CASE REPORT Friday, January 03th2014 Team on duty : dr. Syafwan Azhari dr. Joko Siswanto dr.

Guruh L.S. dr. Lea ar!an dr. "u!irda dr. Andri #u$ia dr. #ohan I. Patient identity %a!e A'e Se) Address *# 0hone ri3in' $isen-e 0atient -a!e : : : : : : : : A&du$$ah 1( years o$d #a$e esa. #eunasah *ot +si&ak ,a&. A-eh +tara .( /2 .( 0(/211(23(// 456 at 23.11 0#

II. III.

Chief complain e-rease of -ons-iousness Patient illnes History 7he 8atient refrred fro! distri- hos8ita$ *ut #eutia to "ainoe$ A&idin e!er'en-y roo! with a -hief -o!8$aint de-rease of -ons-iousness for 3 days a'o. 7he -o!8$aint started when the 8atient was ridin' !otor-y-$e and stru-ked &y a -ar and he fe$t down to the street and his head hit the as8ha$t. 9hen the a--ident, the 8atient did not used he$!et. :istory of nausea and 3o!itin' 456 Physical examination 0ri!ary sur3ey : A: +n-$ear ;77 <: S8ontaneous with , ==: 23 &reaths> !inute *: 0u$se: 10/ &eats>!inute <0 1/1>(0 #!h' : G*S: 2, 4;1 #4 ?16 iso-hori- 8u8i$ 4=i'ht 3!!,Left 3!!6 , $atera$ization 456, Li'ht ref$e) 4@>@6 Se-ondary sur3ey : %o trau!a at the other 8art of &ody

IV.

V.

Assessments Se3ere :ead AnBury

VI.

!ana"ement :ead u8 30o Cksi'en 3 L>!nt 3ia ;77 A?F %a*$ 0,. D 20 dri8s>!nt %G7 *o$$ar %e-k *atheter urine AnB. *eftria)on 1 'r AnB. ,etoro$a- 30 !' La&oratory e)a!ination =adio$o'y e)a!ination #a$oratory result :& 9hite &$ood -ount 0$ate$et :t *7 <7 G$u-ose ad rando! +reu! *reatinin

VII.

: : : : : : : : :

14,2 'r>d$ 12,100 >u$ 222.000 >u$ 42 D 1 !inute 2 !inute .2 !'>d$ 22 !'>d$ 1,4 !'>d

VIII. Radiolo"y examination :ead *75S-an S-a$8 he!ato!e at the ri'ht and ri'ht te!8oro8arieta$ re'ion %o fra-ture at the &one window Su$-us and 'yrus was narrow 7here was hi8erdens a&nor!a$ at the ri'ht fronta$ and o--i8ita$e A*: 7here was hi8erdens a&nor!a$ at su&ara-hnoid SA: ?entri-$e and *ysterna syste! was narrow %o !id$ine I%. &ia"nose Se3ere :ead AnBury 4A* 5105*# S02.26 @ 105*# S02.26 iffuse A)ona$ AnBury 'rade AAA 4A* 5

%.

Consult to 'eurosur"ery &i(ision *ranie-to!y &ifronta$

 %I.

0ost o8 in A*+

)ollo* up S 456 C Genera$ -ondition : 8oor <0 : 1/0>100!!h' G*SE 2 4 ;1#4?16 0u$se: 10/ &eats>!inute =es8iratory: 30&reath>!inute 7:31,0 0* A Se3ere :ead AnBury 4A* 5105*# S02.26 @ iffuse A)ona$ AnBury 'rade AAA 4A* 5105*# S02.26 0 :ead u8 30 A?F %a*L 0,.D 20 dri8s>!nt AnB. *eftria)one 1 'r>12 hr AnB. ,etoro$a- 30 !'>( hr AnB. =anitidine 1 a!8 > ( hr #anito$ 1/0 -->2 hr iet 2 ) /0 --

ate 15152014 ay53