Patient Identity

• Name : Rosmiati TA
• Age : 51 years old
• Sex : Female
• Address : Peukan Bada, Aceh Besar
• MR : 1-02-23-87
• Phone : 081381712020
• Driving licence : (+)
• Admission time : 09.18 PM
 Time Response
Date/hour Examinatio Laboratory Radiology Hour of Date/hou suverviso
patient n hour Examination Examination Diagnosti r patient r
came to ER Send Result Send Result cs out from
ER

March 16th 09.20 09.40 11.45 10.00 11.30 11.50 Patient dr.
2020 PM PM PM PM PM PM send to Bustami,
OR Sp.BS
09.18 PM
March
17th 2020
10.00
AM
Chief complain
• Decrease of consciousness.

Patient illness History

• The patient referred from Harapan Bunda hospital
came to Zainoel Abidin emergency room with chief
complain decrease of consciousness for 3 hours.
• Initially the patient was riding motorcycle without
helmet then strucked by another motorcycle from
opposite of her. Then her head hit the asphalt.
• There were no history of nausea and vomiting
• Eyes opening response to verbal command, motoric
response to localized pain, verbal response with
confused.
Physical examination
Primary Survey
• A : Clear, C-Spine control with collar neck
• B : Spontaneous, 20 breaths/minute, O2 : 10 L/minute
via facemask, SpO2 : 98 %
Right hemithorax Left hemithorax

Inspection Symmetrical, there was no deviation of trachea, JVP in normal limit, lession (-)

Palpation Emphysema Subcutaneous (-), pain (-) Emphysema Subcutaneous (-), pain (-)
Percussion Sonor Sonor
Auscultation Vesicular (+), ronchi (-), wheezing (-) Vesicular (+), ronchi (-), wheezing (-)

• C : BP: 120/90 mmHg, Pulse: 90 beats/minute, IVFD

Nacl 0,9 % 1500 cc, folley cateter urine initial 400
cc yellowish
• D : GCS E3 M5 V4 : 12, isochoric pupil (3 mm/3 mm),
light refleks (+/+)
• E
Log roll examination:
• Cervical : in normal limit
• Vertebrae : in normal limit
• Sacrum : in normal limit
Secondary survey
• Head and neck
L/S at the head region
L: Hematome (+) at the left frontal, Wound (-)
F: Pain can’t eximine

• Thorax  in normal limit

• Abdominal  in normal limit
• Pelvic region  in normal limit
• Upper extremity  in normal limit
Lower extremity 
L/S at the right leg
• L : Deformity (+), Swelling (+), hematoma (-)
• F : Pain (+), NVD (-)
• M : ROM limited
Assessment:
1. Moderate head injury
2. Suspect closed fracture of the left leg
Management
• Stop oral intake
• Head up 30o
• Cefriaxone Inj. 2 gr
• Novalgin Inj. 1 gr
• Laboratory examination
• Radiology examination
Laboratory result
• Hemoglobin : 121.1 g/dL
• White Blood Count : 14.900/µl
• Platelets : 201.000/µl
• Hematocrit : 34 %
• CT : 8 minutes
• BT : 3 minutes
 Radiology result
Head CT Scan:
• There was SCALP hematome at the left temporoparietal region
• There was hyperdense area at the right temporopparietal region
ICH
• There was hyperdense area at the right temporopparietal region
SDH
• Cysterna system was narrow
• Ventricle system was narrow
• There was midline shift to the left more than 0.6 cm

Cervical lateral
• In normal limit
Left leg AP/Lat:
• There was discontinuity of bone at the middle
third of the tibia
Diagnose:
1. Moderate head injury (ICD 10 CM S09.9)
2. ICH at the right temporoparietal region (ICD 10 CM
I61.9)
3. SDH at the right temporoparietal region (ICD 10 CM
S06.5X9A)
4. Close fracture of middle third of the left tibia (ICD
10 CM S82.4)
Consult to Neurosurgery division
• Craniectomy ICH + SDH evacuation emergency

Consult to Orthopaedic surgery division:

• Back Slap
• ORIF elective if good condition
Operative report
• Performed horse shoe incision at the right temporal
region
• Performed 6 burrholes
• Bone was sawed by giggly, performed dura hit-stiches
• Duramater was open sharply
• Evacuation ICH about 30 cc
• Performed durafascial graft
• Bone was put on subgaleal
• Left 1 tube drain
Post Operative Diagnosed
1. Moderate head injury (ICD 10 CM S09.9)
2. ICH at the right temporoparietal region (ICD 10 CM
I61.9)
3. SDH at the right temporoparietal region (ICD 10 CM
S06.5X9A)
4. Close fracture of middle third of the left tibia (ICD
10 CM S82.4)
Post Craniectomy + ICH + SDH evacuated + Back Slap
 Follow up
Date S O A P
March 18th On Vital Sign: Post Operative Diagnosed • Head up 30o
2020 sedation • BP : 110/70 mmHg 1. Moderate head injury • IVFD NaCl 0,9 % 20
• HR : 90 beats/minute (ICD 10 CM S09.9) drips/ minute
POD 1 • RR : 20 breaths/ 2. ICH at the right • Inj. Cefriaxone 2
• minute temporoparietal region gr/24 hours
ICU C • Temp : 37,0 C (ICD 10 CM I61.9) • Inj. Ketorolac 30
• Urine : 30cc/hours 3. SDH at the right mg/8 hours
• GCS : On ventilator, temporoparietal region • Drips fentanyl
mode : CMV (ICD 10 CM S06.5X9A) 20 /hours
VT : 380 4. Close fracture of middle • Drips propofol 20
PEEP : 5 third of the left tibia (ICD mg/hours
10 CM S82.4)
L/S at head region Post Craniectomy + ICH + SDH Planning:
• L : Operation wound evacuated + Back Slap observation GCS
dry, drain 30 cc ORIF elective if good
serohemoragic condition
• F : Pain can not
examined
L/S at the left leg region
• L : wound (-), back
slab (+),
• F : Pain (+), NVD (-)
• M : ROM limited