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  • Duty Report: Annisa Ayu Rahmawati Nazza Rizky Ramdhagama Khalidah Ecah

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    The 11-year-old patient presented with pain in his nose, ear, and head after being hit by a train while playing on railroad tracks 2 hours prior. He had active bleeding from his left ear and head that was controlled, as well as nausea and vomiting. On examination, he had wounds on his head, nose, and abdomen. He was diagnosed with a subdural hematoma and basilar skull fracture based on tenderness, crepitus, and neurological exam findings. He received medications and wound care.

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    The 11-year-old patient presented with pain in his nose, ear, and head after being hit by a train while playing on railroad tracks 2 hours prior. He had active bleeding from his left ear and head that was controlled, as well as nausea and vomiting. On examination, he had wounds on his head, nose, and abdomen. He was diagnosed with a subdural hematoma and basilar skull fracture based on tenderness, crepitus, and neurological exam findings. He received medications and wound care.

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    29 views17 pages

    Duty Report: Annisa Ayu Rahmawati Nazza Rizky Ramdhagama Khalidah Ecah

    Uploaded by

    sasoy
    The 11-year-old patient presented with pain in his nose, ear, and head after being hit by a train while playing on railroad tracks 2 hours prior. He had active bleeding from his left ear and head that was controlled, as well as nausea and vomiting. On examination, he had wounds on his head, nose, and abdomen. He was diagnosed with a subdural hematoma and basilar skull fracture based on tenderness, crepitus, and neurological exam findings. He received medications and wound care.

    Copyright:

    © All Rights Reserved
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    of 17

    DUTY REPORT

    Annisa Ayu Rahmawati


    Nazza Rizky Ramdhagama
    Khalidah
    Ecah
    M (11 years old)

    Chief complain: Patient presented with chief complain pain on his nose,
    ear and head.

    Additional complains: Patient said there’s active bleeding on his left


    ear and head. The bleeding has been controlled by firm pressure with
    sterile cotton pad and already hected, he didn’t has any difficulty
    moving his neck, no fever, no diploplia, no blurry vision. He had nausea
    and vomitus. There is an abrasion wound on his stomach.
    History of Present Illness
    Patient presented with chief complain pain on his nose, ear and head since 2 hour before entering
    hospital. Patient claimed that he got injured when he was playing on the railroad tracks. Patient
    didn’thas any difficulty moving his neck, no fever, no diploplia, no blurry vision. He had nausea and
    vomitus. He had projectile vomits twice right after being hit by the train. There is an abrasion wound
    on his stomach. Patient said there’s active bleeding on his left ear and head. The bleeding has been
    controlled by firm pressure with sterile cotton pad and already hected in Suka Mulya Hospital. After
    the bleeding has been controlled, the patient go to Koja General Hospital due to lack of instruments.
    MECHANISM OF TRAUMA
     Patient claimed that he got injured when he was playing on the
    railroad tracks. He was hit and thud by the train.
     Loss of conciousness post trauma (-), nausea and vomitus (+)
     Past medical history: hypertension (-), dm (-), asthma (-),
    congenital/acquired heart disease (-), past allergy history (-).
    PRIMARY SURVEY

    Airway: Airway obstruction (-).


    Breathing: symmetrical chest rise with spontaneous
    breathing, no use of the accessory muscles of respiration.
    Circulation: regular heart rate with good pulse volume,
    warm extremity, BP: 115/71mmHg, HR: 92x/menit, SpO2
    99%
    Disability: GCS: E4M6V5 (15), CM
    SECONDARY SURVEY
    HEAD : Hected wound in occipital sinistra and frontal region

    EYES : Pupil reactive 3mm ODS, isokor, anemic conjungtiva (-/-),


    icteric sklera (-/-), edema palpebra (+/-).

    NOSE : Hected wound (+)

    EARS : Blood otorrhea (+)

    MOUTH : Pink, Cyanosis (-)

    NECK : Lymph nodes enlargement (-)

    THROAT : T1/T1, No detritus, Pink


    Thorax Abdomen
    Inspection : symmetric chest expantion, effortless
    respiration, retraction (-), no scar.
     Inspection: flat, masses (-),
    abrasion wound on the right
    Palpation: tenderness (-), normal vocal fremitus, masses
    (-)
    region (+)
    Percusion: sonor throughout the pulmonary area  Auscultation: bowel sound
    Auscultation: Vesiculer sound, Rh (-/-), Wh (-/-). Heart
    6x/min.
    sound I and II regular, Murmur (-), Gallop (-).  Palpation: tenderness (-),
    defans muskular (-)
     Percution: tympanic
    throughout the abdominal area
     Extremities: CRT <2, edema (-),
    Localist Status
    Look : Hecting wound in nose and head on occipital sinistra and
    frontal region

    Feel : tenderness to light palpation (+), crepitation (+)

    Move: ROM (+)


    Neurological Status
    Glasgow Coma Scale : E4V5M6
    Direct Light Reflex : +/+
    Undirect Light Reflex : +/+

    Motoric : 5I5
    5I5

    Sensoric: +I+
    +I+

    Intracranial Pressure
    Nausea : (+)
    Vomitus : (+) projectile
    Headache : (+)
    Seizure : (-)
    Diagnosis
    Subdural Hematome and Basilar Skull Fracture
    Pharmacology

     TIG (250IU,IM)

     Ceftriaxone 1g inj

     Ketorolac inj 30mg.

    Non pharmacology

     Change bandages

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