Mild head injury + Open depressed fracture of the frontalis sinus
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Transcript of Mild head injury + Open depressed fracture of the frontalis sinus
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8/11/2019 Mild head injury + Open depressed fracture of the frontalis sinus
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Bedah Saraf
Mild head injury + Open depressed
fracture of the frontalis sinus
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8/11/2019 Mild head injury + Open depressed fracture of the frontalis sinus
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Patient identity
Name : Zulfahmi
Age : 23 years old
Sex : Male Address : Pesantren darul
hijrah,
Samahani, Aceh Besar
MR
: 987808
Phone : 085260422626
Drive license : (-)
Patient came at: 09.00 AM
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Chief complaintDecrease of consciousness
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Patient illnes historyThe patient was referred from private clinic to ZainoEmergency Room with decrease of consciousness for 1 houcomplaint started when he was riding motorcycle withoand suddenly strucked with another motorcycle from besidthen his head hit to the asphalt. History of decrease of cons(-). History of nausea and vomiting (+).
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Physical examination
Primary survey :
A: Clear
B: Spontaneous, RR: 20 breaths/ minute, C: Pulse 82 beats/minute, Blood Pressure:
110/80 mmHg
D: GCS: 14 (E3M6V5) ; isochoric pupil Right3mm/ Left 3mm,
E:
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L/S at the right frontal region
L: Wound (-), Swelling (+)
F: Deformity (+)
L/S at the upper face region
L: Hematoma (+), Edeme(+)
L/S at the mid face region
L: Swellling (-)
F: maxilla floating (+)
L/S at the lower face region
L: Swelling (-)
F: mandible floating (+)
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Assessments:Mild head injury + Maxillofacial fracture (Le Fort II) + Mandfracture
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Management
Stop oral intake
Head up 30
Oxygen 4 litre via canule
IVFDNaCl 0,9 % 20 drips/minutes
Urinary Catheter
Ceftriaxone inj. 1 gr
Metamizol Sodium inj 1 gr
Laboratory examination Radiology examination
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Laboratory result Hb
: 11,8 gr/dl
White blood count : 8.500 /ul
Platelet : 239.000 /ul
CT : 7 minute
BT : 2 minute Ht : 35 %
Blood glucose ad random: 98 mg/dl
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Radiology result
Head CT-Scan:
SCALP hematome ar the frontal region
There was depressed fracture at the right frontalregion
Sulcy and gyrus in normal limit
Ventricle and cysterna system in normal limit
There was no midline shift.
Scheddle AP / Lat
Parasymphisis of mandible fracture
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8/11/2019 Mild head injury + Open depressed fracture of the frontalis sinus
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8/11/2019 Mild head injury + Open depressed fracture of the frontalis sinus
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8/11/2019 Mild head injury + Open depressed fracture of the frontalis sinus
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Diagnose:Mild head injury + Open depressed fracture of the frontalis Maxillofacial fracture (Le Fort II) + Parasymphisis mandible fAnemia
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Consult to Neurosurgery Division :Craniotomy depressed fracture elevated
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Consult to Plastic surgery ORIF Elective
Head CT 3D
Oral hygiene
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Intra operative
Patient in supine position, head up 300 with general anesthesia.
Performed aseptic and anti septic procedure
Performed linear incision at the frontal until bone
Identified depressed fracture at the anterior and posterior wall of frontalsinus
Irrigated wound with perhydrol 3% + povidone iodine 10% + normal salin0,9 %
Bone was removed with canable
Duramater intact and not tension
Performed decortication
Bleeding control
Bone was returned with mozaic position Wound closed by primary suture.
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Post Operative diagnose
Mild head injury (ICD 10 CM S.06) + Open depressed fractfrontalis sinus (ICD 10 CM S.06) + Maxillofacial fracture ((ICD 10 CM S.06) + Parasymphisis mandible fracture (ICS02.60) + Anemia (ICD 10 CM D50)
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8/11/2019 Mild head injury + Open depressed fracture of the frontalis sinus
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Date S O A P
22/1/2014
POD I
Pain
(-)
VS/
BP : 110/70
mmHgPulse: 80
beats/mnt
RR:20
breaths/minute
GCS : E4 M6 V5
= 15
isochoric pupil
Mild head
injury (ICD 10
CM S.06) +Open
depressed
fracture of the
frontalis sinus
(ICD 10 CM
S.06) +
Maxillofacial
fracture (LeFort II) (ICD
10 CM S.06) +
Parasymphisis
mandible
fracture (ICD
10 CM S02.60)
+ Anemia (ICD
10 CM D50)
IVFD NaCl 0,9 % 30
drips/minutes
Ceftriaxone inj 2g/24hours
Ranitidin inj 25 mg
/12 hours
Metamizol Sodium 1
gr/8 hours
Liquid diet 6 x 100 cc
Oral hygiene