morep bedah 25 agustus 2014 cob

8/11/2019 Morep Bedah 25 Agustus 2014 COB

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Department of Surgery

Aug 26, 2014


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Name : Mrs. WAge : 19 y.o

Sex : femaleAddress : TubanDate examination: aug 25, 2014


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ANAMNESIS

Chief complaint

loss of consciousness

MOI

Patient came referral from Bojonegoro Aisyiah Hospital with

loss of consciousness post traffic accident four hours before

addmision into the hospital. patients was riding motorcyle

and was hit by a motorcycle. Patient fell with head hit theasphalt, History unconsiousness +, vomit 2x . Helmet (-).

seizure-, short of breathness -, rhinorea -, otorea-


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Airway and spine control : clear (+), snorring (-), gargling (-), potensial obstruction (+) pasang OFT, cervical collarBreathing : spontan, simetric (+), RR24x/minutes, ves/ves, rh-/-, wh-/-Circulation : PR 86x/minutes, acral warm dryred, CRT < 2, Sp02 98% with O2 support, BP126/62 mmhgDisability : GCS 125, LP + weak/+, isocor pupil3mm/3mm, lateralisasi-Exposure : temp 37,1 C


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Regio temporoparietal dex: scalp hematomdex 4cmx3cmx3cm

regio temporal dex: vul scissum + hematom1cmx0,5cmx0,5cm

Regio femur dextra: hematom 2cmx2cm


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Assesment

severe brain injury


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CBC CT-BT

GDA RFT CT Scan skull

X-ray thorax AP X-Ray cervical AP/L


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CBC

Diff 3/1/91/4/1Hct 36,1Hb 11,7Lekosit 19600Trombosit 216.000GDA 153BT 200 CT 800


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CT Scan


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CT Scan


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Thorax


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Assesment

severe brain injurySDH

ICH


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IVFD Assering 1500 cc/24 hours Head up 30 02 nrm 10 lpm Kateter foley

Inj.Metamizole 3x1 g i.v Inj. Ranitidin 2x50mg i.v Inj. Piracetam 4x3g i.v Inj. citicolin 3x250mg i.v Inj manitol 200cc 6x100mg

Inj kutoin 400mg 3x100mg Inj terfacef 2 g pre op C/Sp.BS


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Subjective complaintVital sign

sign of increased pressure intracranial


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Explain to the patients family about thediagnosis, etiology, intervention of therapy,complication, and prognosis.

morep bedah 25 agustus 2014 cob

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