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    CASE REPORT (23.00) : No. CM Name Age/Sex Diagnose Therapy Inpatient/Outpatient

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    Alvin Pratama
    A 50-year-old male was admitted to the hospital after a motorcycle accident. He suffered a mild head injury, lacerations to the back of his head and right foot, and a suspected skull base fracture. His Glasgow Coma Scale was 15. He received sutures, oxygen supplementation, intravenous antibiotics and analgesics, and was admitted for observation of his head injury.

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    CASE REPORT (23.00) : No. CM Name Age/Sex Diagnose Therapy Inpatient/Outpatient

    Uploaded by

    Alvin Pratama
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    A 50-year-old male was admitted to the hospital after a motorcycle accident. He suffered a mild head injury, lacerations to the back of his head and right foot, and a suspected skull base fracture. His Glasgow Coma Scale was 15. He received sutures, oxygen supplementation, intravenous antibiotics and analgesics, and was admitted for observation of his head injury.

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    A 50-year-old male was admitted to the hospital after a motorcycle accident. He suffered a mild head injury, lacerations to the back of his head and right foot, and a suspected skull base fracture. His Glasgow Coma Scale was 15. He received sutures, oxygen supplementation, intravenous antibiotics and analgesics, and was admitted for observation of his head injury.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    19 views7 pages

    CASE REPORT (23.00) : No. CM Name Age/Sex Diagnose Therapy Inpatient/Outpatient

    Uploaded by

    Alvin Pratama
    A 50-year-old male was admitted to the hospital after a motorcycle accident. He suffered a mild head injury, lacerations to the back of his head and right foot, and a suspected skull base fracture. His Glasgow Coma Scale was 15. He received sutures, oxygen supplementation, intravenous antibiotics and analgesics, and was admitted for observation of his head injury.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 7

    No.

    CM Name Age/Sex Diagnose Therapy Inpatient/Outpatient

    1. 397347 Ahmad tafsir 50 y.o/ Mild Head Injury (GCS : Head up 30ᵒ Inpatient
    M E4M6V5 -15)
    Oxigenation 4 lpm (nasal
    multiple laceration canule)
    wound (regio occipital et
    Inf RL 20 dpm
    dorsum pedis dextra)
    sutured Inj Ceftriaxone 1g/24h i/v
    Clinical skull base Inj Ketorolac 30mg/12h
    fracture on right medial
    fossa Inj Ranitidin 50mg/12h

    Et causa traffic light Inj Ondansetron 4mg/8 jam


    accident 4 hours ago Observation

    CASE REPORT (23.00)

    50 years old male came to ER post road accident 4 hours ago

    PRIMARY SURVEY

    Airway & C-spine control

    Voices loud and clear Airway patent

     Cervical Collar

    Breathing

    RR : 20x/minute

    Thorax :

    I : Static : right hemithorax = left hemithorax

    Dinamic : right hemithorax = left hemithorax

    P : Tactile fremitus right = left

    P : Sonor all around area

    A : Vesikuler basic sound, additional sound (-)

    Circulation & Control haemorrage

    HR : 98 bpm

    BP : 140/90 mmHg

    Ear bleeding

    Dissability

    GCS E4M6V5 : 15

    Pupil isocor 3mm . Light Reflex (+/+)


    Exposure

    Wound on thorax (-)

    Wound on abdomen (-)

    • Chief complain : Pain in the head

    • ± 2 hours prior to hospital admission, patient involved in a road accident. He was riding
    motorcycle , and crashed with another motorcycle from another side of the road. Patient fell
    backwards with his head hitting the road. Patent were still conscious, there was no vomitting
    nor blurry vision. Got s

    • Patient complained about pain in the head. The pain is persisting and feel worse when the
    head is touched or given pressure. Patient got hospitalized in Puskesmas. Patient received
    several sutures in the back of the head and left foot. Patient vomitted twice, consist of food
    and blood. Patient bwas told that he suffered from Mild Head Injury and being refffered to
    RSUD Batang for further observations.

    PE :

    General Condition :

    Moderately ill

    VS :

    RR : 22x/mnts

    HR : 98x/mnts

    BP : 140/90 mmHg

    t : 36,5 ºC (A)

    Pain : 4 VAS

    BW : 60 kilograms

    Consciousness : composmentis, GCS E4M6V5=15

    Head/Neck : - Equal pupil Ø 3 mm, LR +/+

    - Conj. palp wasn’t anemic

    - Right ear : bleed (+) halo sign (-)

    Chest :

    Heart :

    I : IC cannot be seen

    P : IC palpable on SIC IV, ± 2 cm medial LMCS

    P : Configuration wnl
    A : Basic sound wnl

    Lungs :

    I : Static : right hemithorax = left hemithorax

    Dinamic : right hemithorax = left hemithorax

    P : Tactile fremitus right = left

    P : Sonor all around area

    A : Vesikuler basic sound, additional sound (-)

    • Abdomen :

    I : Distended, bowel pattern/movement (-)

    P: Tenderness (-), DM (-)

    P: Tympanic, liver dullness (+), flank dullness (+) N, shifting dullness (-)

    A: Bowel sound (+) increased, metallic sound (-)

    • Extremity Sup Inf

    Cold acral -/- -/-

    Motoric 555/555 555/555

    Sensoric +/+ +/+

    Local state

    Head

    I : wound (+) sutured and bandaged, seepage of blood (+)

    P: tenderness (+)

    Local state
    Pedis

    I : wound (+) sutured and bandaged,swelling (-) seepage of blood (-)

    P: tenderness (+) , step of deformity (-)

    Local state

    Ear

    I : wound (+), swelling(-), redness(-)

    P: tenderness (+) , Step of deformity (-)

    Working Diagnose :
    • Mild Head Injury (GCS : E4M6V5 -15)

    • Multiple vulnus laceration (regio occipital et dorsum pedis dextra) sutured

    • Clinical skull base fracture on right medial fossa

    • Et causa traffic light accident 4 hours ago

    Initial Management :

    - IpDx :

    S : Complain of nausea, Pain

    O : Scale of Consciousess (GCS)

    IpTx :

    Head up 30ᵒ

    Oxigenation 4 lpm (nasal canule)

    Inf RL 20 dpm

    Inj Ceftriaxone 1g/24h i/v

    Inj Ketorolac 30mg/12h

    Inj Ranitidin 50mg/12h

    Inj Ondansetron 4mg/8 jam

    Observation

    - IpMx :

    Complaint, Consciousness, Vital signs

    - IpEx :

    – Informed consent :

    • To explain the patient that there might be fracture t the back of the skull

    • To explain the patient and the family to mmediately tell doctors or nurses if
    patient feels worse

    • To explain the patients and the family to tell the doctors if patients start to
    rumble and being disoriented
    Duty
    Report
    Friday, 28th
    September 2018

    Presented by :
     Yanuarius Alvin Pratama Budianto
     Adzzahra Dzakiyah

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