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Department of SurgeryJanuary, 20 2015
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DAFTAR OBTn Abdul rohman Susp fraktur mandibula Nn Akhadiyah COS Tn Suheri Fr mandibulae, open fraktur cruris 1/3 medial
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Name: Mrs. AAge: 21 y.oSex: FemaleAddress: Tikung, LamonganDate examination: january 20, 2015
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ANAMNESISChief complaint loss of consciousnessMOIPatient came with loss of consciousness post traffic accident 30 minutes before addmision into the hospital. According to a witness in an accident , the patient 's own fall from the motorcycle due to slippery roads sandy . patients on a motorcycle at moderate speed .Patient is using a helmet but apart, History unconsiousness +, vomiting blood mixed with the food one time when in hospital Bloody otorrhea (+), Nausea-, seizure-, short of breathness -. The patients look fidgeted.
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History illness Alergy-, DM-, HT-Family illness :(-)Social history : (-)
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PHYSICAL EXAMINATION VITAL SIGN :GCS: 225BP: 145/69 mmHgPULSE RATE: 95 x/minutesTEMP: 36,2oCRR: 23 x / minutes
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Airway and spine control : clear (+), snorring (-), gargling (-), potensial obstruction (-)Breathing : spontan, simetric (+), RR 23x/minutes, ves/ves, rh-/-, wh-/-, Sp02 98% Circulation : PR 95x/minutes, acral warm dry red, CRT < 2, BP 145/69 mmhgDisability : GCS 225, LP +/+, isocor pupil 3mm/3mm, lateralisasi-Exposure : temp 36, 2CPRIMARY SURVEY
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Head and neck : anemic (-), icteric (-), cyanosis (-), dyspneu (-). Diplopia-. Lession + hematom parieto occipital dex with diameter 5 cmThorax : simetric (-), retraction (-)Pulmo : ves/ves, rh-/-, wh-/-Cor : S1S2 single, murmur (-), gallop (-), lession -Abdomen : flat, distended (-), tympani (+), liver and spleen were not palpable, bowel sound (+), lession-Extremities : acral warm, dry, red, lession-
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et regio parieto occipital dex :Lession + hematom parieto occipital dex with diameter 5 cm
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Clue and cue
Female, 21 y.oloss of consciousnessPost traffic accidentBloody vomitBloody otorrheaRegio parieto occipital dex :hematom with diameter 5 cm
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Early AssesmentModerate brain injury
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CBCCT-BTGDACT Scan Thorax AP
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CBCDiff 3/2/49/44/2Hct 33,8Hb 11,0LED 5/11Lekosit 17.100Trombosit 430.000BT 130CT 730
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CT SCAN
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CT Scan
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FOTO THORAX
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Assesment moderate brain injuryContusio cerebri
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IVFD Assering 1500 cc/24 hoursHead up 30 02 nrm 8 lpmInj.Metamizole 3x1ampInj. Ranitidin 2x50mgInj. Ceftriaxon 2x1 gr IVInj. Mersitropil 4x3 gr IVInj manitol 200cc6x100mgInj kutoin 400mg 3x100mgC/Sp.BS
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Subjective complaintVital signsign of increased pressure intracranial
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Explain to the patients family about the diagnosis, etiology, intervention of therapy, complication, and prognosis.
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