MORNING REPORT

DEPRESSED FRACTURE OS. PARIETAL

SINISTRA WITH
HEMIPARESIS DEXTRA AND
APHASIA MOTORIC
ICD X Code : S02.0, G81.01, R47.01
Level of Competence : 2
Iriandanu Nugraha
1608437691

Clinical Clerkship of Surgery Department

Faculty of Medicine Riau University
Arifin Achmad General Hospital
Patients Identity
Name : DA
Age : 9 years old
Sex : Male
Occupation : Student
No. RM : 965264
Admitted to hospital on 9th September 2017
Primary Survey
Male, 9 years old, trauma, post traffic accident 4 hour
before admitted, with Alert response.
Airway & C-spine control

Immobilization cervical / collar neck to control cervical spine

Objective:
The patient unable to communicate verbally.
No abnormal breathing sounds (gurgling (-), snoring (-), stridor (-)).

Assessment:
Airway is clear

Action:
O2 via NRM 8 L/minute
Attached pulse oximetry

Evaluation:
Pulse oximetry 98 %
Breathing
Objective:
Chest movement is symmetric, RR 26 x/minute.
Breathing sound Vesicular (+/+)
Percussion sonor (+/+)

Assessment:
Ventilation and lung expansion is normal.

Action:
Continue with O2 via NRM 8 L/m

Evaluation
Lung expansion normal
Circulation
Objective:
Warm acrals, CRT <2 sec, radial pulse is palpable, regular, frec 94
x/min
Blood pressure: 110/70 mmHg.

Assessment:
Shock (-), Circulation stable

Action:
IVFD RL 18 dpm with blood set

Evaluation
Shock (-)
Disability
Objective:
Glasgow coma scale (GCS)
Eyes: Eyes open spontaneously (E4)
Verbal: Unable to speak
Motoric: Follows commands (M6)

Pupillary light reflex, direct (+/+) indirect (+/+), pupils are

isochoric; 2mm/2mm.
Disability (Cont.)
-Right sided muscle weaknesses

Assessment:
Motoric Aphasia
Right hemiparesis
Exposure
Objective:
Axillary temperature : 370 C
Wet cloth (-)

Assessment:
Hypothermia (-)

Action:
Cover the patients body with blanket.
Do re-evaluation from beginning.
SECONDARY SURVEY
Mechanism of trauma
Injury of organ
Sign and symptom
Treatment
 Mechanism of Injury and
History of present Illness
4 hours before admitted patient had an accident, the
patient was hit by motorcycle while crossing the road.
Theres a penetrating injury into the scalp of the patient.
Theres pretty much bleeding of the scalp. Right
after the accident, the patient could still cry and scream for
pain. Loss of consciousness (-), Projecting vomiting (-),
active bleeding from nose, ear, and mouth (-). And than
patient admitted to primary health care.
 Mechanism of Injury and
History of present Illness (cont.)
After being taken to the clinic and examined, the
doctor just realized that patient had a limb weaknesses and
unable to speak.
I Vulnus laceratum at left side parietal
region that has been sutured

s Pain and bleeding of scalp

Weakness of the right sided limb
Patient Unable to speak

T IVFD NaCl 20 dpm

Suturing of the wound
 AMPLE

Allergic : History of allergic (-)

Medication : Patient not under drugs or
alcohol effect
Past illness : None
Last Meal : 5 Hours before trauma
Event : Mechanisme of injury
 PAST ILLNESS HISTORY
There are no history of past illness related
to present illness

FAMILY ILLNESS HISTORY

There are no History of family illness

related to present illness
3. PHYSICAL EXAMINATIONS
General State
General appereance : Moderate illness
Conciousness : Composmentis
Vital signs
BP : 110/70 mmHg
HR : 94 x/i
RR : 26 x/i
T : 37,0 oC
 PHYSICAL EXAMINATION

Head and neck : Localize Status

Thoraks : Within normal limit
Abdomen : Within normal limit
Extrimity : Within normal limit
Genitourinarius : Within normal limit
 Localize State

SCALP
Inspection :
2 cm Vulnus Laceratum at Parietalis Region that has been
sutured
Swelling (-)
Palpasi :
Tenderness (+), there are sunken feel on sutured area.
Neurological status
Consciousness : Composmentis
Cranial nerves :
N. I (Olfactory nerve) not done
N. II (Optic nerve)
Right Left
Visus bedside normal normal
Visual field Not done Not done
 N. III, IV, and VI (Occulomotor, Trochlear, abdusens)

Right Left
Ptosis - -
Eyeballs movement normal normal
Eyeballs position Ortophoria Ortophoria
Pupillary light reflex + +
(direct, indirect)
Diplopia - -
 N. V (trigeminal nerve) :
Right Left
Jaw opening Deviate to the left

N. VII (facial nerve) :

Right Left
Forehead-frontal motoric + +
Orbicularis oculi motoric + +
Orbicularis oris motoric - +
 N. VIII (Vestibulocochlear nerve) : not done
N. IX-X (Glossopharyngeal vagus nerve) :

Arcus pharyngeal symmetric

Tongue tasting (1/3 posterior) Not done

N. XI (Accessorial nerve) :
Shrugging Not done
Turned to left and right normal
Working diagnose
Vulnus laceratum at the left parietal
region
Susp fracture at the left os Parietalis
Right hemiparesis
Aphasia Motoric
Work up plan
Blood routine test
Head CT Scan
Work up result
Hb : 9,7 g/dl
Ht : 28,7 %
WBC: 18.480 /uL
Platelet : 271.000 /uL
Bone window Head CT Scan

Interpretation
Depress fracture at the
left os. parietal
Brain window CT Scan
Interpretation
Soft tissue swelling (-)
Hiperdense mass at the
left parietal region
Ventriculomegaly (-)

Conclusion
Contusio cerebri at the left
parietal region
Diagnose
Open Fracture Depress at the left Os
Parietal
Contusio cerebri at left parietal region
Right hemiparesis
Aphasia Motoric
Treatment
Non Pharmacologic
Surgical operatif

Phamacologic
Inj ATS 1 x 1500 IU im
Inj Ceftriaxone 2 x 500 mg
Inj Paracetamol 3 x 300 mg
LITERATURE
Scalp
 Traumatic Brain Injury
Non degenerative, non congenital insult to the brain from
an external mechanical force, possibly leading to
impairment of cognitive, physical, and psychosocial
functions, with an associated diminished or altered state
of consciousness
 Hemiparesis
Weakness of one entire side of
the body. The affected siide of
the body can still move, but
there are reduced of muscle
strength
 Aphasia
Aphasia is an impairment of language, affecting the
production or comprehension of speech and the ability to
read or write. It result from demage to the parts of the
brain that contain language (typically in the left half of the
brain)
Types of aphasia
1. Aphasia Motoric / broca
2. Aphasia Sensoric / Wernick
3. Aphasia Fasciculus / Conduction