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Department of SurgeryJanuary , 27 2015
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NAME DXROOMr. MFr. Basis Cranii14.4
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Name: Mr. M Age: 17 y.oSex: MaleAddress: Plumpang Sukodadi Lamongan
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ANAMNESISChief complaint :Decrease of conciousnessMOIPatient post traffic accident thirty minute before addmission to the hospital. Patient didnt remember about the accident. Heteroanamnesis patient riding motorcycle and was hit by a motorcycle from the front (data from another victim), Decrease of conciousness (+), blood vomit + one times when he was admission and 3 times in hospital, it was proyectile vomit, his nose was bleeding, seizure 1x, he didnt use helmet when it happened.
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Airway and spine control : unclear, snorring (-), gargling (+), potensial obstruction (-) Breathing : spontan, simetric (+), RR 20x/minutes, ves/ves, rh-/+, wh-/-, Sp02 97% without O2 NRMCirculation : PR 112x/minutes, acral warm dry red, CRT < 2, BP 149/80 mmhgDisability : GCS 115, lateralisasi -, Light perception +/+Exposure : temp 36.7C,
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History past illness Asma (+) since he was 5 y.oStatus GeneralisHead and neck : anemic (-), icteric (-), cyanosis (-), dyspneu (-)Thorax : 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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Status Lokalisvull. Appertum et regio cruris sinistra uk 1x 0,5. vull. Appertum et regio metatarsal digiti 1 uk 2x0.2 cm
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Clue and cueMale 17 y.o.Post traffic accidentDecrease of conciousnessPTA +, amnesia retrograde +Status lokalis:vull. Appertum et regio cruris sinistra uk 1x 0,5. vull. Appertum et regio metatarsal digiti 1 uk 2x0.2 cm
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AssesmentFr MaxillaFr Basis CraniiSevere brain injury
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CBCBleeding TimeClothing TimeFoto Skull AP/LSkull CT-Scan with contras
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Lab Diff : 0/0/38/55/7Hct : 45,7Hb : 15,4LED : 9/17Leukosit : 24.000Trombosit : 531.000BT : 2 00CT : 8 00
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Clinical sign
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Thorax Photo
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Skull CT-Scan
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Assesment Fr. MaxillaSevere brain injury + Fr. Basis Cranii
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IVFD Assering 1500 cc/24 hoursO2 NRMKateter foleyInj. Manitol loading 200 cc 6 x 100ccInj. Phenytoin 400 mg 3x100 mgInj. Antrain 3x1 g ivInj Acran 2x1 amp ivInj. Ceteron 1 amp prnInj. Ceftriaxon 2x1 g ivInj. Cithicolin 3x250 mg ivC/Sp.BS Inj Ceftriaxon 2x1 g, manitol abd phenytoin C /Sp. MC /Sp. B
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Subjective complaintVital sign
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Explain to the patients family about the diagnosis, etiology, intervention of therapy, complication, and prognosis.
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