CASE REPORTWednesday, October 1st 2014

Team on duty: dr. Fachrul Razidr. M.Nazir Tambunandr. Rynaldi Andriansyadr. Lea Darman Huseindr. Jauhari Deslo Angkasa Wijayadr. Sumrahadi Manurungdr. Zumirda Zainaldr. Muhammad Rezadr. Yoki Oktadi

I. Patient Identity Name : Hasbi Age : 43 years oldSex : Male Address : Desa Cot Jabet,kec. Ganda Pura,Bireuen MR : 1-20-11-32 HP : 082360737533 Driving license : (-) Patient came at : 09.46 PM

II. Chief Complain :

Decrease of consciousness

III. Present illness historyThe patient came to Zainoel Abidin emergency room with decrease of consciousness for 10 hours ago. The patient was riding motorcycle and he strucked by another motorcycle from behind of him. There was no history of nausea, vomitting (+), history of lucid interval (-). History of diabetes mellitus (+)

IV. Physical examination Primary Survey • A: clear• B: spontaneous, RR: 22 breaths/ minute• C: Blood pressure : 110/70 mmHg,Pulse: 96 beats/minute• D: GCS: 12 (E3 M5 V4); isochoric pupil (L/R) Ø 3mm/3mm, lateralization (-)• E :

L/S at the head region :• I : wound 2 cm, deformity (-)• P : discontinuity of bone (-)

Secondary survey• At the Head

I : wound 2 cm, deformity (-)P : discontinuity of bone (-)

• Neck : in normal limit• Thorax : in normal limit• Abdomen : in normal limit• Pelvis : in normal limit• Upper extremity : in normal limit• Lower extremity : in normal limit

V. Assessment1.Moderate Head Injury 2.Diabetes Mellitus type II

  VI. Management

Head up 30 ° Oxygen 8 litre via face mask NGT Urinary catether IVFD NaCl 0,9% 20 drips/minutes Inj. Ceftriaxone 1 gram Inj. Ketorolac 30 mg Inj. Tetagam 250 IU Laboratory examination Radiology examination

VII. Laboratory result• Hb : 17.0 gr/dl• White blood count : 27.200 /ul • Platelet : 325.000 /ul • CT : 6 minute• BT : 2 minute• Ht : 49% • Blood glucose ad random : 421 mg/dlàregulation of blood glucose

VIII. Radiology resultHead CT-Scan: SCALP haematoma at the right temporal region There was linear fracture at the right temporalat the bone window Sulcus gyrus was narrow There was hyperdense area abnormal at the left temporal à ICH Cysterna and ventricle system was normal No midline shift

IX. Diagnose

1. Moderate head injury 2. ICH at the left temporal region 3. Linear fracture at the right temporal region 4. Diabetes Mellitus Type II

X. Consult to Neurosurgery division Craniotomy evacuation ICH emergency

Consult to Endocrinology departement : Regulation of blood glucose

 XI Intraoperative

• Question mark incision• Performed 6 burrhole • Identified SDH and ICH at the left temporal• Duraplasty• Bone keep at subgaleal

XII. Post Operative Diagnosed 1. Moderate head injury (ICD 10 CM S09.90) 2. ICH at the left temporal region (ICD 10 CM I61.0)3. SDH at the left temporal region (ICD 10 CM 4. Linear Fracture at the right temporal region (ICD 10 CM S02.0) 5. Diabetes Mellitus Type II (ICD 10 CM E11)

XII Follow UpDate S O A P

3/10/2014 POD 2

- VS/ GCS : E2 M5 V2BP : 120/80 mmHg Pulse: 80 beats/mnt RR: 16 breaths/minute GCS : E4 M6 V5Isochoric pupil Sat O2 100 % Temp 36,2 oC

Urin Output : 50 cc/hour

Drain : 150 cc serous hemorrhagic

1. Moderate head injury (ICD 10 CM S09.90)

2. ICH at the left temporal region (ICD 10 CM I61.0)

3. SDH at the left temporal region (ICD 10 CM

4. Linear Fracture at the right temporal region (ICD 10 CM S02.0)

5. Diabetes Mellitus Type II (ICD 10 CM E11)

Ward in HCUHead up 30o Oxygen 8 litre via face maskIVFD NaCl 0,9% 15drips/minutes Ceftriaxone inj 1 gram/24 hr Metamizole sodium inj 1 gr/ 8 hr