depres ismu hadi
TRANSCRIPT
-
7/24/2019 Depres Ismu Hadi
1/19
Patient identity
Name : Ismu Hadi
Age : 8 years old
Sex : Boy
Address : Curee Tunong, Kec. Simpang
amplam, Ka!. Bireuen" : # $% 8% &8
'aren()s '*one : $8%+8#88#+&
Admission Time: $-.& A
-
7/24/2019 Depres Ismu Hadi
2/19
Time ResponseDate/hourpatientcameto ER
Examinationhour
LaboratoryExamination
RadiologyExamination
HourofDiagnostics
Date/hourpatientoutfrom
ER
DPJP
Send Result
Send Result
18 July2015/
04:36AM
04:40AM
05:10AM
07:00AM
05:40AM
06:10AM
06;20AM
10:00AM
DrBus!
mi"pB"
-
7/24/2019 Depres Ismu Hadi
3/19
Chief complain:
Headac*e a/(er (rauma
Patient illnes history
T*e pa(ien( come (o (*e emergency 0i(* a c*ie/ complain(
*eadac*e a/(er (rauma /or # *our. T*e pa(ien( !ac1 /rom (*e
mos2ue and s(ruc1ed !y mo(orcycle and *is *ead *i( (*e
asp*al(. T*ere 0as *is(ory o/ unconsciousness. His(ory o/nausea and 3omi(ing 456.
-
7/24/2019 Depres Ismu Hadi
4/19
Physical examination
A: Clear
B: Spon(aneous, "": #8 !rea(*s7 minu(e
C: 'ulse + !ea(s7minu(e,B' ##$78$ mmHg
: 9CS: #% 4- ;%6< isoc*oric pupil
= &mm7&mm, la(erali>a(ion456
:
?7S a( (*e rig*( parie(al
?: 0ound 4@6 si>e cm 0as su(ured, s0elling 4@6
: pain 4@6, discon(inui(y o/ !one 4@6
?7S a( (*e /acial region?: excoria(ed 0ound
: pain 4@6
-
7/24/2019 Depres Ismu Hadi
5/19
Secondary Sur3ey
Head and Nec1
?7S a( (*e rig*( parie(al
?: 0ound 4@6 si>e cm 0as su(ured, s0elling 4@6
: pain 4@6, discon(inui(y o/ !one 4@6
?7S a( (*e /acial region
?: excoria(ed 0ound
: pain 4@6
T*orax : in normal limi(
A!dominal : in normal limi(
'el3ic : in normal limi(
pper x(remi(y : in normal limi(
?o0er x(remi(y : in normal limi(
-
7/24/2019 Depres Ismu Hadi
6/19
#A" :Mil$
Mild !" Moderate #!$ Se%ere &!'
%on opioi$ &
!$'u(!n-)*+,2--.uproen-Aspirin-Ae!minopen
*pioi$ &
nonopioi$ &!$'u(!n- )o$ein- ropoypen
e- y$roo$one
*pioi$ &
nonopioi$ &!$'u(!n- *yo$one- Morpine- y$romorp
one
-
7/24/2019 Depres Ismu Hadi
7/19
-
7/24/2019 Depres Ismu Hadi
8/19
Assessment:
ild Head Inury
Dpen depress /rac(ure a( (*e rig*( parie(al region
-
7/24/2019 Depres Ismu Hadi
9/19
Management:
Head up &$$
I; NaCl $, E #$ drips7minu(e
Ce/(riaxone in. %$$ mg
Ke(orolac in #$ mg
Te(agam +%$ iu ?a!ora(ory examina(ion
"adiology examina(ion
-
7/24/2019 Depres Ismu Hadi
10/19
Laboratory result
H! : #$.% gr7dl
Hema(ocri( : &+ E
F*i(e !lood coun( : #-.&$$ 7ul
'la(ele( : &&%.$$$ 7ul
CT : G minu(e
BT : + minu(e
-
7/24/2019 Depres Ismu Hadi
11/19
-
7/24/2019 Depres Ismu Hadi
12/19
-
7/24/2019 Depres Ismu Hadi
13/19
Radiology result:
Head CT Scan :
SCA?' *ema(ome o/ (*e rig*( parie(al region
T*ere 0as depress /rac(ure a( (*e parie(al region
# (a!ule
Sulcus and gyrus 0as narro0
;en(ricle and sys(erna sys(em 0as normal
T*ere 0as no midline s*i/(
-
7/24/2019 Depres Ismu Hadi
14/19
iagnose:
ild *ead inury 4IC #$ C S$.$6
Dpen depress /rac(ure a( (*e rig*( parie(al region
4IC #$ C S$+.#6
-
7/24/2019 Depres Ismu Hadi
15/19
Consult to neurosurgery di!ision
e!ridemen(
le3a(ion depress /rac(ure
-
7/24/2019 Depres Ismu Hadi
16/19
"ntra operati!e
'er/ormed de!ridemen(
x(ended incision /rom (*e old 0ound
T*ere 0as depress /rac(ure
Bone pulled ou(, durama(er and cere!ral cor(ex
0as lacera(ed 'er/ormed dura/acial gra/(
Bone 0as re(urn 0i(* mossaic (ec*ni2ue and
/ixa(ed
-
7/24/2019 Depres Ismu Hadi
17/19
-
7/24/2019 Depres Ismu Hadi
18/19
Post #perati!e iagnose
#. ild *ead inury 4IC #$ C S$.$6
+. Dpen depress /rac(ure a( (*e rig*( parie(al region
4IC #$ C S$+.#6
&. ?ea1age urama(er 4IC #$ C S$.&&6
-
7/24/2019 Depres Ismu Hadi
19/19
**
ate S # A P
++5G5+$#%
'D &
456 9eneral condi(ion : good
9CS #%
'ulse: 8$ !ea(s7minu(e
"espira(ory:+$ !rea(*7minu(e
T:&G,$ $C
#. ild *eadinury 4IC #$C S$.$6
+. Dpen depress/rac(ure a( (*erig*( parie(alregion 4IC #$C S$+.#6
&. ?ea1ageurama(er4IC #$ C
S$.&&6
I; NaCl $, E
#$ drips7minu(e
Ce/(riaxone in.
%$$ mgKe(orolac in #$
mg