CASE REPORTMonday, October 13rd 2014

Team on duty:dr. Fachrul Razidr. Nizarlidr. Rynaldi Andriansyadr. Lea Darman S. Husendr. Jauhari Deslo Angkasa Wijayadr. Sumrahadi Manurungdr. Zumirda Zainaldr. Muhammad Rezadr. Yoki Oktadi

I. Patient identity • Name : Sofyan • Age : 35 years old• Sex : Male • Address : Ds.Tuwi Kareung , Kec. Panga, Aceh Jaya • MR : 1-02-25-72 • Phone : 085358750221 • Patient came at : 10.30 PM• Driving license : (+)

II. Chief complain Headache after trauma

III. Patient illnes history

The patient came to Zainoel Abidin emergency room with a chief complain headache after trauma since 13 hours ago. He was riding motorcycle without helmet and suddenly headlong by buffalo rampage on its head. History of nausea and vomit (-), history of decrease of consciousness (-)

IV. Physical Examination Primary Survey : A : Clear B : Spontaneous, RR: 20 breaths/ minuteC : Pulse: 85 beats/minute, Blood Pressure: 120/80 mmHgD : GCS : E4M6V5 : 15; isochoric pupil, Ø 3mm/ 3mm no lateralization, light reflex (+/+)

E : L/S ar left temporal region :

L : hematoma (+), oedema (+), sutured wound (+) size 8 x 1 cm F : Pain (-)

Visus : in normal limit

Secondary surveyHead : L/S ar left temporal region :

L : hematoma (+), oedema (+), wound (+) F : Pain (-)

Visus : in normal limit Neck : In normal limitedThorax : In normal limitedAbdomen : In normal limitedPelvis : In normal limitedLower limb : In normal limited

V. Assessment : 1. Mild head injury 2. Excoriated wound at the left temporoparietal region

VI. Management • Stop oral intake• Head up 30 ° • Oxygen 7 litre via facemask • IVFD NaCl 0,9% 20 drips/minutes • Urinary catheter • Ceftriaxone inj. 1 gr • Ketorolac inj. 30 mg• Laboratory examination• Radiology examination

VII. Laboratory result Hb : 15,3 gr/dl White blood count : 14.500 /ul Platelet : 178.000 /ul CT : 7 minute BT : 2 minute Ht : 45 % Ureum : 23 mg/dl Creatinin : 0,90 mg/dl

VIII. Radiology result Head CT-Scan :

• There was SCALP hematoma at left temporoparietal • There was depressed fracture at the left temporal region • Sulcus and gyrus was narrow • There was hypodense/ hyperdense area • Ventricle and cysterna system normal • There was no midline shift.

IX. Diagnose

1. Mild head injury2. Excoriated wound at the left temporoparietal region3. Open depressed fracture at the left temporal region

X. Consult to Neurosurgery Division

Craniotomy elevation depressed fracture

XI. Operative Report • Patient was supine position, extended to the right side, head up 300, with general

anesthesia • Performed horse shoe incision at the left temporoparietal region, incision layer by

layer until bone • Identified depressed fracture at the left temporal region • Performed one burr hole• Performed elevation depressed fracture • Performed one tube drain

XII. Diagnose 1. Mild head injury (ICD 10 CM S.06) 2. Excoriated wound at the left temporoparietal region3. Open depressed fracture at the left temporal region (ICD 10 CM S.02)

XIII. Follow upDate S O A P

15/10/2014 POD II

Pain (-)

Vital signGCSBP : 120/80 mmHgHR : 80 beats/minuteRR : 20 breaths/minuteTemp : oCL/S left temporal region : Drain L : hematoma (+), gauzeF : Pain (-)Urin output

1. Mild head injury (ICD 10 CM S.06)

2. Excoriated wound at the right temporoparietal region

3. Open depressed fracture at the left temporal region (ICD 10 CM S.02)

Post Elevation depressed fracture

Head up 30 ° Oxygen 7 litre via facemask IVFD NaCl 0,9% 20 drips/minutes Ceftriaxone inj. 1 gr Ketorolac inj. 30 mg