Translated from Indonesian to English - www.onlinedoctranslator.

com

Ask for permission from the doctor for permission to

report new patients to the ER Tuesday, October 12,
2021:

Aririn, F, 29 years old, 1989197

Primary Surveys:
A: snorring (-), gurgling (+) —> unclear —> intubation —
> clear
B: RR 24 x/min, 100% SpO2 on NRM 10lpm, symmetric
(+), KG (-), (sonor/sonor), vesicular (+/+) --> clear
C: Acral warm (+), BP 119/71 mmHg, HR 125 x/minute,
CRT <2 sec --> clear
D: GCS E2V2M5, pupil isocor 3 mm/3 mm, lateralization
(-) --> clear

Initial assessment: potential life threatening

Secondary Survey:
A: none
M: nothing
Q: no
L: last meal at 22.00
E: post hit the stone pot

Main Ex:
Loss of consciousness

RPS:
2 hours at SMRS the patient rode a motorcycle using a
helmet and then hit a stone pot on the side of the road.
It is not known whether the helmet came off or not.
The patient was then found by a local resident who was
unconscious and was taken to the RSS for further
treatment.

RPD:
Allergy history (-) , DM (-), HT(-)
Pen. Heart (-), asthma (-)

Physical examination
KU weak, E2V3M4
BP: 119/71 mmHg
N: 125 x/min
RR: 24 x/min
SpO2 100% on NRM 10lpm
S: 36°C

Head:
Pupil anisokor 4 mm/3 mm, CA (-/-), SI (-/-), RC (-/-) VL
(+) region zygoma dextra, VE (-), hematoma region
maxilla dextra

Upper face
I : symmetrical, VE (-) VL (-), hematoma (-), swelling (-),
active bleeding (-),
P: sensory is difficult to assess, NT is difficult to assess,
crepitus (-), step off (-)

Midface
I : asymmetrical, racoon eye (+/-) telecanthus (-),
diplopia difficult to assess, eye movement difficult to
assess, rhinorrhea (+), bloody otorrhea (+), battle sign
(-), nasal septal deviation (-), step off (-), VE (-), VL (+)
region of zygoma dextra uk 1x0.2cm subcutis base,
swelling (+) region of maxilla dextra, deformity (-)
P: sensory is difficult to assess, floating maxilla (+), NT is
difficult to assess, crepitus (+) maxilla dextra

lower face
I : asymmetry, dental avulsion (-), VE (-), VL (-), edema
of the labium oris superior et inferior dextra, deformity
(-) malocclusion (+) open bite
P : sensory dbn, NT (-), mandibular gliding difficult to
assess crepitus (-)

Neck:
Damage (-), JVP does not increase, NT (-)

Thorax:
I: Damage (-), symmetrical (+), lagging motion (-/-)
P: VF ka=ki
P: sonor/sonor
A: Vesicular (+ /+), wheezing (-/-), rhonchi (-/-)

Abdomen:
I: Distension (-), VE (-), injury (-)
A: BU (+) is normal
P: tympanic (+)
P: Helpful, defans (-), NT (-)

Pelvis:
I: Damage (-)
P: NT (-), Crepitus (-)

Extremities:
Acral warm (+), strong pulse, CRT <2 seconds, deformity
(+) humerus dextra

Local status of the right humerus region:

L : swelling (+) deformity (+)
F : NT is difficult to assess, NVD (-)
M: ROM is difficult to assess

Lab 12/10/2021
AL 36.07
Hb 11.0
AT 449
3.45
SGOT 525
SGPT 243
PPT 17.4/14.8
APTT 34.2/31.2
INR 1.21
BUN 15.4
Creat 0.88
GDS 302
LDH 1073
CRP < 5
Na 136
K 3.76
Cl 103
Anti-SARS CoV-2 NR

Assessments:
- EDH of the right temporal region
- Cerebral contusion of the right frontal lobe
- Linear fracture of the right temporal bone
- Traumatic SAH
- Traumatic cerebral edema
- Zygomaticomaxillary complex dextra fracture
- Zygoma dextra segmental fracture
- Maxilla dextra fracture
- Fracture of the left mandibular parasymphysis
- Vulnus laceratum region zygoma dextra
- Close fracture of distal third of the right humerus

Plans:
Neurosurgery
- Observation of GCS and vital signs
- Treat HCU

Plastic Surgery (proposal)

- Keep an eye on KU/VS
- Wound toilet
- Primary suturing VL with Nylon 5.0 (cutis) and Safil 5.0
(Subcutis)
- Pro Reconstruction of facial bones elective
- Others according to related TS

Orthopedics
- immobilization with u-slab
- Elective orif

Please advise, Doctor.

Thank you Doctor