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Emergency Case ReportJuly 28th 2015 Resident on Duty :dr. Yan Adityadr. Ardi

Patient ListNoIdentityAdmission to E.R.DiagnosisTreatment1.Mr. Safrudin/ 43 th/ 1-15-87-05July 28th 2015 at 21.30 WITA

Moderate Head Injuries GCS E3V4M5 + SDH a/r Parietal + SAH a/r Frontalis + Contussio Cerebri + Closed Fracture Linier Occipitalis + Closed Fracture Zygomatic SinistraObs Vital SignO2 NRMHead Up 30oIVFD KristaloidAntibioticH2 BlockerAnalgetic

Consult Neurosurgery :HospitalizedMannitol 4x150

Consult Plastic Surgery :Pro ORIF ElectivePatient ListNoIdentityAdmission to E.R.DiagnosisTreatment2.Ch. Dimas/ 14 Y.O/ 1-14-87-13July 28th 2015 at 23.30 WITA

Closed Fracture End Distal Radius et ulna Transverse Displaced+Closed Fracture 1/3 Distal Femur Sinistra Transverse Displaced+Closed Fracture 1/3 Proximal Femur Dextra Transverse Oblique DisplacedObs Vital SignIVFD KristaloidH2 BlockerAnalgeticImmobilization w/ Anterior Slab and Skin Traction

Consult Orthopaedy department :HospitalizedPlanned for Elective ORIFMr. Safrrudin/ 43 th/ 1-15-87-/ July 26th 2015 at 14.30 WITAChief Complain : Decreased of ConciousnessHistory : 4 Hour before admitted to hospital patient get crashed by a motorcycle as he riding motorcycle alone at Pelaihari Area. The motorcycle collided from the opposite direction, and then he fell to the road and his head bumped to the ground. Theres history of lost of consciousness. History of bleeding from ear (-), mouth (-), and nose (+) Nausea (-) and vomiting (-). Seizure (-) After that patient brought to Pelaihari Hospital by society. There he got first aid, after that he referred to Ulin Hospital for further treatment.

5Primary Survey6Secondary survey8Maxillofacial statusPeriorbita sinistraInspection : Oedem (+) Hematome (+) Palpation : Pain (+) Eye ROM palpable in normal limit, eye opening limited due to swelling, rima orbita sinistra Crepitation (-)

Zygoma SinistraInspection: Deformity (+) Swelling (+) Open Wound (-)Palpation : Pain (+) Crepitation (-) Step Off defect (-)Clinical Picture

Head CT Scan

Bone Window CT Scan

Skull AP Lat

Thorax X Ray

ItemsResultNormal ValueUnitHemoglobine13,614.00 - 18.00g/dlLeukocyte19,64.0 10.5thousand/ulEritrocyte3,674.00 5.50million/ulHematocrit28,432.00 44.00Vol%Trombocyte284150 450Ribu/ulRDW-CV14,311.5 14.7%MCV77,580.0 97.0FlMCH25,627.0 32.0PgMCHC33,032.0 38.0%Laboratory Result on July 28th 18ItemsResultNormal ValueUnitGran%68,350.0-70.0%Lymphocyte%12,525.0-40.0%MID%19,44.00-11.00million/ulGran#13,402.50-7.00Billion/ulLimfosit #2,41.25-4.0Billion/ulMID#3,8Billion/ul19ItemsResultNormal ValueUnitGDS158