Morning Report

FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH MALANGRUMAH SAKIT MUHAMMADIYAH LAMONGAN2016

Dept. of SurgeryJ-23

Patient Identity• Name : Mr. ME• Age : 30 y.o• Address : Lamongan• Occupation : -• Marriage status: Married

Present History Patient reffered from PKU Cepu Hospital with EDH. Patient was encountered traffic accident 3 days before admission to hospital. Patient was ride a motorbike himself, helmet (+), medium speed, then in front of him there was a child crossing street, patient was about to denying him but he was fall, in sliding left position. Loss of consiusness (-) bleediing from nose (+) after accident, bleeding from ear (-), vomiting (-) Patient was treat on PKU Cepu Hospital for 3 days and got dexamethasone and metilcobalamin

Physical ExaminationVital sign:TD: 100/62 mHgN: 68 xmRR: 19x/mT: 36.8CSpO2: 100% without O2 supportGCS 356Primary Survey:A : Gargling (-) snoring (-) pot. Obstruction (+)B : Spontan, RR 19x/m, ves|ves, rh -|-, wh -|-C : Extremity WRD, CRT <2’’, N 73x/m, TD 100/62D: GCS 356, lateralisasi (-) pupil isocor 3mm|3mm LP +|+

Physical ExaminationSecondary Survey:Head and neck: a-/- i -/- c -/- d –

Brill hematome bilateral (+), vulnus apertum right frontoparietal head sewn. Bloody otorheae (-) bloody rhinroheae (-) lesion retro aurikula (-)Lesion supraclavicula (-) subconjunctival bleeding bilateral (+)

Thorax: Inspection: Simetris, retraction (-|-) cor: s1 s2 single reg, m (-), g (-)pulmo: sonor|sonor, ves|ve, rh -|-, wh -|-Abdomen:Flat, soefl, lesion (-), tympani, bowel

sound (+) wnlExtremity:Acral warm dry red, CRT 2’’

Laboratory findings• Eri 5.50• Hb 13.8• Leu 11.2• Neu 83.7• Plt 285• HbsAg (-)• PT 11.40 (10.30-16.30)• aPTT 26.20 (24.20-38.20)• BUN 35• SC 0.8

CT scan w.o contrast

CT Scan kepala irisan axial tanpa kontras-Tampak area hiperdens daerah fronto-parieta kanan tebal 4,3 cm disertai perifocal edema mendesak ventrikal lateral kiri sejauh 1.2 cm-Tampak fraktur os fronto parietal, temporal, dan zygoma kanan-Tampak perselubungan kedua sinus etmoidalis, sphenoidalis, dan frontalis-tampak soft tissue hematome pd frontoparietal kanan-tampak area hiperdens mengisi cysterna dan sulcy gyri

Kes: EDH di fronto-parietal kanan tebal 4.3cm disertai perifocal edema mendesak ventrikal lateral kiri sejauh 1.2 cm-SAH minimal-Fr.os frontoparietal dan zygoma kanan-soft tissue hematom pd frntoparietal kanan-hematosinus ethmoidalis, sphenoidalis, dan frontalis kanan kiri

Skull 3D

Clue and cue• Headache• Post traffic accident• Brill hematome bilateral (+), vulnus apertum right

frontoparietal head sewn. Bloody otorheae (-) bloody rhinroheae (-) lesion retro aurikula (-)Lesion supraclavicula (-) subconjunctival bleeding bilateral (+)

• EDH di fronto-parietal kanan tebal 4.3cm disertai perifocal edema mendesak ventrikal lateral kiri sejauh 1.2 cm

• Fr. os frontoparietal dan zygoma kanan• soft tissue hematom pd frntoparietal kanan• hematosinus ethmoidalis, sphenoidalis, dan frontalis

kanan kiri

Problem list• EDH• Fr. os frontoparietal dan zygoma

kanan

Therapy• O2 nasal 3 lpm• Head up 30 derajat• Attach DK• Inf. asering 1500cc/24 j• Inj. Metamizole 3x1 gr iv• Inj. Ceftriaxone 2x1 gr iv• Inj. Ranitidine 2x50 mg iv• Inj. Ceteron 3x8 mg iv• Inj. Piracetam 4x 3 gr iv• Inj. Citikolin 3x250 mg iv• Inj. Manitol 20% oading 200cc lanjut 6x100cc inj.

Kutoin 100 mg iv 300 mg iv drip in pz 100• Consult neurosurgery CITO op