Download - Depres Ismu Hadi

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


2/19

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"


3/19

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.


4/19

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 4@6 si>e cm 0as su(ured, s0elling 4@6

: pain 4@6, discon(inui(y o/ !one 4@6

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

: pain 4@6


5/19

Secondary Sur3ey

Head and Nec1

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

?: 0ound 4@6 si>e cm 0as su(ured, s0elling 4@6

: pain 4@6, discon(inui(y o/ !one 4@6

?7S a( (*e /acial region

?: excoria(ed 0ound

: pain 4@6

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(


6/19

#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


7/19


8/19

Assessment:

ild Head Inury

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


9/19

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


10/19

Laboratory result

H! : #$.% gr7dl

Hema(ocri( : &+ E

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

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

CT : G minu(e

BT : + minu(e


11/19


12/19


13/19

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/(


14/19

iagnose:

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

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

4IC #$ C S$+.#6


15/19

Consult to neurosurgery di!ision

e!ridemen(

le3a(ion depress /rac(ure


16/19

"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


17/19


18/19

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


19/19

**

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

Download - Depres Ismu Hadi

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