Patient identity

Name : Tira Insyah

Age : 55 years old
Sex : Female
Address : Birem Bayeun
CM : 119 79 49
HP : 082274236865
Admission time : 11.23 WIB
Driving license : (+)

Time Response
Laboratory Radiology
Date/hour patient Examination Examination Examination Hour of Date/hour patient
Supervisor
came to ER hour Diagnostics out from ER
Send Result Send Result

Jan 20th 2019 11.25 11.45 13.00 02.45 03.45 17.00 20.00 dr. Bustami,
11.23 WIB WIB WIB WIB WIB WIB WIB Sp.BS
WIB

Chief complaint
Persistens Headeache

Present illness history

Patient was referred from Zubir mahmud Aceh timur distric hospital to Zainoel Abidin emergency
room with a chief complaint persistens headeache for 1 day ago.
Initially the patient passenger motorcycle without helmet and suddenly motorcycle slip and felt
down to asphalt.
The patient also complained pain and difficult to move right thigh after trauma.
There were no history of nausea and vomiting.
There was no history of lucid interval.
Eyes opened to speech, motoric obeys commands, verbal good orientation.
Physical examination :
Primary survey
A : Clear
B : Spontaneous, RR = 22 breaths/minute
C : BP: 110/80 mmHg, Pulse: 90 beats/minute
Urinary catheter  initial 50 cc yellowish
D : GCS E4 M6 V5 = 15, isochoric pupil (3 mm/ 3 mm), light reflex (+/+)
E:
L/S at head region :
I : Hematoma (+) at the parietal sinistra, wound (-)
F : Pain (+)
L/S at Right Femur :
I : Deformity (+), swelling (+), wound (-)
F : Pain (+), NVD (-)
M : ROM Limited

Secondary survey
Head and neck :
L/S at head region :
I : Hematoma (+) at the parietal sinistra, wound (-)
F: Pain (+)
S/L Thorax :
Abdomen  in normal limit
Upper Extremity  in normal limit
lower Extremity
L/S at Right Femur :
I : Deformity (+), swelling (+), wound (-)
F: Pain (+), NVD (-)
M : ROM Limited
Assessments:
Mild head injury
Close fracture of the left thigh
Management :
Stop oral intake
Head Up 30°
O2 4L/minute via canule
IVFD NaCl 0,9 % 1500 cc/24 hours
Ceftriaxone Inj. 1 gr
Ketorolac Inj. 30 mg
Laboratory examination
Radiology examination
Laboratory result
• Hb : 11,3 g/dL
• Ht : 33 %
• White blood count : 7.900 u/L
• Platelet : 174.000 u/L
• CT : 8 Minute
• BT : 2 Minute
 • Blood glucose : 110 mg/dL
• Ur : 28 mg/ dl
• Cr : 0,54 mg/ dl

Radiology result
Head CT-Scan
There was SCALP hematoma at the left Frontal region
There was no discontiunity of bone
There was biconvex hyperdense appearance at the left frontal region EDH thickness 3 cm
Sulcus and gyrus were narrow
Ventricel system and cysterna were narrow
There was no midline shift
Pelvic AP
There was Discontuinity of bone at the right intertrochanter femur

Diagnosed:
1. Mild head injury (ICD 10 CM S10.10)
2. EDH at the left frontal region (ICD 10 CM S06.4)
3. Close fracture of the right intertrochanter femur

Consult to Neurosurgery Division

Craniotomy evacuation EDH emergency

Consult to Orthopaedic Division

Skin Traction
Orif Elektif

Operative report
Performed 3/4 coronal incision
Performed 4 burrholes, the skull was sawed with gigly and the fragment was pulled out
Found EDH  evacuation EDH about thick 3 cm
Performed dura hit stiched
Bone was returned
Wound was closed by primary suture and performed 1 tube drain

Post Operative Diagnosed:

1. Mild head injury (ICD 10 CM S10.10)
2. EDH at the left frontal region (ICD 10 CM S06.4)
Post Craniotomy evacuation EDH
3. Close fracture of the right intertrochanter femur
(ICD 10 CM S72.143A )
Follow up
Date S O A P
Jan 21 th
Pain (+) • General Condition : Post Operative Diagnosed: • Head Up 30⁰
2019 decrease Good 1. Mild head injury (ICD • O2 4 L/minute
POD 1 • BP : 130/80 mmHg 10 CM S10.10) via canule
Raudah • HR : 86 beats/minute 2. EDH at the left frontal • IVFD NaCl 0,9%
6 • RR : 20 breaths/minute region (ICD 10 CM 1500 cc/24hours
• T : 36,7oC S06.4) • Inj. Ceftriaxone 1
• GCS : E4 M6 V5 : 15 Post Craniotomy evacuation gr/24 hours
• Pupil isokor ( EDH • Inj. Ketorolac 30
3mm/3mm ) 3. Close fracture of the mg/8 hours
• RC (+/+) right intertrochanter • Free diet
L/S at left Frontal region : femur Planning:
• L : Gauze was (ICD 10 CM S72.143A • Obervation GCS
dry, drain 50 cc ) • Mobilization
• F : Pain (+) • Wound care and
L/S at Right Femur : aff tube drain
• I : Deformity (+), POD 3
swelling (+), wound (-
), Skin traction (+)
• F : Pain (+), NVD (-)
• M : ROM Limited