CASE REPORT

Wednesday, October 1st 2014

Team on duty:

I.

dr. Fachrul Razi

dr. M.Nazir Tambunan
dr. Rynaldi Andriansya
dr. Lea Darman Husein
dr. Jauhari Deslo Angkasa Wijaya
dr. Sumrahadi Manurung
dr. Zumirda Zainal
dr. Muhammad Reza
dr. Yoki Oktadi

Patient Identity
Name
Age
Sex
Address
MR
HP
Driving license
Patient came at

: Hasbi
: 43 years old
: Male
: Desa Cot Jabet,kec. Ganda Pura,Bireuen
: 1-20-11-32
: 082360737533
: (-)
: 09.46 PM

II.

Chief Complain :
Decrease of consciousness

III.

Present illness history

The patient came to Zainoel Abidin emergency room with decrease of consciousness
for 10 hours ago. The patient was riding motorcycle and he strucked by another
motorcycle from behind of him. There was no history of nausea, vomitting (+), history
of lucid interval (-). History of diabetes mellitus (+)

IV.

Physical examination
Primary Survey
A: clear
B: spontaneous, RR: 22 breaths/ minute
C: Blood pressure : 110/70 mmHg,Pulse: 96 beats/minute
D: GCS: 12 (E3 M5 V4); isochoric pupil (L/R) 3mm/3mm, lateralization (-)
E:
L/S at the head region :
I : wound 2 cm, deformity (-)
P : discontinuity of bone (-)
Secondary survey
At the Head
I : wound 2 cm, deformity (-)
P : discontinuity of bone (-)

Neck
Thorax
Abdomen
Pelvis
Upper extremity
Lower extremity

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

V.

Assessment
1.Moderate Head Injury
2.Diabetes Mellitus type II

VI.

Management
Head up 30
Oxygen 8 litre via face mask
NGT
Urinary catether
IVFD NaCl 0,9% 20 drips/minutes
Inj. Ceftriaxone 1 gram
Inj. Ketorolac 30 mg
Inj. Tetagam 250 IU
Laboratory examination
Radiology examination

VII.

Laboratory result
Hb
White blood count
Platelet
CT
BT
Ht
Blood glucose ad random

VIII.

: 17.0 gr/dl
: 27.200 /ul
: 325.000 /ul
: 6 minute
: 2 minute
: 49%
: 421 mg/dlregulation of blood glucose

Radiology result
Head CT-Scan:
SCALP haematoma at the right temporal region
There was linear fracture at the right temporalat the bone window
Sulcus gyrus was narrow
There was hyperdense area abnormal at the left temporal ICH
Cysterna and ventricle system was normal
No midline shift

IX.

Diagnose
1. Moderate head injury
2. ICH at the left temporal region
3. Linear fracture at the right temporal region
4. Diabetes Mellitus Type II

X.

Consult to Neurosurgery division

Craniotomy evacuation ICH emergency
Consult to Endocrinology departement :
Regulation of blood glucose

XI

Intraoperative
Question mark incision
Performed 6 burrhole
Identified SDH and ICH at the left temporal
Duraplasty
Bone keep at subgaleal

XII.

Post Operative Diagnosed

1. Moderate head injury (ICD 10 CM S09.90)
2. ICH at the left temporal region (ICD 10 CM I61.0)
3. SDH at the left temporal region (ICD 10 CM
4. Linear Fracture at the right temporal region (ICD 10 CM S02.0)
5. Diabetes Mellitus Type II (ICD 10 CM E11)

XII

Follow Up

Date
3/10/2014
POD 2

S
-

O
VS/
GCS : E2 M5 V2
BP : 120/80 mmHg
Pulse: 80 beats/mnt
RR: 16 breaths/minute
GCS : E4 M6 V5
Isochoric pupil
Sat O2 100 %
Temp 36,2 oC

1.
2.
3.
4.
5.

Urin Output : 50 cc/hour

Drain : 150 cc serous
hemorrhagic

A
P
Moderate head injury (ICD Ward in HCU
Head up 30o
10 CM S09.90)
ICH at the left temporal
Oxygen 8 litre via
region (ICD 10 CM I61.0) face mask
SDH at the left temporal IVFD NaCl 0,9%
region (ICD 10 CM
15drips/minutes
Linear Fracture at the rightCeftriaxone inj 1
temporal region (ICD 10 gram/24 hr
CM S02.0)
Metamizole sodium
Diabetes Mellitus Type II inj 1 gr/ 8 hr
(ICD 10 CM E11)