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Duty ReportSaturday, July19th 2014Resident in charge : dr. Wahyu R Wibowo
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Consultant in chargeDigestive surgery Dr. Arief setiawan SpB(K)BDUrology surgery :Dr.Nindra P., SpU.Neuro surgery :Dr. Agus Aulia SpBSOncology surgery :Dr.Ktristina Maria SpB Orthopaedic surgery :Dr. AB Mulyanto, SpOTPediatric surgery :Dr. IrhamniSpBAPlastic surgery :Dr Asrofi,SpBP, MARSCardiothoracic surgery :Dr. Dedi A Zaelani, SpB(K)BV
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Resume Outpatients : 2 patientsOperations : 0 patientHospitalized : 1 patient
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Mr. Gerry, 35 y.o, WD: Laceration wound of the right lower leg region (ICD-10:S81.819)Mr. Anton, 32 y.o,WD: Laceration wound of the right foot region. (ICD-10:S81.819A)
Outpatient
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Nn.Nurlaili/ 31 yoCC :Patients felt pain on her head and vomite since 1 hour before admission HPI :1 hour hours before admission, patien had a motor vehicle accident while he was driving a motorcycle, she wore helmet. The mechanism of trauma was unknown, she was found by people arround and brought to GS Hospital. History of fainted (+), vomite(+) more than 2x. Patients felt pain on her head . There was hematoma wound on the right parietal region, no bleeding from ear nor nose.Patien is being pregnant 6 months (G3P1A1)
Hispitalized
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Primary Survey :A : Clear B : Spontaneous, RR : 20 x/mnts , O2 saturation 100 percentC : BP : 100/70 mmHg, HR : 96 x/mntsD : Alert with GCS = E4M6V4 : 14Pain score VAS : 5
- Secondary Survey :General conditionHead: subgaleal hematome (+) at right parietooccipitalEye: anemic -/-, icteric -/-, Isocore pupil with diameter 3 mm.Chest: symmetric, vesicular +/+, rhonchi -/-, wheezing -/-Heart: HS I-II normal, murmur (-), gallop (-)Abdomen: flat, supple, tenderness (-), bowel sound (+)Ekstremity: warm, CRT
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Local status :Head : There was hematoma wound on the parietal region, no bleeding from ear nor nose.Face : No excoriation , no laceration on hematom periorbita, no diplopia.No maloclutio, no floating maxilla.
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Neurological state:GCS E4M6V4=14isochor pupil, diameter 3 mm, light reflex of eye +/ +Motoric: 4 extremity are normaly activeSensoric : within normal limitsAutonomic : within normal limits (BP : 100/70 mmHg, HR : 96 x/mnts RR 20x/mnts)
Laboratory finding :within normal limits
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Chest and cevical X-ray finding :within normal limits
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Head CT-Scan
Sub Galleal hematom on the right temporo-parietal region
Contucio cerebri on the left frontal dan temporal pole.
No intra cerebral bleedingNo mid line reft, Normal gyrus and sulcus
(No sing of Space Occpying P rocess finding)
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No Fracture of calvariaNo Fracture of bone face
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Working Diagnosed:Mild head injury with Contucio cerebri on the left frontal and temporal pole. (ICD-10: S06.2X)Sub Galleal hematom on the right temporo-parietal region (ICD-10: S00.T88)Pregnant 6 months (G3P1A1) (ICD-10: 000.09A)
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Treatment Antibiotic, Analgesic Anti odema cerebriConserfative tratment of neuro Surgery Obsevation, If decrease of consciousness evaluation Re-Head CT Scan (Z51.81)
Consultation to OBSGIN Depatement :good condition of her prengnacy (Z34.0) Anti uterus contraction : Duvadilan 2x1/2 tabets
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Today Condition :Stable condition, no dizzy , no vomitePain score : 2
Plan: Discharge to day
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Thank you
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GCS
- CT scan of the brain within one hour (with a written radiology report within one hour of the scan being undertaken): Glasgow Coma Scale (GCS)
- Selection of children (under 16 years) for CT scanCT scan of the brain within one hour (with a written radiology report within one hour of the scan being undertaken): Clinical suspicion of non-accidental injuryPost-traumatic seizure (no past medical history of epilepsy)GCS
