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  • Department of Surgery January Report

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    Rachma Susteriana Putri
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    Mr. M, a 17-year-old male, was admitted to the hospital after a traffic accident where he was riding a motorcycle without a helmet and was hit from the front by another motorcycle. Upon admission, he was unconscious with vomiting blood and a nose bleed. A CT scan showed fractures of the maxilla and base of the skull. He was assessed as having severe brain injury and base of skull fractures. Treatment included IV fluids, oxygen, antibiotics, mannitol, and phenytoin to reduce swelling and prevent seizures. The family was informed of the diagnosis, treatment plan, and risks of complications.

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    morep bedah 270115

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    Morep Bedah B21 270115

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    Mr. M, a 17-year-old male, was admitted to the hospital after a traffic accident where he was riding a motorcycle without a helmet and was hit from the front by another motorcycle. Upon admission, he was unconscious with vomiting blood and a nose bleed. A CT scan showed fractures of the maxilla and base of the skull. He was assessed as having severe brain injury and base of skull fractures. Treatment included IV fluids, oxygen, antibiotics, mannitol, and phenytoin to reduce swelling and prevent seizures. The family was informed of the diagnosis, treatment plan, and risks of complications.

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    © All Rights Reserved
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    14 views19 pages

    Department of Surgery January Report

    Uploaded by

    Rachma Susteriana Putri
    Mr. M, a 17-year-old male, was admitted to the hospital after a traffic accident where he was riding a motorcycle without a helmet and was hit from the front by another motorcycle. Upon admission, he was unconscious with vomiting blood and a nose bleed. A CT scan showed fractures of the maxilla and base of the skull. He was assessed as having severe brain injury and base of skull fractures. Treatment included IV fluids, oxygen, antibiotics, mannitol, and phenytoin to reduce swelling and prevent seizures. The family was informed of the diagnosis, treatment plan, and risks of complications.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
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    of 19

    Department of Surgery

    January , 27 2015

    NAME

    DX

    ROO

    Mr. M

    Fr. Basis Cranii

    14.4

    Name : Mr. M
    Age
    : 17 y.o
    Sex
    : Male
    Address
    : Plumpang Sukodadi
    Lamongan

    ANAMNESIS

    Chief complaint :

    Decrease of conciousness
    MOI
    Patient post traffic accident thirty minute before addmission
    to the hospital. Patient didnt remember about the accident.
    Heteroanamnesis patient riding motorcycle and was hit by
    a motorcycle from the front (data from another victim),
    Decrease of conciousness (+), blood vomit + one times when
    he was admission and 3 times in hospital, it was proyectile
    vomit, his nose was bleeding, seizure 1x, he didnt use
    helmet when it happened.

    Airway and spine control : unclear,


    snorring (-), gargling (+), potensial
    obstruction (-)
    Breathing : spontan, simetric (+), RR
    20x/minutes, ves/ves, rh-/+, wh-/-, Sp02
    97% without O2 NRM
    Circulation : PR 112x/minutes, acral warm
    dry red, CRT < 2, BP 149/80 mmhg
    Disability : GCS 115, lateralisasi -, Light
    perception +/+
    Exposure : temp 36.7C,

    History past illness Asma (+) since he was 5 y.o


    Status Generalis
    Head and neck : anemic (-), icteric (-), cyanosis
    (-), dyspneu (-)
    Thorax : simetric (+), retraction (-)
    Pulmo : ves/ves, rh-/-, wh-/Cor : S1S2 single, murmur (-), gallop (-), lession Abdomen : flat, distended (-), tympani (+), liver
    and spleen were not palpable, bowel sound (+),
    lession Extremities : acral warm, dry, red, lession-

    Status Lokalis
    vull. Appertum et regio cruris sinistra
    uk 1x 0,5.
    vull. Appertum et regio metatarsal
    digiti 1 uk 2x0.2 cm

    Clue and cue


    Male 17 y.o.
    Post traffic accident
    Decrease of conciousness
    PTA +, amnesia retrograde +
    Status lokalis:
    vull. Appertum et regio cruris sinistra uk
    1x 0,5.
    vull. Appertum et regio metatarsal digiti 1
    uk 2x0.2 cm

    Assesment
    Fr Maxilla
    Fr Basis Cranii
    Severe brain injury

    CBC
    Bleeding Time
    Clothing Time
    Foto Skull AP/L
    Skull CT-Scan with contras

    Lab
    Diff : 0/0/38/55/7
    Hct : 45,7
    Hb : 15,4
    LED : 9/17
    Leukosit : 24.000
    Trombosit : 531.000
    BT : 2 00
    CT : 8 00

    Clinical sign

    Thorax Photo

    Skull CT-Scan

    Assesment
    Fr. Maxilla
    Severe brain injury + Fr. Basis Cranii

    IVFD Assering 1500 cc/24 hours


    O2 NRM
    Kateter foley
    Inj. Manitol loading 200 cc 6 x 100cc
    Inj. Phenytoin 400 mg 3x100 mg
    Inj. Antrain 3x1 g iv
    Inj Acran 2x1 amp iv
    Inj. Ceteron 1 amp prn
    Inj. Ceftriaxon 2x1 g iv
    Inj. Cithicolin 3x250 mg iv
    C/Sp.BS Inj Ceftriaxon 2x1 g, manitol abd phenytoin
    C /Sp. M
    C /Sp. B

    Subjective complaint
    Vital sign

    Explain to the patients family about


    the diagnosis, etiology, intervention
    of
    therapy,
    complication,
    and
    prognosis.

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