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Selasa, 12 Oktober 2021 : report new patients to the ER Tuesday, October 12,
2021:
Aririn, P, 29 tahun, 1989197
Aririn, F, 29 years old, 1989197
Primary Survey:
A: snorring (-), gurgling (+) —> unclear —> intubasi —> Primary Surveys:
clear A: snorring (-), gurgling (+) —> unclear —> intubation —
B: RR 24 x/mnt, SpO2 100% on NRM 10lpm, simetris (+), > clear
KG (-), (sonor/sonor), vesikuler (+/+) --> clear B: RR 24 x/min, 100% SpO2 on NRM 10lpm, symmetric
C: Akral hangat (+), TD 119/71 mmHg, HR 125 x/menit, (+), KG (-), (sonor/sonor), vesicular (+/+) --> clear
CRT <2 dtk --> clear C: Acral warm (+), BP 119/71 mmHg, HR 125 x/minute,
D: GCS E2V2M5, pupil isokor 3 mm/3 mm, lateralisasi CRT <2 sec --> clear
(-) --> clear D: GCS E2V2M5, pupil isocor 3 mm/3 mm, lateralization
(-) --> clear
Initial assessment: potential life threatening
Initial assessment: potential life threatening
Secondary Survey:
A: tidak ada Secondary Survey:
M: tidak ada A: none
P: tidak ada M: nothing
L: makan terakhir jam 22.00 Q: no
E: post menabrak pot batu L: last meal at 22.00
E: post hit the stone pot
Kel.utama:
Penurunan kesadaran Main Ex:
Loss of consciousness
RPS:
2 jam SMRS pasien mengendarai motor menggunakan RPS:
helm kemudian menabrak pot batu yang ada di pinggir 2 hours at SMRS the patient rode a motorcycle using a
jalan. Tidak diketahui helm terlepas atau tidak. Pasien helmet and then hit a stone pot on the side of the road.
lalu ditemukan warga setempat sudah tidak sadarkan It is not known whether the helmet came off or not.
diri dan dibawa ke RSS untuk penanganan selanjutnya. The patient was then found by a local resident who was
unconscious and was taken to the RSS for further
RPD: treatment.
Riwayat Alergi (-) , DM (-), HT(-)
Peny. Jantung (-), asma (-) RPD:
Allergy history (-) , DM (-), HT(-)
Pemeriksaan Fisik Pen. Heart (-), asthma (-)
KU lemah, E2V3M4
TD: 119/71 mmHg Physical examination
N: 125 x/mnt KU weak, E2V3M4
RR: 24 x/mnt BP: 119/71 mmHg
SpO2 100% on NRM 10lpm N: 125 x/min
S: 36°C RR: 24 x/min
SpO2 100% on NRM 10lpm
Kepala: S: 36°C
Pupil anisokor 4 mm/3 mm, CA (-/-), SI (-/-), RC (-/-) VL
(+) regio zygoma dextra, VE (-), hematom regio maxilla Head:
dextra Pupil anisokor 4 mm/3 mm, CA (-/-), SI (-/-), RC (-/-) VL
(+) region zygoma dextra, VE (-), hematoma region
Upper face maxilla dextra
I : simetris, VE (-) VL (-), hematoma (-), swelling (-),
bleeding aktif (-), Upper face
P: sensoris sulit dinilai, NT sulit dinilai, krepitasi (-), step I : symmetrical, VE (-) VL (-), hematoma (-), swelling (-),
off (-) active bleeding (-),
 P: sensory is difficult to assess, NT is difficult to assess,
Midface crepitus (-), step off (-)
I : asimetris , racoon eye (+/-) telekantus (-), diplopia
sulit dinilai, gerakan bola mata sulit dinilai, rhinorrhea Midface
(+) , bloody otorrhea (+), battle sign (-), deviasi septum I : asymmetrical, racoon eye (+/-) telecanthus (-),
nasi (-), step off (-), VE (-), VL (+) regio zygoma dextra uk diplopia difficult to assess, eye movement difficult to
1x0.2cm dasar subkutis, swelling (+) regio maxilla assess, rhinorrhea (+), bloody otorrhea (+), battle sign
dextra, deformitas (-) (-), nasal septal deviation (-), step off (-), VE (-), VL (+)
P : sensoris sulit dinilai, floating maxilla (+), NT sulit region of right zygoma size about 1x0.2cm subcutis
dinilai, krepitasi (+) maxilla dextra base, swelling (+) region of right maxilla, deformity (-)
P: sensory is difficult to assess, floating maxilla (+), NT is
Lower face difficult to assess, crepitus (+) on the right maxilla
I : asimetris, avulsi dental (-), VE (-), VL (-), edema
labium oris superior et inferior dextra, deformitas (-) lower face
maloklusi (+) open bite I : asymmetry, dental avulsion (-), VE (-), VL (-), edema
P : sensoris dbn, NT (-), gliding mandibula sulit dinilai of the right labium oris superior et inferior, deformity
krepitasi (-) (-) malocclusion (+) open bite
P : sensory normal, NT (-), mandibular gliding difficult to
Leher: assess crepitus (-)
Jejas (-), JVP tidak meningkat, NT (-)
Neck:
Thorax: Damage (-), JVP does not increase, NT (-)
I: Jejas (-), simetris (+), ketinggalan gerak (-/-)
P: VF ka=ki Thorax:
P: sonor/sonor I: Damage (-), symmetrical (+), lagging motion (-/-)
A: Vesikuler (+ /+), wheezing (-/-), ronkhi (-/-) P: VF Right = Left
P: sonor/sonor
Abdomen: A: Vesicular (+ /+), wheezing (-/-), rhonchi (-/-)
I: Distensi (-), VE (-), jejas (-)
A: BU (+) normal Abdomen:
P: timpani (+)  I: Distension (-), VE (-), injury (-)
P: Supel, defans (-), NT (-) A: BU (+) is normal
P: tympanic (+)
Pelvis: P: Helpful, defans (-), NT (-)
I: Jejas (-)
P: NT (-), Krepitasi (-) Pelvis:
I: Damage (-)
Ekstremitas: P: NT (-), Crepitus (-)
Akral hangat (+), nadi kuat, CRT <2 detik, deformitas (+)
humerus dextra Extremities:
Acral warm (+), strong pulse, CRT <2 seconds, deformity
Status lokalis regio humerus dextra : (+) of the humerus
L : swelling (+) deformitas (+)
F : NT sulit dinilai, NVD (-) Local status of the right humerus region:
M : ROM sulit dinilai L : swelling (+) deformity (+)
F : NT is difficult to assess, NVD (-)
Lab 12/10/2021 M: ROM is difficult to assess
AL 36.07
Hb 11.0 Lab 12/10/2021
AT 449 AL 36.07
Alb 3.45 Hb 11.0
SGOT 525 AT 449
SGPT 243 3.45
PPT 17.4/14.8 SGOT 525
APTT  34.2/31.2 SGPT 243
INR 1.21 PPT 17.4/14.8
BUN 15.4 APTT 34.2/31.2
Creat 0.88 INR 1.21
GDS 302 BUN 15.4
LDH 1073 Creatinine 0.88
CRP <5 GDS 302
Na 136 LDH 1073
K 3.76 CRP < 5
Cl 103 Na 136
Anti SARS CoV-2 NR K 3.76
Cl 103
Assessment: Anti-SARS CoV-2 NR
- EDH of the right temporal region
- Cerebral contusion of the right frontal lobe Assessments:
- Linear fracture of the right temporal bone - EDH of the right temporal region
- Traumatic SAH - Cerebral contusion of the right frontal lobe
- Traumatic cerebral edema - Linear fracture of the right temporal bone
- Fraktur Zygomaticomaxillary complex dextra - Traumatic SAH
- Fraktur segmental arkus zygoma dextra - Traumatic cerebral edema
- Fraktur maxilla dextra - Fracture of the right zygomaticomaxillary complex
- Fraktur parasimfisis mandibula sinistra - Segmental fracture of the right zygoma
- Vulnus laceratum regio zygoma dextra - fracture of the right maxilla
- Close fracture of distal third of the right humerus - Fracture of the left parasymphysis of mandibular
- lacerated wound of the right region zygoma
Plan: - Close fracture of distal third of the right humerus
Bedah Saraf
- Observasi GCS dan vital sign Plans:
- Rawat HCU Neurosurgery
- Observation of GCS and vital signs
Bedah Plastik (usul) - Treat HCU
- Awasi KU/VS
- Wound toilet Plastic Surgery (proposal)
- Primary suturing VL dengan Nylon 5.0 (kutis) dan Safil - Keep an eye on KU/VS
5.0 (Subkutis) - Wound toilet
- Pro Reconstruction of facial bones elektif - Primary suturing VL with Nylon 5.0 (cutis) and Safil 5.0
- Lain-lain sesuai TS terkait (Subcutis)
- Pro Reconstruction of facial bones elective
Orthopaedi - Others according to related TS
- immobilisasi dengan u-slab
- Orif elektif Orthopedics
- immobilization with u-slab
Mohon arahan, Dokter. - Elective Open reduction internal fixation
Terima kasih Dokter
Please advise, Doctor.
Thank you Doctor