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  • An Rifki/L/11 Th/12526678: No Identitas TGL Mrs Ruang Kasus Diagnosa Rencanatindaka N Lain-Lain

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    1) The patient experienced a loss of consciousness after a motorcycle accident, falling by himself. He was brought to the emergency room 10 hours later still unconscious. 2) CT scan results showed frontal diastasis of the lambdoid suture + EDH TPO D + internal bleeding. 3) The patient's treatment plan was for craniotomy and evacuation of the EDH along with decompression.

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    An. Rifki

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    1) The patient experienced a loss of consciousness after a motorcycle accident, falling by himself. He was brought to the emergency room 10 hours later still unconscious. 2) CT scan results showed frontal diastasis of the lambdoid suture + EDH TPO D + internal bleeding. 3) The patient's treatment plan was for craniotomy and evacuation of the EDH along with decompression.

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    11 views1 page

    An Rifki/L/11 Th/12526678: No Identitas TGL Mrs Ruang Kasus Diagnosa Rencanatindaka N Lain-Lain

    Uploaded by

    YhafapCez
    1) The patient experienced a loss of consciousness after a motorcycle accident, falling by himself. He was brought to the emergency room 10 hours later still unconscious. 2) CT scan results showed frontal diastasis of the lambdoid suture + EDH TPO D + internal bleeding. 3) The patient's treatment plan was for craniotomy and evacuation of the EDH along with decompression.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 1

    No

    Identitas

    An Rifki/L/11
    Th/12526678

    Tgl
    MRS

    Ruang

    Kasus

    21/8/16

    ROI

    Ped

    Diagnosa

    RencanaTindaka
    n

    COB + Fr.
    Diastasis Sutura
    Lambdoidea +
    EDH TPO D +
    Internal Bleeding
    HD Stabil + Fr.
    Antebrachii D et S

    Craniotomy
    Evakuasi EDH +
    Dekompresi

    Lain-lain
    CT Scan
    KU :Penurunan kesadaran
    Pasien mengalami penurunan kesadaran post KLL sepeda motor jatuh sendiri,
    10 jam SMRS, Pasien langsung tidak sadar, muntah (+) 1x, kejang (-) keluar
    darah dari hidung (-) telinga (-)
    St. Generalis
    KU : cukup
    VS N : 114x, RR : 22x, T : 36,7C
    K/L aicd(-)
    Tho sim, ret(-)
    Abd flat, BU(+)N, supel
    Eks akral HKM CRT < 2
    St. Neurologis
    GCS 224 PBI 3/3 RC +/+ hem (-)
    MS KK (+)
    Motorik : kesan hemiparese (-)
    Sensorik : sde
    RF: BPR +2/+2 KPR +2/+2
    TPR +2/+2 APR +2/+2
    RP: Babs -/-, Chad -/CV ANS dbn

    HasilLaboratorium
    Tgl
    Hb
    21/8/16
    9,5

    WBC
    44

    Plat
    450

    CRP

    GDA

    Alb

    SGOT

    SGPT

    BUN
    28

    Creat
    2,4

    Na
    150

    K
    4,4

    Cl
    118

    PPT

    APTT

    1/1

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