MORNING REPORT

SUNDAY, JULY 22 TH 2018

NIGHT SHIFT

dr. Anto / dr. Aya / dr. Lucky / dr. Indra

dr. Ratna / dr. Anin
dr. Raisa / dr.Adam

1
 PATIENT ADMISSION

• MELATI 2 WARD: (-)

• HCU NEONATUS: (-)
• NICU : (-)
• HCU MELATI 2 : (-)
• PICU : (-)
• ER :
• N, 12 yo, 40kgs, Severe Brain Injury,Susp Fracture Left costae, Incomplete
fracture right scapula bone, DIC due to Severe Brain Injury, Anemia due to
Severe Brain Injury, Wellnourished

2
 PATIENT IDENTITY

• Name :N
• Sex : Male
• Age : 12 years old
• W/H : 40 kgs / 142 cm
• Address : Surakarta
• Medical Record : 01426360

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 CHIEF COMPLAINT

Decrease of conciusness

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 PRESENT MEDIAL HISTORY

• Patient driving bicycle

• Attacked by motorcycle
• Falling Position unknown
• Unconcius (+)
• Vomit (+) projectile
3hours before
admission • Seizure (-)
• Brought to Private Hospital
• Lack of Facility  reffered to Dr.Moewardi Hospital

• Looked Unconcius
• Seizure (-), Vomit (-)
On ER

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 PAST MEDICAL HISTORY

• History of trauma before : denied

• History of hypertension : denied
• History of diabetes : denied

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 FAMILY MEDICAL HISTORY

• History of hypertension : denied

• History of diabetes : denied

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 HISTORY OF PREGNANCY AND DELIVERY

Pregnancy

• This is the second pregnancy of his mother(G2P1A0). Gestational age was 39

weeks. The mother never consumed “jamu” or drug, only consumed vitamins
and pills that routinely given by obstetrician. She routinely check up to
obstetrician. There was no history of hospital admission, vaginal bleeding,
hypertension, swollen in the body, and urinary tract infection during
pregnancy.
Delivery
• The baby boy was born by spontaneous delivery. No premature rupture of
membrane. When he was born, baby was cried loudly. The baby weight is
3200grams, lenght= 50 cm, HC= 32 cm, with APGAR score 8-9-10

Conclusion: pregnancy and delivery history was normal

 VACCINATION HISTORY

• BCG : 1 month
• Hepatitis B : at birth
• DPT-HB-HiB : 2, 3, 4, 18 months
• Polio : 1, 2, 3, 4 month
• Measles : 9, 18 months
• MR : 12 years

• Conclusion: complete immunization, according to

Ministry of Health’s schedule 2005
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 NUTRITION HISTORY

Patient eats rice and side dish, also vegetables 2-3 times a day in 1 portion

Conclusion : quality and quantity of nutrition are adequate

Growth and Development

He is now he is now 12 years old and able to do activities like his friend, he can
follow studies well.
Her weight is 40 kg and her height is 142 cm
Conclusion: growth and development is normal

1
0
 NUTRITIONAL STATUS

• Weight for Age : 40 / 48 x 100% = 83.3%

• Length for Age : 142 / 160 x 100% = 88.75%

• Weight for Length : 40 / 41 x 100% = 97.5%

Conclusion: well-nourished, normoweight, normoheight 11

 FAMILY TREE

II

III

N, 12 yo, 40kgs

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 PHYSIC AL EXAMINATION

• General appearance : severe illness, unconcious (GCS E1V2Mx)

• Vital sign :
• Heart Rate = 88 bpm
S D
• Respiration rate = 26 bpm
p95 120 79
• Temperature = 36.5 0C p99+5 132 92
• Blood Pressure = 100/70 mmHg KH >180 >120
• O2 saturation = 98%

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Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflexes (-/+), anisochoric pupil 5 mm/4mm,
periorbital hematoma (+/-)
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+)
Neck : no enlargement of lymph node

1
4
 LUNG:
• I : normal, symmetric
• P : crepitation (-/+)
• P : sonor in both lung
• A : vesicular breath sound(+/+) additional breath sound (-),
coarse -/- crackles -/- wheezing -/-

CARDIAC:
• I : ictus cordis not visible
• P : ictus cordis palpable at SIC IV LMCS
• P : there is no cardiac enlargement
• A : 1st 2nd Heart sound normal intensity, regular, no murmur

1
5
ABDOMINAL:
I : abdominal wall // thorax wall
A: peristaltic sound increased
P : tympani
P : tenderness (-), no enlargement of the spleen and liver

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong

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 Laboratory Findings (July 22th 2018)
Value Reference Units
Hemoglobin 10,6 12,3-15.3 g/dl
Hematocrit 33 33-45 %
Leucocyte 20.2 4.5-14.5 x103/ul
Thrombocyte 253 150-450 x103/ul
Erythrocyte 4.39 3.8-5.8 x106/ul
PT 18.8 10-15 Seconds
aPTT 54.5 20-40 Seconds
INR 1580
Sodium 130 129-147 mmol/L
Kalium 3.2 3.1-5.1 mmol/L
Chloride 103 98-106 mmol/L
HbsAg nonreactive nonreactive

Conclusion :
Anemia, prolonged PT/aPTT
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 Chest X-Ray Finding (July 22th 2018)

Conclusion :
Heart and Lung within normal limit, incomplete fracture right scapule bone
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 Cervical X-Ray Finding (July 22th 2018)

Conclusion :
No fracture, cervical muscle spasm, ETT projected on VTh 2
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Head CT-Scan Finding (July 22th 2018)
Conclusion :
1. ICH frontal lobe and right
parietal with perifocal
edema make subfalcine
herniation to left 1.4cm
and make bilateral ventricle
narrowed
2. Susp diffuse axonal injury
3. EDH Right Temporoparietal
Region
4. SDH Falx Cerebri
5. Edema Cerebri
6. Subgaleal hematom right
frontotemporoparietal
region
7. Sphenoidal and frontalis
sinusitis
8. Fracture right
temporoparietal bone
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 PROBLEM LISTS

N, 12 years old, 40 kgs with:

• Patient driving bicycle
• Attacked by motorcycle
• Falling Position unknown
• Unconcius (+)
• Vomit (+) projectile
• Seizure (-)
• Brought to Private Hospital  Lack of Facility  reffered to
Dr.Moewardi Hospital
• In ER : Unconcius (+), Vomit (-), Seizure (-)

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• Physical Exam: light reflexes (-/+), anisochoric pupil 5 mm/4mm, periorbital
hematoma (+/-), crepitation (-/+)

• Lab finding: Anemia, Prolonged PT/aPTT

• X-Ray Finding : Heart and Lung within normal limit, incomplete fracture right
scapule bone

• Cervical X-Ray Finding : No fracture, cervical muscle spasm, ETT projected on

VTh 2

• Head CT finding : ICH frontal lobe and right parietal with perifocal edema make
subfalcine herniation to left 1.4cm and make bilateral ventricle narrowed, Susp
diffuse axonal injury, EDH Right Temporoparietal Region, SDH Falx Cerebri,
Edema Cerebri, Subgaleal hematom right frontotemporoparietal region,
Sphenoidal and frontalis sinusitis, Fracture right temporoparietal bone

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 DIFFERENTIAL DIAGNOSIS

1. Severe Brain Injury

2. Susp Fracture Left costae
3. Incomplete fracture right scapule bone
4. Prolonged PT/aPTT due to Severe Brain Injury
5. Anemia due to Severe Brain Injury

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 WORKING DIAGNOSIS

1. Severe Brain Injury

2. Susp Fracture Left costae
3. Incomplete fracture right scapule bone
4. DIC due to Severe Brain Injury
5. Anemia due to Severe Brain Injury
6. Wellnourished

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 THERAPY

1. Admitted to pediatric nephrology ward

2. Head up 300
3. IVFD NaCl 0.9% 20dpm
4. Inj. Metamizole (10mg/kg/8hrs) = 50mg/8hrs
5. Inj. Ranitidine (1mg/kg/8hrs) = 40mg/8hrs
6. Transfusion FFP (10-20ml BW) = 400-800ml

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 PLAN

• Educate family
• Craniotomy Decompresion when getting better (NeuroSurgery Department)
• Consult to Pediatric Department

MONITORING

• General appearance/Vital signs/Blood Pressure/Saturation/4 hours

• Fluid balance & diuresis/8hr

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FOLLOW UP

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 MONDAY, JULY 23 TH 2018

S : seizure (-), vomit (-)

O:
• General appearance : severe illness, unconciusnes (GCS E1V2Mx)
• Vital sign :
• Heart Rate = 88 bpm
S D
• Respiration rate = 22 bpm
p95 120 79
• Temperature = 36.8 0C
p99+5 132 92
• Blood Pressure = 100/70 mmHg KH >180 >120
• O2 saturation = 98%

28
Head : mesocephal
Eyes : pale conjunctiva (-/-), icteric conjunctiva(-/-)
light reflexes (-/+), anisochoric pupil 5 mm/4mm,
periorbital hematoma (+/-)
Nose : nasal flare (-/-),discharge (-/-)
Mouth : lips and tongue cyanotic, moist lips mucosa (+)
Neck : no enlargement of lymph node

2
9
 LUNG:
• I : normal, symmetric
• P : crepitation (-/+)
• P : sonor in both lung
• A : vesicular breath sound(+/+) additional breath sound (-),
coarse -/- crackles -/- wheezing -/-

CARDIAC:
• I : ictus cordis not visible
• P : ictus cordis palpable at SIC IV LMCS
• P : there is no cardiac enlargement
• A : 1st 2nd Heart sound normal intensity, regular, no murmur

3
0
ABDOMINAL:
I : abdominal wall // thorax wall
A: peristaltic sound increased
P : tympani
P : tenderness (-), no enlargement of the spleen and liver

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong

31
 WORKING DIAGNOSIS

1. Severe Brain Injury

2. Susp Fracture Left costae
3. Incomplete fracture right scapule bone
4. DIC due to Severe Brain Injury
5. Anemia due to Severe Brain Injury
6. Wellnourished

32
 THERAPY

1. Admitted to pediatric nephrology ward

2. Head up 300
3. IVFD NaCl 0.9% 20dpm
4. Inj. Metamizole 1g/8hrs
5. Inj. Ranitidine (1mg/kg/8hrs) = 40mg/8hrs
6. Transfusion FFP (10-20ml BW) = 400-800ml

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 PLAN

• Educate family
• Craniotomy Decompresion when getting better (NeuroSurgery Department)

MONITORING

• General appearance/Vital signs/Blood Pressure/Saturation/4 hours

• Fluid balance & diuresis/8hr

34
SHOULD TRANSFUSION BE PERFORMED IN
PEDIATRIC TRAUMA ?

P • Pediatric trauma patients with

transfusion therapy

I •-

C •-

O • outcome
 VALIDITY
Is it stated clearly why systematic review should be
done ?
• Yes.
• It showed clearly in background that coagulopathy was
present in pediatric trauma and transfusion are designed to
treat haemorrhagic shock and coagulopathy

Were the studies validated ?

• Not clearly mentioned.

4
0
 IMPORTANCY

Are the result of systematic review clinically

important and influence to change treatment in
patient ?
• Yes.
• Transfusion with RBC:FFP:PLT for
preoperative pediatric trauma showed
better outcome

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 APPLIC ABILITY

Are our patients simillar to the patient in this study?

• Yes. The patient in this study was child below 18

years old with traumatic brain injury

Are the terapy available, affordable, and acceptable to

patient ?
• Yes. Transfusion of RBC, FFP, PLT are available in our
hospital. 42
 LEVEL OF EVIDENCE

Important

Valid Applicable

LoE
4B
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THANK YOU

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