HEAD INJURY

From physical examination From theory

Consciousness : Compos Mentis GCS : 15

Consciousness Compos Mentis GCS 15

MILD HEAD INJURY

Imanging studies From theory

Minimal intracerebral haemmorhage at left frontal regio Subdural higroma at right frontotemporal regio

No abnormalities in imaging studies

MILD HEAD INJURY

Patient treatment

Theory

Inpatient O2 via nasal canule Intravenous fluid Ringer Lactate 1000cc/24 hour Metampiron and Diazepam 3 times a day Multivitamins 3 times a day p.o Beta histine 3 times a day p.o Ranitidine 3 times a day p.o Ketorolac twice a day p.o Citicholine 3 times a day p.o Metochlorpamide 3 times a day i.v Mannitol 125 cc 4 times i.v Peptisol 150 mg 6 times a day

Inpatient Oksigen Barbiturates Anticonvulsants

THANK YOU