Patient identity

• Name : Rizal Maulana

• Age : 21 years Old
• Sex : Male
• Address : Bireuen, Kab Bireuen
• MR : 119-50-18
• Phone : 0852 160 535
• Admission time : 06.10 wib
• Drive license : +
 Time respon
Date/ Time Examination Laboratory Radiology Time of Date/ DPJP
patient came hour Examination Examination Diagnostics Time
to ER Send Result Send Result patient
out
from ER

Dec 22nd 06.15 06.20 07.20 08.30 08.50 09.00 Dec 22nd Dr.
2018 Wib Wib Wib Wib Wib Wib 2018 Iskandar,
SpBS
06.10
Chief complaint
• Decrease of consciousness

Patient illnes History

• The patient was referred from BMC Bireuen District Hospital to Zainoel
Abidin Emergency room with chief complaint deacrease of
consciousness for 6 hours. Innitialy Patient was riding a motorcycle
without helmet and suddenly felt down when strucked by another
motorcycle from behind, then his head hit the asphalt.
• History of vomiting (-). History of alert after trauma (-),
Physical examination
Primary Survey :
• A : Clear + C-Spine control
• B : Spontan, RR: 24 breaths/min, SpO2 : 97 %
• C : BP : 120/110 mmHg, HR : 98 beats/minute
• D : GCS: E3 M5 V3  isochoric pupil (3 mm/ 3 mm), light reflect (+/+)

• E :L/S at the left temporal region

L : lacerate wound about 2x2 cm, base of wound is bone
F : Discontiunity of bone (+)
Secondary survey
• Head and Neck
• L/S at the right temporal parietal region
L : lacerate wound about 2x2 cm, base of wound is bone
F : Discontiunity of bone (+)
• Thorax : in normal limit
• Abdominal : in normal limit
• Pelvic : in normal limit
• Extremity : in Normal limit
Foto Klinis
Assessments
1. Moderate head injury
2. Open depressed fracture at the left temporal
region
3. Lacerated wound at the left temporal region
Management
• Head up 30°
• Stop oral intake
• Catheter urine  clear, initial 200 cc
• IVFD NaCl 0,9% 20 drips/minute
• Inj. Ceftriaxon 1 gr
• Inj. Metamizole sodium 500 mg
• Laboratory examination
• Radiology examination
Laboratory examination
• Hb : 11.2gr/dl
• White blood count : 16.500/ul
• Platelet : 221.000/ul
• Ht : 32 %
• CT : 7 minute
• BT : 2 minute
• Creatinin : 0.71 mg/dl
• Ureum : 17 mg/dl
• Sodium : 139 mmol/L
• Pottasium : 4,3 mmol/L
• Chlorida : 98 mmol/L
Radiology examination
Cervical Lateral
• Lost of lordotic

Thorax AP
• In Normal Limit

Pelvic AP
• In normal lilmit
Radiology examination
Head CT-Scan:
• SCALP hematome at left temporoparietal region
• There is fracture at the bone window at the left temporal region 
depress fracture
• Sulcus and gyrus was narrow
• Cisterna was narrow
• Ventricle starting compress
• There was no midline shift
Diagnose:
1. Moderate head injury (ICD 10 CM S60.1)
2. Cerebral edema (ICD 10 CM G93.6)
3. Open Depressed fracture at the left temporal region (ICD 10
S02.91X B)
4. Laceration wound at the left temporal region (ICD 10
S0191.XA)
Consult to Neurosurgery division :
• Craniotomy elevation depress fracture
Operative Report
• Performed question mark incision at the left temporal-parietal region
• Deeper layer by layer  Found depressed fracture
• Elevation of fragment fracture  found duramater intake
• Perfomed debridement with normal saline 0.9%
• Fragment fracture was put back
Post operative diagnose
Post craniotomy elevation depress fracture due to :
1. Open Depressed fracture at the left temporal region (ICD 10
S02.91X B)
2. Moderate head injury (ICD 10 CM S60.1)
3. Cerebral edema (ICD 10 CM G93.6)
4. Laceration wound at the left temporal region (ICD 10 S0191.XA)
 Follow up
Date S O A P
Dec 26 Decrease of
th
Vital sign : Post craniotomy • Head Up 30º
2018 conciousnes BP : 113/ 70 mmhg elevated fracture • IVFD Nacl 0.9 % 20
s (+) HR : 84 beats/min depress due to drips/min
POD 4 RR : 20 breaths/min (on ventilator) • Inj Ceftriaxon 1
Temp : 37,2 0 C 1. Open Depressed gr/12 hours
fracture at the left • Inj Ketorolac 30
GCS : can’t examine (On ventilator and temporal region (ICD mg/8 hours
sedation) 10 S02.91X B) • Inj. Ranitidin 50
Pupil was dilated, light releks (-/-) 2. Moderate head mg/12 hours
injury (ICD 10 CM • Inj. Phenitoin 100
L/S at the left temporal region: S60.1) mg/ 8 hours
L : Gauze dry 3. Cerebral edema (ICD • Inj. Piracetam 1 gr/8
F : soft, bone (-) 10 CM G93.6) hrs
4. Laceration wound at Diet sonde 6x100 cc
the left temporal •
Ventilator : region (ICD 10
Mode: SCMV S0191.XA)
PEEP : 5 cmH2O
FiO2 : 80 %