Coass : 1.

Firman
2. Lambert
3. Komang
4. Liliana
5. Desy
Consultant : dr. Tommy, Sp.BS
Cognita Manu Melia Cultu Neurosurgery Division
Mr.Yohanis Pallo/Male/ 18 y.o/ 451793

 Chief complaint :
 Present illness :
Patient came to the emergency care unit with headache after
falling from a motorcycle 2 months ago. Previously the patient
had been treated at another hospital but there was no
improvement. Fainted (+) Fever (-), nausea (+) vomitting (+),
defecation/urination: minimal, Seizures (-).
 History of ilness : -

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Yohanis Pallo/Male/ 18 y.o/ 457093
 Physical examination :
• General state: limp/ GCS 15: E4V5M6
• Motorik 5 5 VAS: 7-8

5 5

• Sensorik: Normal
• VS, BP:120/80 : HR : 100 bpm, RR : 24 x/m, T: 37,0˚C, SpO2: 99% spontan
• Normocephal, anemic conjuctiva -/-, light reflex +/+, corneal reflex +/+, blurred
vision: +/+, Parese N.VI sinistra
• Thorax: cor and pulmo within normal limit
• Abdomen: within normal limit
• Extremities: within normal limit

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Yohanis Pallo/Male/ 18 y.o/ 451793
 Clinical Diagnosis : headache
 Topical Diagnosis : regio frontotemporoparietal sinistra
 Etiological Diagnosis : Subduralhemorragic cronic

Further examination :
• Laboratory examination
• Chest X-ray, Thoracolumbal MSCT.

Cognita Manu Melia Cultu Neurosurgery Division

Laboratorium Examination
Lab Result Lab Result
HB 13,5 Albumin -
HCT 42,8 SGOT 55,1
RBC 6,11
SGPT 124,2
WBC 8,39
PLT 321
PT 10,5
DDR Neg
APTT 25,9
GDS 116
BUN 9,7
Creatinin 0,44
Kalium darah 4,79
Natrium darah 139,10
Cl darah -
Calcium darah -

Cognita Manu Melia Cultu Neurosurgery Division

Plan
 Apply II line infusion
- IVFD RL 500cc / 8 hour
- IVFD Manitol Loading 200-150-150, maintanance manitol 4x125cc
 Injection Receptor H 2 blocker 50 mg/12 hours
 Injection Antagonis serotonin 5-HT3 4mg/ 8 hours
 Injection analgesic opiate 100mg /8 hour
 Injection Phenytoin 100mg/ 8 jam
 Pro Burrhole drainage

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Yohanis Pallo/Male/ 18 y.o/ 451793
MSCT skull

Cognita Manu Melia Cultu Neurosurgery Division

 MSCT

Impression:

Cognita Manu Melia Cultu Neurosurgery Division

 Thank You

Cognita Manu Melia Cultu Neurosurgery Division