depres ismu hadi

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  • 7/24/2019 Depres Ismu Hadi

    1/19

    Patient identity

    Name : Ismu Hadi

    Age : 8 years old

    Sex : Boy

    Address : Curee Tunong, Kec. Simpang

    amplam, Ka!. Bireuen" : # $% 8% &8

    'aren()s '*one : $8%+8#88#+&

    Admission Time: $-.& A

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    Time ResponseDate/hourpatientcameto ER

    Examinationhour

    LaboratoryExamination

    RadiologyExamination

    HourofDiagnostics

    Date/hourpatientoutfrom

    ER

    DPJP

    Send Result

    Send Result

    18 July2015/

    04:36AM

    04:40AM

    05:10AM

    07:00AM

    05:40AM

    06:10AM

    06;20AM

    10:00AM

    DrBus!

    mi"pB"

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    Chief complain:

    Headac*e a/(er (rauma

    Patient illnes history

    T*e pa(ien( come (o (*e emergency 0i(* a c*ie/ complain(

    *eadac*e a/(er (rauma /or # *our. T*e pa(ien( !ac1 /rom (*e

    mos2ue and s(ruc1ed !y mo(orcycle and *is *ead *i( (*e

    asp*al(. T*ere 0as *is(ory o/ unconsciousness. His(ory o/nausea and 3omi(ing 456.

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    Physical examination

    A: Clear

    B: Spon(aneous, "": #8 !rea(*s7 minu(e

    C: 'ulse + !ea(s7minu(e,B' ##$78$ mmHg

    : 9CS: #% 4- ;%6< isoc*oric pupil

    = &mm7&mm, la(erali>a(ion456

    :

    ?7S a( (*e rig*( parie(al

    ?: 0ound [email protected] si>e cm 0as su(ured, s0elling [email protected]

    : pain [email protected], discon(inui(y o/ !one [email protected]

    ?7S a( (*e /acial region?: excoria(ed 0ound

    : pain [email protected]

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    Secondary Sur3ey

    Head and Nec1

    ?7S a( (*e rig*( parie(al

    ?: 0ound [email protected] si>e cm 0as su(ured, s0elling [email protected]

    : pain [email protected], discon(inui(y o/ !one [email protected]

    ?7S a( (*e /acial region

    ?: excoria(ed 0ound

    : pain [email protected]

    T*orax : in normal limi(

    A!dominal : in normal limi(

    'el3ic : in normal limi(

    pper x(remi(y : in normal limi(

    ?o0er x(remi(y : in normal limi(

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    #A" :Mil$

    Mild !" Moderate #!$ Se%ere &!'

    %on opioi$ &

    !$'u(!n-)*+,2--.uproen-Aspirin-Ae!minopen

    *pioi$ &

    nonopioi$ &!$'u(!n- )o$ein- ropoypen

    e- y$roo$one

    *pioi$ &

    nonopioi$ &!$'u(!n- *yo$one- Morpine- y$romorp

    one

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  • 7/24/2019 Depres Ismu Hadi

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    Assessment:

    ild Head Inury

    Dpen depress /rac(ure a( (*e rig*( parie(al region

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    Management:

    Head up &$$

    I; NaCl $, E #$ drips7minu(e

    Ce/(riaxone in. %$$ mg

    Ke(orolac in #$ mg

    Te(agam +%$ iu ?a!ora(ory examina(ion

    "adiology examina(ion

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    Laboratory result

    H! : #$.% gr7dl

    Hema(ocri( : &+ E

    F*i(e !lood coun( : #-.&$$ 7ul

    'la(ele( : &&%.$$$ 7ul

    CT : G minu(e

    BT : + minu(e

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    Radiology result:

    Head CT Scan :

    SCA?' *ema(ome o/ (*e rig*( parie(al region

    T*ere 0as depress /rac(ure a( (*e parie(al region

    # (a!ule

    Sulcus and gyrus 0as narro0

    ;en(ricle and sys(erna sys(em 0as normal

    T*ere 0as no midline s*i/(

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    iagnose:

    ild *ead inury 4IC #$ C S$.$6

    Dpen depress /rac(ure a( (*e rig*( parie(al region

    4IC #$ C S$+.#6

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    Consult to neurosurgery di!ision

    e!ridemen(

    le3a(ion depress /rac(ure

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    "ntra operati!e

    'er/ormed de!ridemen(

    x(ended incision /rom (*e old 0ound

    T*ere 0as depress /rac(ure

    Bone pulled ou(, durama(er and cere!ral cor(ex

    0as lacera(ed 'er/ormed dura/acial gra/(

    Bone 0as re(urn 0i(* mossaic (ec*ni2ue and

    /ixa(ed

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    Post #perati!e iagnose

    #. ild *ead inury 4IC #$ C S$.$6

    +. Dpen depress /rac(ure a( (*e rig*( parie(al region

    4IC #$ C S$+.#6

    &. ?ea1age urama(er 4IC #$ C S$.&&6

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    **

    ate S # A P

    ++5G5+$#%

    'D &

    456 9eneral condi(ion : good

    9CS #%

    'ulse: 8$ !ea(s7minu(e

    "espira(ory:+$ !rea(*7minu(e

    T:&G,$ $C

    #. ild *eadinury 4IC #$C S$.$6

    +. Dpen depress/rac(ure a( (*erig*( parie(alregion 4IC #$C S$+.#6

    &. ?ea1ageurama(er4IC #$ C

    S$.&&6

    I; NaCl $, E

    #$ drips7minu(e

    Ce/(riaxone in.

    %$$ mgKe(orolac in #$

    mg