J/F/33yo

88.05.79
Chief Complain: Unconsiousness
It has been suffered by the patient since 16 hours before
admitted to Haji Adam Malik hospital. Initially the patient
was fallen from stairs and her head hit the stone. Another
injury mechanism was unclear. Patient was alert and
become unconsiousness around 6 hours after the accident.
Projectile vomiting and seizure was found. Headache was
difficult to evaluate. Shortness of breath and bloody cough
was not found. Chest pain and abdominal pain was difficult
to evaluate. Patient was referred from district hospital.
 Primary Survey:
A : Clear
B : Spontaneous, RR : 26 tpm, SpO2 98% with O2
15 lpm via NRM
C : warm extremities, HR : 98 bpm, BP : 130/80
mmHg, active bleeding (-), CRT<2”
D :GCS 9, E2M5V2, isochor pupil 3mm, Light
reflex (+/+)
E : undress, logroll —> sutured wound o/t right
parietal, bruise (+) o/t left hemithorax
 AMPLE History
• A : No history of allergy
• M: history of medication was found
• P : Schizophrenia
• L : 2 hours before accident
• E : on the road
 Localized state
Head : In localized state
Neck : No abnormality was found
Chest : In localized state
Abdomen : In localized state
Genital : female, no abnormality was found
Extremities : No abnormality was found
Localized State :
Head:
1/3 upper part :
• L : sutured wound (+) o/t right parietal, excoriated wound (-), oedem (-),
active bleeding (-)
• F : crepitation (-), pain difficult to evaluate

1/3 middle part:

• Eye : equal pupil’s diameter 3/3 mm, light reflex (+/+), diplopia hard to
adjust, dystopia (-), visual acuity hard to adjust, eye ball movement hard
to adjust. Periorbital hematoma (-), subconjunctival bleeding (-/-)
• Mid face : excoriated wound (-), symmetrical, deformity (-), crepitation
(-), swelling (-), depressed malar (-), nasal deviation (-), blood came out
from nose and ear (-).

1/3 lower part:

• L : lacerated wound (-), excoriated wound (-), oedem (-), active bleeding
(-).
• F : crepitation (-), pain difficult to evaluate
• Intra oral: step off deformity (-), teeth avulsion (-), floating maxilla (-),
malocclusion (-).
 Localized stase
Chest
I : Symmetrical, bruise (+) o/t (L)
hemithorax
A: vesicular o/t both hemithorax,
Ronchi-/-,Wheezing-/-
P :Tactile fremitus equal o/t both
hemithorax, discontinuity (+) o/t upper
both hemithorax, Crepitation (-), pain
difficult to evaluate
P : sonor o/t both hemithorax
Abdomen
I: Symmetrical, distension (-)
A: Peristaltic (+) normal
P: Soepel, tenderness difficult to evaluate
P: Tympani, liver dullness (+)
 Laboratory Finding
Hb/Ht/L/Tr : 9,8/29,4/11.879/163.000
Na/K/Cl :116/3,5/91
pH/pO2/pCO2/HCO3/BE: 7,550/186/18/15,7/-4,4
Blood glucose level : 137
Schedel Xray
Cervical X-ray
Chest x-ray
 USG FAST

• Hepatorenal • Splenorenal
Pouch: collecting Pouch: collecting
fluid (-) fluid (-)
 USG FAST

• Douglash Pouch:
collecting fluid (-)
Head Ct-Scan
Head Ct-Scan
 Working diagnosis
Head injury GCS 7 + Subgaleal hematoma +
Blunt thoracic injury with stable haemodynamic
+ Closed (L) 1st,2nd,3rd ribs anterior fracture +
Closed (R) 1st and 2nd ribs anterior fracture +
Lacerated wound o/t (R) Parietal post primary
suture + Schizophrenia + Anemia (9,8) +
hyponatremia (115)
Treatment in the Emergency room
TIME TREATMENT

22:40 O2 15 lpm via NRM

IVFD crystalloid -> 20 dpm
Analgesic injection ->Inj Fentanyl 60mcg IV bolus, maintenance
300mcg in 50cc NaCl 0,9% via syringe pump
Urinary Catheter Insertion -> Yellow, initial output 100cc, UOP
60cc/hr

22:50 Laboratory test

Radiology examination

23:50 Plan:
- Hospitalized in ICU
- Blood transfusion (10-9,8)x65x4 = 1 bag PRC
- Sodium substitution (135-116)x65x0,8= 988 meq
- Consult to neurologist department —> treatment for
schizophrenia