Morning Report

Dept. of Surgery
J-23

FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH

MALANG
RUMAH SAKIT MUHAMMADIYAH LAMONGAN

Patient Identity

Name
: Mr. ME
Age : 30 y.o
Address
: Lamongan
Occupation : Marriage status: Married

Present History
Patient reffered from PKU Cepu Hospital with EDH.
Patient was encountered traffic accident 3 days
before admission to hospital. Patient was ride a
motorbike himself, helmet (+), medium speed,
then in front of him there was a child crossing
street, patient was about to denying him but he
was fall, in sliding left position. Loss of
consiusness (-) bleediing from nose (+) after
accident, bleeding from ear (-), vomiting (-) Patient
was treat on PKU Cepu Hospital for 3 days and got
dexamethasone and metilcobalamin

Physical Examination
Vital sign:
TD: 100/62 mHg
N: 68 xm
RR: 19x/m
T: 36.8C
SpO2: 100% without O2 support
GCS 356
Primary Survey:
A : Gargling (-) snoring (-) pot. Obstruction (+)
B : Spontan, RR 19x/m, ves|ves, rh -|-, wh -|C : Extremity WRD, CRT <2, N 73x/m, TD 100/62
D: GCS 356, lateralisasi (-) pupil isocor 3mm|3mm
LP +|+

Physical Examination
Secondary Survey:
Head and neck: a-/- i -/- c -/- d
Brill hematome bilateral (+), vulnus
apertum right frontoparietal head
sewn. Bloody otorheae (-) bloody
rhinroheae (-) lesion retro aurikula
(-)Lesion supraclavicula (-)
subconjunctival bleeding bilateral (+)
Thorax:
Inspection: Simetris, retraction (-|-)
cor: s1 s2 single reg, m (-), g (-)
pulmo: sonor|sonor, ves|ve, rh -|-, wh
-|Abdomen:
Flat, soefl, lesion (-), tympani, bowel
sound (+) wnl
Extremity:
Acral warm dry red, CRT 2

Laboratory findings

Eri 5.50
Hb 13.8
Leu 11.2
Neu 83.7
Plt 285
HbsAg (-)
PT 11.40 (10.30-16.30)
aPTT 26.20 (24.20-38.20)
BUN 35
SC 0.8

CT scan w.o
contrast

CT Scan kepala irisan axial tanpa kontras

-Tampak area hiperdens daerah fronto-parieta kanan
tebal 4,3 cm disertai perifocal edema mendesak ventrikal
lateral kiri sejauh 1.2 cm
-Tampak fraktur os fronto parietal, temporal, dan zygoma
kanan
-Tampak perselubungan kedua sinus etmoidalis,
sphenoidalis, dan frontalis
-tampak soft tissue hematome pd frontoparietal kanan
-tampak area hiperdens mengisi cysterna dan sulcy gyri
Kes: EDH di fronto-parietal kanan tebal 4.3cm disertai
perifocal edema mendesak ventrikal lateral kiri sejauh
1.2 cm
-SAH minimal
-Fr.os frontoparietal dan zygoma kanan
-soft tissue hematom pd frntoparietal kanan
-hematosinus ethmoidalis, sphenoidalis, dan frontalis
kanan kiri

Skull 3D

Clue and cue

Headache
Post traffic accident
Brill hematome bilateral (+), vulnus apertum right
frontoparietal head sewn. Bloody otorheae (-) bloody
rhinroheae (-) lesion retro aurikula (-)Lesion supraclavicula
(-) subconjunctival bleeding bilateral (+)
EDH di fronto-parietal kanan tebal 4.3cm disertai perifocal
edema mendesak ventrikal lateral kiri sejauh 1.2 cm
Fr. os frontoparietal dan zygoma kanan
soft tissue hematom pd frntoparietal kanan
hematosinus ethmoidalis, sphenoidalis, dan frontalis
kanan kiri

Problem list
EDH
Fr. os frontoparietal dan zygoma
kanan

Therapy

O2 nasal 3 lpm
Head up 30 derajat
Attach DK
Inf. asering 1500cc/24 j
Inj. Metamizole 3x1 gr iv
Inj. Ceftriaxone 2x1 gr iv
Inj. Ranitidine 2x50 mg iv
Inj. Ceteron 3x8 mg iv
Inj. Piracetam 4x 3 gr iv
Inj. Citikolin 3x250 mg iv
Inj. Manitol 20% oading 200cc lanjut 6x100cc inj.
Kutoin 100 mg iv 300 mg iv drip in pz 100
Consult neurosurgery CITO op