CASE REPORT

Tuesday, August 4th 2015

Team on duty
dr. M. Nazir Tambunan
dr. Tommy Rivelino
dr. Andri Mulia
dr. Bobby HE Fermi
dr. Herdi Gunanta S
dr. Syahmardani Ibnu
Patient identity
Name
Age
Sex
Address
MR
Phone Number
Admission time

(Jaga 1)
(Jaga 2)
(Jaga 3)
(Jaga 4)
(Jaga 5)
(Jaga 6)

: Fadhlul
: 6 years old
: Boy
: Blang Geulumpang, Peudada, Bireun
: 1 06 02 21
: 085306440498
: 09.00 PM

Chief complaint
Decrease of consciousness
Patient illnes history
The patient referred from Bireun district hospital to RSUZA Emergency Room
with a chief complaint decrease of consciousness since 2 day ago. Initially,
patient was playing under coconut tree and suddenly hit by a coconut at his
head. There was no history of lucid interval. There was history of nausea and
vomiting.

Physical examination
Primary Survey :
A : Clear
B : Spontaneous, RR = 20 breaths/minute
C : Pulse : 96 beats/minute
D : GCS = E3 M6 V5 = 14, isochoric pupil
(3mm/3mm), light reflex (+/+)
E :
L/S at the right temporoparietal
L : Haematom(+), wound (-)
F : Pain (+)

Secondary survey :
Head and neck
:
L/S at the right temporoparietal
L : Haematom(+), wound (-)
F : Pain (+)

Thorax
Abdominal
Upper Extremity
Lower Extremity

: in normal limit
: in normal limit
: in normal limit
: in normal limit

VAS : Moderate

Assessments:
Mild Head Injury
Management

Stop oral intake

Head up 300

Oxygen 4 litre / i via nasal canule

IVFD NaCl 0,9% 20 drips/minute

Inj. Ceftriaxone 750 mg

Inj. Ketorolac 10 mg

Catheter urine

Laboratory examination

Radiology examination

Laboratory examination
Hb
White blood count
Platelet
Ht
CT
BT

: 12.4 g/dL
: 19.200 /ul
: 332.000 /ul
: 31 %
: 7 minute
: 2 minute

Radiologi examination
Head CT-Scan
:
There was SCALP hematoma at the right tcemporoparietal region
Sulcus and gyrus was narrow
There was hyperdense abnormal at the right Temporo-parietal region EDH
Ventricle and cysterna system was narrow
There is Midline shift to the right >0,5 mm
Diagnose
1. Mild head injury
2. EDH at the Right Temporo-parietal region
Consult to Neurosurgery Division :
Craniotomy evacuation EDH emergency
Operative Report Pedriatic Surgery
Performed 5 Burr hole, bone was sawed with gigly and pulled out
Identified EDH at the right temporoparietal with thick 2 cm 50 cc
Performed dura hit stiches and evacuated the EDH
Bone was return
Post Operation Diagnose
1. Mild head injury (ICD 10 CM S09.9)
2. EDH at the right fronto-temporo-parietal(ICD 10 CM S06.4)

Follow up
Date
5/6/2015
POD I

O
Pain ( - )

VS/
Pulse : 88 beats/minute
RR : 20 breaths/minute
Temp : 36,7oC
GCS : E4 M6 V5
pupil isochoric, light reflex
(+/+)
Drain : 20 cc

Mild head injury

(ICD 10 CM
S09.9)
EDH at the right
temporoparietal(ICD 10
CM S06.4)

IVFD NaCl 0,9%

20 drips/minutes
Ceftriaxone inj
750g/12 hours
Ketorolac inj /8
hours