Department of Surgery

Aug 26, 2014

Name : Mrs. W
Age : 19 y.o
Sex : female
Address : Tuban
Date examination: aug 25, 2014
ANAMNESIS
Chief complaint
loss of consciousness
MOI
Patient came referral from Bojonegoro Aisyiah Hospital with
loss of consciousness post traffic accident four hours before
addmision into the hospital. patients was riding motorcyle
and was hit by a motorcycle. Patient fell with head hit the
asphalt, History unconsiousness +, vomit 2x . Helmet (-).
seizure-, short of breathness -, rhinorea -, otorea-
Airway and spine control : clear (+), snorring (-
), gargling (-), potensial obstruction (+)
pasang OFT, cervical collar
Breathing : spontan, simetric (+), RR
24x/minutes, ves/ves, rh-/-, wh-/-
Circulation : PR 86x/minutes, acral warm dry
red, CRT < 2, Sp02 98% with O2 support, BP
126/62 mmhg
Disability : GCS 125, LP + weak/+, isocor pupil
3mm/3mm, lateralisasi-
Exposure : temp 37,1 C
Head and neck : anemic (-), icteric (-), cyanosis (-),
dyspneu (-). Diplopia-. Scalp hematom at temporo
parietal dex 4cmx3cmx3cm
Thorax : minimum hematom et sternum, simetric,
retraction (-)
Pulmo : ves/ves, rh-/-, wh-/-
Cor : S1S2 single, murmur (-), gallop (-), lession -
Abdomen : flat, distended (-), tympani (+), liver and
spleen were not palpable, bowel sound (+), lession-
Extremities : acral warm, dry, red, lession-
Regio temporoparietal dex: scalp hematom
dex 4cmx3cmx3cm
regio temporal dex: vul scissum + hematom
1cmx0,5cmx0,5cm
Regio femur dextra: hematom 2cmx2cm
Clue and cue
female, 19 y.o
loss of consciousness
Post traffic accident
Vomite
Regio temporoparietal dex: scalp hematom dex
4cmx3cmx3cm
regio temporal dex: vul scissum + hematom
1cmx0,5cmx0,5cm
Regio femur dextra: hematom 2cmx2cm




Assesment
severe brain injury
CBC
CT-BT
GDA
RFT
CT Scan skull
X-ray thorax AP
X-Ray cervical AP/L

CBC
Diff 3/1/91/4/1
Hct 36,1
Hb 11,7
Lekosit 19600
Trombosit 216.000
GDA 153
BT 200
CT 800
CT Scan

CT Scan
Thorax

Assesment
severe brain injury
SDH
ICH
IVFD Assering 1500 cc/24 hours
Head up 30
02 nrm 10 lpm
Kateter foley
Inj.Metamizole 3x1 g i.v
Inj. Ranitidin 2x50mg i.v
Inj. Piracetam 4x3g i.v
Inj. citicolin 3x250mg i.v
Inj manitol 200cc6x100mg
Inj kutoin 400mg 3x100mg
Inj terfacef 2 g pre op
C/Sp.BS
Subjective complaint
Vital sign
sign of increased pressure intracranial
Explain to the patients family about the
diagnosis, etiology, intervention of therapy,
complication, and prognosis.