History Taking

 A Male, 14 years old, admitted to hospital with a chief complaint:

unconsciousness after an accident.
 7 hours before admission, the patient was sitting on a motorcycle
rode by the driver. , suddenly get hit by motorcycle from the opposite
direction.
 He fell down and his head hit the ground. Temporarily loss of
consciousness that the patient didn’t know how long it is. Helmet (-).
 There was vomiting about 3 times of the patient, Blood from the nose
(-), blood from ears(-) blood from the mouth (+), Seizure (-),
Fever(-), Slurred Speech(-), Weakness of one side of the body(-).
Alcohol (-)
 He was taken to Kotamobagu Hospital for the first aid and after that
patient referred to Kandou Hospital
History of Past Illness
Hypertension (-)
Cholesterol (-)
Heart Disease (-)
DM (-)
Kidney (-)
 Physical Examination
 General examination:
 General condition: Severe, Consciousness : Coma
 BP: 150/60 mmHg, HR: 97 times per minute reg, RR: 24 times per
minute , T: 36,7 °C, SaO2 : 97%
 Conjunctiva: pale (-/-), sclera ikteric (-/-)
 JVP : normal
 Thorax : Rale -/-, Wh -/-, heart sound I/II normal, gallop -, murmur –
 Abdomen : Flat, normal turgor, peristaltic normal
 Extremities : warm acral
 Neurological Examination
 GCS E1M5V2. Pupil :anisokor ø 5mm / ø 3mm. Direct light Reflex
+/+, Indirect Light Reflex +/+
 Meningeal Sign: nuchal rigidity not evaluated. Lasegue (>70/>70)
Kernig (>135/>135)
 Cranial Nerves: impression of paresis (-).
 Motoric examination : hemiparesis impression (-).
MT : N N PhyR : ++/++/++ ++/++/++ PathR : - -
N N ++/++ ++/++ - -
 Sensoric exam : can’t be evaluated
 Autonomic state : incontinentia urine et alvi -
Localized Examination
 Otorrhea - / -
 Rhinorrhea - / -
 Racoon eye +/+
 Battle sign - / -
 Brill Hematoma +/+
WDx
Severe head injury
Susp. Fracture Basis Craniii Anterior
 Planning
 Bed rest + C Spine control
 Oxygen 10 LPM via Non Rebreathing Mask
 Pro OGT, cateter, consult ICU and anesthesiologist (approval by
family).
 IVFD NaCl 0,9% 500 cc 20gtt /m
 Paracetamol drips 3x1g IV
 Vitamin C 2x200mg IV
 Ceftriaxone 2x2gr IV
 Observe GCS/Pupil/VS per hour.
Diagnostic Planning
 Blood exam: hematology, blood sugar, electrolyte, renal
function, liver function.
 Brain CtScan + BW
 Thoraks AP/Lat
 ECG
Laboratory Examination 29 October 2017
 Hb : 16.1
 Ht : 46.3%
 WBC : 14.600
 PLT : 277.000
 RBC : 5.28 x 10^6
 SGOT : 20
 SGPT : 12
 Ureum : 17
 Creatinine : 0.7
 Random blood sugar : 136
 Na : 135
 K : 3.80
 Cl : 105.0
 OSM : 287.75 mOsm/L
Chest X- Ray
Brain CT
Brain CT Scan (zoomed)
Bone
Window
THANK YOU