Trauma Case Presentation
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Transcript of Trauma Case Presentation
7/26/2019 Trauma Case Presentation
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CASE REP RT
BRAGASTIO SIDHARTA
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Patient Identity
• Name : Mr. S• Age : 13 y
• MR n. : !1."3.#!.$$• O%%&'atin : (t&dent
• Addre(( : Peni Pa)*a'ang Bant&)
• Date + ,i(ite : A'ri)- " "!!
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Anamne(i(
• C/ie+ Cm')aint: Pain n t/e rig/t eye(
• Hi(try + 're(ent i))ne((:
T/ree /&r( *e+re admi((in- /e 0ent a)ngmtr%y%)e 0it/&t /e)met. He +e)t d0n. He
/ad /it gr&nd. He +e)t 'ain in /i( eye. T/ere
0a( &n%n(i&(ne((-na&(e and ,mit. He %amet Bant&) /('ita) and re+ered t Sarit
/('ita)
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Genera) E2aminatin
• Genera) %nditin : &n%n(i&(ne((
• B)d 're((&re : 11!4! mmHg
• P&)(e : 5! 2min&te
• Re('iratin : "! 2min&te
• Tem'erat&r : 34 C
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%)ear )en( %)ear
%)ear
de+ine margin
a,:"3-%d:!-3*rig/t re+)e2 ;<
n
=&nd&(media
'a'i)
ma%&)a
Retina
%)ear
de+ine margin
a,:"3-%d:!-3*rig/t re+)e2 ;<
n
nrma) IOP nrma)+ree)y MO +ree)y
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• B>N : #-4 mgd)• Creatinin : !-#• B)d E2aminatin : G)&%(a : 11! gd)• ?BC : 3"-$• H* : 11-@ gd) T/ra2 PA : ?N9• P9T : 3#!• BT : "
• CT : • NaC) : 1@$ @-3 1!3• TP : 4-3@• A)*&min : 3-4$ gd)
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RESULT:
Fraktur calvaria/ os frontalis dextra until orbital rim dekstra
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S+t ti((&e (0e))ing in +rnt 'arieta) de2tra
=rat&r (.+rnta)e de2tra-'en +rat&r and t/e )atera) 0a)) r*ita
Brain 'r)a'( in de+e%t (.+rnta)e and *)eeding intra)e(i and'ne&men%e'/a)%e)e
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OPERATO! REPORT
• Se'ti% and a(e'ti% n t/e 'eratin area
0it/ *etadine ()&tin
• 9%a) (&*%&tan ana(te(i 0it/ )id%ain "
• ?&nd ti)et de*ridemant
• S&t&ring )ayer *y )ayer 0it/ %&tgat $.!
• S&t&red (&* %&tane&()y 0it/ 'r)en $.!
• S+trat&)e 0a( 'er+rmed
• C/)ram'/eni%) EO a'')ied
• Bandage
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P)ea(e gi,e me (me (&gge(tin( and
ad,i%e( +r +&rt/er management