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    Morep Bedah 20 January 2015

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    Rachma Susteriana Putri
    1) A 21-year-old female presented to the hospital after a motorcycle accident with loss of consciousness, bloody vomiting, and bloody otorrhea. 2) Examination revealed a 5cm hematoma on the right parieto-occipital region of the head and a Glasgow Coma Scale of 12. 3) CT scan showed signs of moderate brain injury including contusions, and her treatment plan included IV fluids, medications, and close monitoring for increased intracranial pressure.

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    Morep Bedah 20 January 2015

    Uploaded by

    Rachma Susteriana Putri
    18 views20 pages
    1) A 21-year-old female presented to the hospital after a motorcycle accident with loss of consciousness, bloody vomiting, and bloody otorrhea. 2) Examination revealed a 5cm hematoma on the right parieto-occipital region of the head and a Glasgow Coma Scale of 12. 3) CT scan showed signs of moderate brain injury including contusions, and her treatment plan included IV fluids, medications, and close monitoring for increased intracranial pressure.

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    morep bedahh

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    1) A 21-year-old female presented to the hospital after a motorcycle accident with loss of consciousness, bloody vomiting, and bloody otorrhea. 2) Examination revealed a 5cm hematoma on the right parieto-occipital region of the head and a Glasgow Coma Scale of 12. 3) CT scan showed signs of moderate brain injury including contusions, and her treatment plan included IV fluids, medications, and close monitoring for increased intracranial pressure.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    18 views20 pages

    Morep Bedah 20 January 2015

    Uploaded by

    Rachma Susteriana Putri
    1) A 21-year-old female presented to the hospital after a motorcycle accident with loss of consciousness, bloody vomiting, and bloody otorrhea. 2) Examination revealed a 5cm hematoma on the right parieto-occipital region of the head and a Glasgow Coma Scale of 12. 3) CT scan showed signs of moderate brain injury including contusions, and her treatment plan included IV fluids, medications, and close monitoring for increased intracranial pressure.

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    Download as ppt, pdf, or txt
    of 20

    Department of Surgery

    January, 20 2015

    DAFTAR OB
    Tn Abdul rohman
    mandibula
    Nn Akhadiyah
    Tn Suheri
    open
    1/3 medial

    Susp fraktur
    COS
    Fr mandibulae,
    fraktur cruris

    Name : Mrs. A
    Age
    : 21 y.o
    Sex
    : Female
    Address
    : Tikung, Lamongan
    Date examination: january 20, 2015

    ANAMNESIS

    Chief complaint

    loss of consciousness
    MOI
    Patient came with loss of consciousness post traffic
    accident 30 minutes before addmision into the hospital.
    According to a witness in an accident , the patient 's own
    fall from the motorcycle due to slippery roads sandy .
    patients on a motorcycle at moderate speed .Patient is
    using a helmet but apart, History unconsiousness +,
    vomiting blood mixed with the food one time when in
    hospital Bloody otorrhea (+), Nausea-, seizure-, short of
    breathness -. The patients look fidgeted.

    History illness
    Alergy-, DM-, HTFamily illness :
    (-)
    Social history :
    (-)

    PHYSICAL EXAMINATION
    VITAL SIGN :
    GCS
    BP
    PULSE RATE
    TEMP
    RR

    :
    :
    :
    :
    :

    225
    145/69 mmHg
    95 x/minutes
    36,2oC
    23 x / minutes

    PRIMARY SURVEY

    Airway and spine control : clear (+),


    snorring (-), gargling (-), potensial
    obstruction (-)
    Breathing : spontan, simetric (+), RR
    23x/minutes, ves/ves, rh-/-, wh-/-, Sp02 98%
    Circulation : PR 95x/minutes, acral warm
    dry red, CRT < 2, BP 145/69 mmhg
    Disability : GCS 225, LP +/+, isocor pupil
    3mm/3mm, lateralisasi Exposure : temp 36, 2C

    Head and neck : anemic (-), icteric (-), cyanosis


    (-), dyspneu (-). Diplopia-. Lession + hematom
    parieto occipital dex with diameter 5 cm
    Thorax : simetric (-), retraction (-)
    Pulmo : ves/ves, rh-/-, wh-/Cor : S1S2 single, murmur (-), gallop (-), lession
    Abdomen : flat, distended (-), tympani (+), liver
    and spleen were not palpable, bowel sound (+),
    lession Extremities : acral warm, dry, red, lession-

    et regio parieto occipital dex :


    Lession + hematom parieto occipital
    dex with diameter 5 cm

    Clue and cue

    Female, 21 y.o
    loss of consciousness
    Post traffic accident
    Bloody vomit
    Bloody otorrhea
    Regio parieto occipital dex :hematom with
    diameter 5 cm

    Early Assesment
    Moderate brain injury

    CBC
    CT-BT
    GDA
    CT Scan
    Thorax AP

    CBC
    Diff 3/2/49/44/2
    Hct 33,8
    Hb 11,0
    LED 5/11
    Lekosit 17.100
    Trombosit 430.000
    BT 130
    CT 730

    CT SCAN

    CT Scan

    FOTO THORAX

    Assesment
    moderate brain injury
    Contusio cerebri

    IVFD Assering 1500 cc/24 hours


    Head up 30
    02 nrm 8 lpm
    Inj.Metamizole 3x1amp
    Inj. Ranitidin 2x50mg
    Inj. Ceftriaxon 2x1 gr IV
    Inj. Mersitropil 4x3 gr IV
    Inj manitol 200cc6x100mg
    Inj kutoin 400mg 3x100mg
    C/Sp.BS

    Subjective complaint
    Vital sign
    sign of increased pressure
    intracranial

    Explain to the patients family about


    the diagnosis, etiology, intervention
    of
    therapy,
    complication,
    and
    prognosis.

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