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Admission
No Identity Diagnosis Planning
to ER
1 Tn. Prantalodi/24 September, 30th Severe head injury + DAI + Treatment in ER :
yo 2018 Cerebral edem + Fracture NRBM 10 lpm
15.50 WITA maxilla lefort 1 + Close Head up 30
fracture of left condylar IVFD NS 20 tpm
mandible displaced + Inj. Ceftriaxone 2x1 gr
Open fracture of Sympisis Inj. Ranitidin 2x50 mg
mandible displaced + Inj. Keteroloc 3x30 mg
Fracture nasalis + Dental Complete blood count
avulsion (Left Incisor + Head CT Scan
Left premolar) DC
Consult to Neurosurgery :
Conservative
Patient passed away Consult to Plastic Surgery :
Pro ORIF elective
Consult to orthopaedic Surgery:
Skin traction
Pro ORIF elective
1. Tn. Prantalodi/ 24 y.o
September 30th 2018 at 15:50 WITA
Chief Complain: Loss of consciousness
History:
Patient came to ER with the chief complaint is loss of consciousness
since 4 days before admission, after hit by a pile of wood while
working. History of seizure (-), nausea (-), vomiting (-), bloody othore (-)
and bloody rhinore (+).
After that the patient taken to Palangkaraya Hospital and cared for 2
days and than patient refer to Ulin Hospital for advanced care.
Primary Survey
A
• Clear (-),
• Without C-Spine control (-), snoring (+), gurgling (-)
Intubation (-) denied (+)
B
• Clear (+)
• Lesion (-), RR: 50 bpm, , vesicular breath sound (+/+),
saturation 91% with O2 10 lpm
P -
L 4 days
2.0
Leukosit 4,0-10,5 ribu/ul
INR 0.94
Electrolyte