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Duty Report

(24th Dec 2019)

Aqim
Glenn
Dokter Jaga Patient
Trauma = 1 patient
dr. Putri Non-Trauma = 0 patient
Admitted = 1 patient

Name Age Diagnosis


Ms N 28 yo Fracture os Parietotemporal dextra
1st case
Identity & History

Name Ms. N
Past Medical History:
Sex Female
(-)
Age 28 y/o

Family History:
(-)
Chief complaint:
Pain on the head after falling
Other complaints:
down
HISTORY OF PRESENT ILLNESS

Three hours before admission, the patient was riding a motorcycle. Suddenly, at
a junction, a car turned and hit her on her right side. She fell down and hit her
head. She was immediately brought to a puskesmas before being referred to
RSUD Koja.
Chronology of Present Illness

17:00 pm
3 hours
IGD
before
RSUD
admission
IGD Koja

Patient was brought to


RSUD Koja.
Patient complaints
Three hours before admission, pain at wound site.
the patient was riding a
motorcycle. Suddenly, at a
junction, a car turned and hit
her on her right side. She fell
down and hit her head. She
was immediately brought to a
puskesmas before being
referred to RSUD Koja.
Biomechanism of Trauma
Primary Survey

Airway :
Airway obstruction (clear), trachea in the middle
Breathing :
Spontaneous breathing (+), retraction (-), wheezing (-), ronchi (-), RR: 22 x/mins
Circulation :
Pulse (+, regular), warm extremities, external bleeding (-), BP: 168/110 mmHg, HR: 96 x/mins, Temp:
36,9 C, CRT <2 sec
Disability :
GCS (E4M6V5) = 15
Secondary Survey

●Head : bleeding (-), swelling (+), tenderness (-), hematoma (-),


●Eyes : eyebrow bleeding (-), isokor 3mm/3mm, CA (-/-), SI (-/-)
●Nose : hair nose (-), bleeding (-)
●Ear : normotia, bleeding (-)
●Mouth : mucosa redness, cyanosis (-)
●Neck : enlargement of lymph nodes (-)
Thorax :
• Inspection : Symmetrical
• Palpation : Vocal fremitus & tactile symmetrical
• Percussion : resonance in both lungs
• Auscultation : Vesicular, Rh -/-, Wh -/-; Heart sound I-II normal

Abdomen :
• Inspection : Flat, mass (-),
• Auscultation : Peristaltic sound (+), normoperistaltic
• Palpation : Soft & non tender, distention (-)
• Percussion : Tymphany
Local state of pareitotemporal
region
• Look: swelling (+), hematoma (-),
open wound (-)
• Feel: tenderness (+), pain (+)

• Move: Normal ROM of cervical.


Diagnosis and problem

Problems:

Working diagnosis: • Pain


Close fracture of Os • Swelling on the head
Parietotemporal Dextra
Management

SURGERY

Consult a neurosurgeon NON SURGERY

Pharmacology
Ketorolac

Non-pharmacology
Observation