CASE REPORT

Friday, January 03
th
2014

Team on duty : dr. Safwan Azhari
dr. Joko Siswanto
dr. Guruh L.S.
dr. Lea Darman
dr. Zumirda
dr. Andri Mulia
dr. Mohan


I. Patient identity
Name : Hakim
Age : 23 years old
Sex : Male
Address : Desa Matang Kec Bandar Baru Kab Pidie Jaya
CM : 98 52 20
Phone : 085314684808
Patient came : at 16.05 PM


II. Chief complain
Decrease of consciousness

III. Patient illnes history
The patient come to Zainoel Abidin emergency room with a chief complaint
decrease of consciousness for 4 hours ago. The complaint started when the
patient was repaired of the roof suddenly he fell down to the floor. History of
nausea and vomiting (+). History alert after trauma (+).


IV. Physical examination
Primary survey :
A: Clear
B: Spontaneous, RR: 22 breaths/ minute
C: Pulse: 98 beats/minute, BP : 99/61 mmHg
D: GCS: E2 M5 V3 isochoric pupil (Right 3mm, Left 3mm), lateralization (-),
Light reflex (+/+)



Secondary survey :
There was no trauma at the other part of body

V. Assessments:
Moderate Head Injury

VI. Management
Head up 30
o

IVFD NaCl 0,9 % 20 drips/mnt
Ceftriaxone Inj. 1 gr
Ketorolac Inj. 30 mg
Catheter urine
Laboratory examination
Radiology examination

VII. Laboratory examination
Hemoglobin : 13.3 gr/dl
White blood count : 6,800 /ul
Platelet : 216.000 /ul
Ht : 39 %
CT : 7 minute
BT : 2 minute
Glucose ad random : 101 gr/dl


VIII. Radiology examination
Head CT-Scan :
Scalp hematome at the right temporo-parietal region
There was fracture of the bone window ( Parieto-occipital) Linier
fracture
Sulcus and gyrus in normal limit
There was hiperdense area at the ganglia basal sinistra
Ventricle and Cysterna system in normal limit
No Midline shift





IX. Diagnose:
Moderate Head Injury (ICD X : S.06.2 ) + Close Linier fracture of the left
parietooccipital region

Planning:
Consult to Neurosurgery Division :
Concervative to Neurology division

XII. Follow up
Date S O A P
7/1/2014






VS/
BP : 100/80 mmHg
HR : 124 x/mnt
RR : 22 x/mnt
GCS; E3 M6 V4
Isochoric pupil
3mm/3mm
Moderate
Head Injury
(ICD X :
S.06.2 ) +
Close Linier
fracture of the
left
parietooccipital
region

IVFD NaCl 20
drips/minutes
Head up 30
O2 2l/ via
canule
Ceftriaxone 1
g/ 12 hours
Ketorolac 3%
Inj 1 amp/ 8
hours
Phenytoin 1
amp /12hr
Ranitidine inj
1 amp /12 hr