CASE REPORT Monday, March 7th 2014 Team On Duty: dr. Andria Saputra dr. M. Nazir Tambunan dr.

Rynaldi Andrian ya dr. Sumrahadi Manurun! dr. "hali#ul dr. $auhari %& lo An!#a a 'i(aya dr. Muharrian yah

I.

Patient identity Nam& : %i#a Mauliza A!& : 1) y&ar old S&* : +oy Addr& : "p Mulia, "&c. Syiah "uala, +anda Ac&h MR : ,, 7) 1%ri.in! /ic&n & : 012 3hon& numb&r : 041-52511--7 3ati&nt cam& at : 05.-5 3M Chief complaint %&cr&a & o6 con ciou n& Patient illnes History Th& pati&nt cam& to 7aino&l Abidin &m&r!&ncy room 8ith d&cr&a & o6 con ciou n& 6or 1 hour. Th& complaint tart&d 8h&n th& pati&nt 8a ridin! motorcycl& 8ithout h&lm&t and udd&nly truc#&d by anoth&r motorcycl& 6rom b& id& o6 him. Th& hi tory o6 lucid int&r.al 8a uncl&ar. Th&r& 8a no trauma at th& oth&r part o6 body. Th&r& 8a hi tory o6 .omitin!. Physical e amination 3rimary Sur.&y A: 9l&ar +: Spontan&ou , RR: 20 br&ath : minut& 9: +3 : 1-0:40 mm;! 3ul &: 70 b&at :minut& %: <9S: =- M5 >4 <9S 1-, i ochoric pupil ? - mm: - mm, li!ht r&6l&* 0@:@2 /:S at th& ri!ht t&mporal r&!ion / : 8&llin! 0@2, 8ound012 S&condary Sur.&y Th&r& 8a no trauma at oth&r part body

II. III.

IV.

V.

Assessments! Mod&rat& h&ad in(ury

VI.

"ana#ement Stop oral inta#& ;&ad up -00 A*y!&n 2 litr& : minut& .ia canul& B>C% Na9l 0,,D 20 drip :minut& Bn(. 9&6tria*on& 1 !r Bn(. M&tamizol odium 1 !r /aboratory &*amination Radiolo!y &*amination $a%oratory result ;b 'hit& blood count 3lat&l&t ;t 9T +T +lood !luco & ad random : : : : : : : 1),) !r:dl 15.400:ul 2,0.000 :ul 45 D 5 minut& 2 minut& 1-- m!:dl

VII.

VIII. Radiolo#y result Head CT&Scan ! 1 Th&r& 8a S9A/3 h&matoma at th& l&6t ocipital r&!ion 1 Th&r& 8a no 6ractur& at th& bon& 8indo8 1 Sulcu and !yru 8a narro8 1 Th&r& 8a hyp&rd&n & bicon.&* ar&a at th& ri!ht t&mporal ba & r&!ion =%; 1 >&ntricl& and cy t&rna y t&m 8a narro8 1 Th&r& 8a no midlin& hi6t I'. '. Dia#nose! Mod&rat& h&ad in(ury @ =%; at th& ri!ht t&mporal ba & r&!ion Consult to (eurosur#ery Di)ision ! 9raniotomy &.acuation =%; &m&r!&ncy

'I. 'II.

Intraoperati)e report 3ati&nt in upin& po ition, h&ad up -0o and turn to th& l&6t 8ith !&n&ral an& th& ia. 3&r6orm&d a &ptic and anti &ptic proc&dur& 3&r6orm&d r&.&r & Eu& tion mar# inci ion until bon& 3&r6orm&d - +urr hol&, bon& 8a a8&d 8ith !i!ly and pull&d out Bd&nti6i&d =%; 8ith thic# - cm -0 cc 3&r6orm&d dura hit tich& and &.acuat&d th& =%; +l&&din! control +on& 8a r&turn 3&r6orm&d on& tub& drain 9lo ur& th& 8ound by primary utur&

Post Operati)e Dia#nosed Mod&rat& h&ad in(ury 0B9% 10 9M S0,.,2 @ =%; at th& ri!ht t&mporal ba & r&!ion 0B9% 10 9M S05.42

'III. *ollo+ up
%at& 11:4:2014 3A% B> S 3ain 012 O >S: +3 : 110: 70 mm;! 3ul &: 44 b&at :mnt RR: 20 br&ath :minut& <9S : =4 M5 >) pupil i ochoric T&mp -5,7o9 A

Mod&rat& h&ad in(ury 0B9% 10 9M S0,.,2 @ =%; at th& ri!ht t&mporal ba & r&!ion 0B9% 10 9M S05.42

P %i&t 1400 "cal ;&ad up -0o B>C% Na9l 0,,D 20 drip :minut& 9&6tria*on& in( 1!:12 hour M&tamizol odium in( 1 !:4 hour