Case illustration Date : 18 September 2010 Name : Asih Budi Mulyati Age : 18 tahun Sex : perempuan Education : ??

Address : ?? Anamnesis : Pasien Chief complaint : Headache since eight hours before come into hospital Recent Illness history : Since 8 hours before hospital, patient was delivering her fathers friend home by motorcycle, when she suddenly fell from her motorcycle. She doesnt remember the exact mechanism. But the police nearby said that she stop her motorcycle too fast using the handbrake. Patient was quickly delivered to RS Bekasi, and was??, but because theres no CT scan in the hospital, the she was referred to RSCM. In RSCM, she vomited 1x (food and blood colored dark chocolate). Active bleeding in the nose (+), both eyes were swelling and there was open wound in left palpebra already stitched in RS Bekasi. During the trip to RSCM, patients the consciousness didnt decrease, headache (+), paralisis (-), projectile vomittin (-). Previous Illness history : Trauma (-), hipertensi (-), DM (-) Family illness history : Hipertensi (-), DM (-), coroner disease (-) Physical examination : General condition : medium sick Nutrition status : medium Consciousness : Compos Mentis Blood pressure : 100/60 mmHg Pulse rate : 96x/minute Temperature : afebrile Respiratory rate : 18x/minute Generalis Status o SKIN : Sawo matang o Head : normochepaly o Hair : black, not easily withdrawed o Eye : Palpebral edem ODS Hematom palpebral ODS Ear : Bleeding (-) Nose : no active bleeding (post epistaxis cavum nasi DS) Throat: normal

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Teeth and mouth : normal Chest : Lung : breathing voice vesikuler, rhonki (-/-), stridor (-) Heart : heart sound I&II normal, murmur (-), gallop (-) Stomach : symmetric, tenderness (-), pain (-), bowel sounds (+) Back : normal Genital : no examination Anus : no examination

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ENT status according to consultation to plastic reconstruction divison ENT : - Cavum nasi DS : wide, inferior turbinate eutrofi, secrete (-), clotting (-), active bleeding (-) - Throat : posterior pharyng : clotting (-), active bleeding (-) Local status : o Frontalis region : edem (+) decreasing, hematom (-), theres a stitch in the left region o Nasalis region : edem (+) decreasing, crepitation (-) o Orbitalis sinistra region : excoriation (+), edem (+) o Zygoma sinistra region : edem (+), hematom (+) o Mandibula region : edem (+) Laboratory examination Hb : 7,7 g/dL Ht : 23% Leukocyte : 12.100/uL Thrombocyte : 206.000/uL Ureum = 32 Creatinine : 0,6 GDS : 193 Na : 142 K : 2,9 Cl : 116 AGD pH : 7,4 pCO2 : 30,4% pO2 : 103,3% SO2 : 96,3% Brain CT : Epidural haematom (EDH) in frontalis sinistra region Subarachnoid haematom (SAH) basal cistern and frontalis region Pneumoencephal basal cistern, bilateral parasternal, frontalis sinistra region, and CPA sinistra Sinus hematom maxillaries, ethmoidales, and sphenoidalis DS Linier fracture on Os. Frontal sinistra, Os. Occipital dextra, and sphenoidales DS. This fractures elongates into Os. Petrossus dextra, lateral and superior wall of sphenoidalis sinus DS, superior wall of

ethmoidales sinus sinistra, superomedial wall of orbita sinistra, lateral wall of orbita sinistra, anterolateral wall of maxillary sinus dextra, anterior and medial and lateral wall of maxillary sinus sinistra Hematom and air in the posterior orbita chamber sinistra Ro thorax : infiltrate in both of the lung. DD : infection, contusion. Cervical AP, lateral Ro : straight ?? Ga jelas nih tulisannya AP and lateral : suspect hematosinus maxillaries and ethmoidales DS Suspect os. Zygomaticum fracture

Neurologic examination a. GCS : E4 M6 V5 b. Meningeal sign : Laseque >70/>70, kernig >135/>135 c. Cranial nerve : paresis (-) d. Motorik : 5555 5555 5555 5555 e. Sensibility : normal f. Physiologic reflex : normal g. Pathologic reflex (-/-)

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Problems List Cephalgia post head trauma EDH frontalis sinistra region and occipitalis dextra SAH traumatic Pneumoencephal posterior orbita sinistra + subkonjungtival bleeding ODS Linier fracture os. Frontalis sinistra, os. Occipital dextra, os. Petrossus dextra 6. Hipokalemia 7. Hematosinus maxillaries, ethmoidales and sphenoidales DS 8. Anemia (post transfusion PRC) 9. Lung Contusion and fracture os. Zygomaticum sinistra 10.Post epistaxis cavum nasi DS and os nasal fracture Working diagnosis : - Multiple facial fracture - Os. Nasal fracture - Hematosinus maxillaries, ethmoidales, sphenoidales DS - Basis craniai fracture - Hematom epidural frontalis sinistra region and occipital dextra region - Lateral and superomedial wall fracture of orbital sinistra Plan Therapy o Head elevation 30 degrees o KIE avoid cough, straining, or sneezing o OGT and liquid diet 1650 kkal/day o IVFD NaCl 0,9% 500cc/8 jam o Ketorolac 3x30 mg (iv)

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Stomacher 1x40 mg (iv) Ceftriaxon ex2 gr (iv) Examine complete peripheral blood Passive mobilization Kompres dingin Prednisone 2x3 tab Extrace 1x400mg Citicholing 2x500mg Another plan therapy according to neurologist Consult ENT for plastic reconstruction ( evaluate antrum, reduction and fixation of the fracture ORIF + reposition of os.nasal) planned for 20 september 2010 Evacuate antrum haematom Consult Eye departemen for plastic reconstruction of the orbita Wound care

Follow Up (13/09/2010) (later I will type) S O A P Follow Up (14/09/2010) Follow up (15/09/2010) Persiapan Pembedahan AGD, dll Hasil Konsul : - Pulmonologi : medium risk - Cardiology : mild risk - Metabolic : mild-medium risk - Hematology : medium risk - Anestesi : ASA II dengan CAP Laporan Hasil Pembedahan ( I will type I later)