Patient identity

Name

: Ismu Hadi

Age

: 8 years old

Sex

: Boy

Address
: Curee Tunong, Kec. Simpang
Mamplam, Kab. Bireuen
MR

: 1 05 85 38

Parents Phone : 085281881923

Admission Time: 04.36 AM

Time Response
Date/h Examin Laboratory
our
ation
Examinatio
patient hour
n
came
Send Resu
to ER
lt

18 July
2015/
04:36
AM

04:40
AM

Radiology
Examinatio
n

Hour
of
Diagn
Send Resu ostics
lt

05:10 07:00 05:40 06:10 06;20

AM
AM
AM
AM
AM

Date/
hour
patie
nt
out
from
ER

DPJP

10:00
AM

Dr
Busta
mi
SpBS

Chief complain:
Headache after trauma
Patient illnes history
The patient come to the emergency with a chief complaint
headache after trauma for 16 hour. The patient back from the
mosque and strucked by motorcycle and his head hit the
asphalt. There was history of unconsciousness. History of
nausea and vomiting (-).

Physical examination
A: Clear
B: Spontaneous, RR: 18 breaths/ minute
C: Pulse 92 beats/minute,BP 110/80 mmHg
D: GCS: 15 (E4 M6 V5); isochoric pupil
3mm/3mm, lateralization(-)
E:
L/S at the right parietal
L: wound (+) size 6 cm was sutured, swelling (+)
F: pain (+), discontinuity of bone (+)
L/S at the facial region
L: excoriated wound
F: pain (+)

Secondary Survey
Head and Neck
L/S at the right parietal
L: wound (+) size 6 cm was sutured, swelling (+)
F: pain (+), discontinuity of bone (+)
L/S at the facial region
L: excoriated wound
F: pain (+)

Thorax

: in normal limit

Abdominal
Pelvic

: in normal limit

: in normal limit

Upper Extremity : in normal limit

Lower Extremity : in normal limit

VAS :Mild

Mild 1-3

Moderate 4-6

Severe 7-10

Non opioid +
adjuvant
- COX-2
- Ibuprofen
- Aspirin
Acetaminophen

Opioid +
nonopioid +
adjuvant
- Codein
- Propoxyphen
e
- Hydrocodone

Opioid +
nonopioid +
adjuvant
- Oxycodone
- Morphine
- Hydromorph
one

Assessment:
Mild Head Injury
Open depress fracture at the right parietal region

Management:
Head up 300
IVFD NaCl 0,9 % 10 drips/minute
Ceftriaxone inj. 500 mg
Ketorolac inj 10 mg
Tetagam 250 iu
Laboratory examination
Radiology examination

Laboratory result
Hb
: 10.5 gr/dl
Hematocrit
: 32 %
White blood count : 14.300 /ul
Platelet
: 335.000 /ul
CT
: 7 minute
BT
: 2 minute

Radiology result:
Head CT Scan :
SCALP hematome of the right parietal region
There was depress fracture at the parietal region >
1 tabule
Sulcus and gyrus was narrow
Ventricle and systerna system was normal
There was no midline shift

Diagnose:
Mild head injury (ICD 10 CM S09.90)
Open depress fracture at the right parietal region
(ICD 10 CM S02.91)

Consult to neurosurgery division

Debridement
Elevation depress fracture

Intra operative
Performed debridement
Extended incision from the old wound
There was depress fracture
Bone pulled out, duramater and cerebral cortex
was lacerated
Performed durafacial graft
Bone was return with mossaic technique and
fixated

Post Operative Diagnose

1. Mild head injury (ICD 10 CM S09.90)
2. Open depress fracture at the right parietal region
(ICD 10 CM S02.91)
3. Leakage Duramater (ICD 10 CM S06.33)

FOLLOW UP
Date
22-7-2015
POD 3

S
(-)

O
General condition : good
GCS 15
Pulse: 80 beats/minute
Respiratory:
20 breath/minute
T:37,0 0C

A
1. Mild head
injury (ICD 10
CM S09.90)
2. Open depress
fracture at the
right parietal
region (ICD 10
CM S02.91)
3. Leakage
Duramater
(ICD 10 CM
S06.33)

P
IVFD NaCl 0,9 %
10 drips/minute
Ceftriaxone inj.
500 mg
Ketorolac inj 10
mg