Patient identity

Name
: Zulfikar
Age
: 17 years old
Sex
: Male
Address
: Matang Kumbang, Kec.
Gandapura
Kab. Bireuen
Phone
: 082362637282
MR : 1 01 95 80
Driving license
: (+)
Time Arrived : 1:35 AM

Chief complaint
Decrease of consciousness

Patient Illnes History

The patient referred from Bireuen distric
hospital with chief complain decrease of
consciousness for 12 hour. The complaint
started when he ride a motorcycle without
helmet and strucked another motorcycle that
suddenly came out from the alley. There was
history of nausea and vomiting (+). There
was no history of alert after trauma.

Physical examination
A : Clear
B : Spontaneous, RR: 24 breaths/ minute
C : BP : 130/90 mmHg, Pulse: 80 beats/minute
D : GCS 10 (E3 M5 V2) ; isochoric pupil
(3mm/3mm)
light reflex (+/+)
E: L/S a.r facialis
Upper Face ( at the frontal )
L : Symetric, Wound (+) size 5 cm was sutured

Mid Face :
L : Symetric, excoriated wound (+), swelling (-)
Lower Face :
L : Asymetric, Wound (-), swelling (+) deformity
(+),
hematoma (-)

Intra Oral
:
Malocclusion (+)
Mandibular floating (+)
Alveolar floating (-)
Maxilla floating (-)

L/S at the neck region

I : Haematoma (+), excoriated wound (+)
P: Pain (-)

Assessments:
1.Moderate Head Injury
2.Mandible Fracture

Management
Head up 30
Neck collar
IVFD NaCl 0,9% 20 drips/minutes
O2 8 l/minutes via facemask
Urine catheter
Inj.Ceftriaxone 1 gr
Inj. Ketorolac 30 mg
Inj. Tetagam 250 IU
Laboratory examination
Radiology examination

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

:
:
:
:
:
:

11,8 gr/dl
17.100/ul
160.000 /ul
36 %
7 minute
2 minute
: 125 gr/L

Radiology examination
Head CT-Scan :
Subgaleal hematoma at left occipital region
Linear fracture at the left frontal bone
There was hiperdens abnormal area at the
right temporal region surely SDH
There was hiperdens abnormal area at the
falx cerebri surely SAH
Ventricle system was narrow
Sulcus and gyrus narrow.
Mid line shift to the left > 0,5 cm

Thorax AP :
In normal limit
Schedell AP/Lat
Segmental fracture of the mandible
Cervical :
Loss of lordotic appereance

Diagnose
1.Moderate head injury
2.Linier fracture of the left frontal region
3.SDH at the right temporo parietal region
4.Segmental fracture of the mandible
Consult to Neurosurgery Division :
Craniotomy SDH evacuation emergency
Consult to Plastic Surgery Division :
Hospitalize
ORIF elective

Intra Operative
Patient in supine position, extended to the left
side, head up 30 0, with general anesthesia.
Aseptic and Antiseptic procedure, drapping
procedure
Reverse question mark incision at the right
temporo parietal region, deeper layer by layer
until bone
Made 4 Burr holes, the skull was sawed with
gigly and the fragment was pulled out.
The dura looked tension and blueish.
Performed dura hit stiches

 Duramater opened with sharp procedure

Perform SDH evacuated with volume about
65 cc.
Founded bleeding from lacerated cortex at
several point and performed bleeding control
Performed dura facial graft
Bone flap was keep at subgaleal
Performed one tube drain
Wound operation closed by primary sutured

Poto-poto intra operatif !!!

Post Operative Diagnose

1.Moderate head injury
2.Linier fracture of the left frontal region
3.SDH at the right temporo parietal region
4.Segmental fracture of the mandible

Date
22/9/2014
POD I

O
VS/
BP : 120/70 mmHg
HR : 90 x/mnt
RR : 22 x/mnt
GCS 12; E2M4 V3
Isochoric pupil
3mm/3mm

A
1.
2.
3.
4.

Moderate
head injury
Linier fracture
of the left
frontal region
SDH at the
right temporo
parietal region
Segmental
fracture of the
mandible

P
IVFD NaCl 20
drips/minutes
Head up 30
O2 4l/minute
via
Ceftriaxone 1 g/
12 hours
Ketorolac 3%
Inj 1 amp/ 8
hours
Liquid diet
6x100 cc