Scribd Logo
Upload

Welcome to Scribd!

  • 32 views

    Duty Report Saturday, July19 2014: Resident in Charge: Dr. Wahyu R Wibowo

    Uploaded by

    Chintya Ayu Champaka
    This document summarizes the duty report from July 19th, 2014. There were 2 outpatients seen for laceration wounds and 1 patient hospitalized. The hospitalized patient is a 31 year old pregnant woman who was in a motorcycle accident and experienced head pain and vomiting. A head CT scan showed a subgaleal hematoma on the right temporal-parietal region and contusions on the left frontal and temporal pole. Her diagnoses included mild head injury and pregnancy. She was treated conservatively and discharged in a stable condition.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd

    Duty Report Saturday, July19 2014: Resident in Charge: Dr. Wahyu R Wibowo

    Uploaded by

    Chintya Ayu Champaka
    32 views20 pages
    This document summarizes the duty report from July 19th, 2014. There were 2 outpatients seen for laceration wounds and 1 patient hospitalized. The hospitalized patient is a 31 year old pregnant woman who was in a motorcycle accident and experienced head pain and vomiting. A head CT scan showed a subgaleal hematoma on the right temporal-parietal region and contusions on the left frontal and temporal pole. Her diagnoses included mild head injury and pregnancy. She was treated conservatively and discharged in a stable condition.

    Original Description:

    contoh laporan jaga

    Original Title

    19 July 2014 Dr.wahyu

    Copyright

    © © All Rights Reserved

    Available Formats

    PPT, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document summarizes the duty report from July 19th, 2014. There were 2 outpatients seen for laceration wounds and 1 patient hospitalized. The hospitalized patient is a 31 year old pregnant woman who was in a motorcycle accident and experienced head pain and vomiting. A head CT scan showed a subgaleal hematoma on the right temporal-parietal region and contusions on the left frontal and temporal pole. Her diagnoses included mild head injury and pregnancy. She was treated conservatively and discharged in a stable condition.

    Copyright:

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

    Duty Report Saturday, July19 2014: Resident in Charge: Dr. Wahyu R Wibowo

    Uploaded by

    Chintya Ayu Champaka
    This document summarizes the duty report from July 19th, 2014. There were 2 outpatients seen for laceration wounds and 1 patient hospitalized. The hospitalized patient is a 31 year old pregnant woman who was in a motorcycle accident and experienced head pain and vomiting. A head CT scan showed a subgaleal hematoma on the right temporal-parietal region and contusions on the left frontal and temporal pole. Her diagnoses included mild head injury and pregnancy. She was treated conservatively and discharged in a stable condition.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 20

    Duty Report

    th
    Saturday, July19 2014
    Resident in charge :
    dr. Wahyu R Wibowo

    Consultant in charge

    Digestive surgery

    Dr. Arief setiawan SpB(K)BD


    Urology surgery :

    Dr.Nindra P., SpU.


    Neuro surgery :

    Dr. Agus Aulia SpBS


    Oncology surgery :

    Dr.Ktristina Maria SpB


    Orthopaedic surgery :

    Dr. AB Mulyanto, SpOT


    Pediatric surgery :

    Dr. IrhamniSpBA
    Plastic surgery :

    Dr Asrofi,SpBP, MARS
    Cardiothoracic surgery :

    Dr. Dedi A Zaelani, SpB(K)BV

    Resume

    Outpatients : 2 patients
    Operations : 0 patient
    Hospitalized : 1 patient

    Outpatient

    Mr. Gerry, 35 y.o,

    WD: Laceration wound of the right


    lower leg region (ICD-10:S81.819)

    Mr. Anton, 32 y.o,

    WD: Laceration wound of the right


    foot region.
    (ICD-10:S81.819A)

    Nn.Nurlaili/ 31 yo

    Hispitalized

    CC :
    Patients felt pain on her head and vomite since 1 hour before
    admission
    HPI :
    1 hour hours before admission, patien had a motor vehicle
    accident while he was driving a motorcycle, she wore
    helmet. The mechanism of trauma was unknown, she was
    found by people arround and brought to GS Hospital.
    History of fainted (+), vomite(+) more than 2x. Patients felt
    pain on her head . There was hematoma wound on the right
    parietal region, no bleeding from ear nor nose.
    Patien is being pregnant 6 months (G3P1A1)

    Primary Survey :

    A : Clear
    B : Spontaneous, RR : 20 x/mnts , O2 saturation
    100 percent
    C : BP : 100/70 mmHg, HR : 96 x/mnts
    D : Alert with GCS = E4M6V4 : 14
    Pain score VAS : 5

    Secondary Survey :
    General condition
    Head: subgaleal hematome (+) at right parietooccipital
    Eye: anemic -/-, icteric -/-, Isocore pupil with diameter 3 mm.
    Chest: symmetric, vesicular +/+, rhonchi -/-, wheezing -/Heart: HS I-II normal, murmur (-), gallop (-)
    Abdomen: flat, supple, tenderness (-), bowel sound (+)
    Ekstremity: warm, CRT<2

    Local status :

    Head : There was hematoma


    wound on the parietal region, no
    bleeding from ear nor nose.
    Face : No excoriation , no
    laceration on hematom periorbita,
    no diplopia.
    No maloclutio, no floating maxilla.

    Neurological state:

    GCS E4M6V4=14

    isochor pupil, diameter 3 mm, light reflex of eye +/ +

    Motoric: 4 extremity are normaly active


    Sensoric : within normal limits

    Autonomic : within normal limits


    (BP : 100/70 mmHg, HR : 96 x/mnts RR 20x/mnts)

    Laboratory finding :

    within normal limits

    Chest and cevical X-ray finding :


    within normal limits

    Head CT-Scan

    Sub Galleal hematom on the right


    temporo-parietal region
    Contucio cerebri on the left frontal
    dan temporal pole.
    No intra cerebral bleeding
    No mid line reft,
    Normal gyrus and sulcus
    (No sing of Space Occpying P
    rocess finding)

    No Fracture of calvaria
    No Fracture of bone face

    Working Diagnosed:
    Mild head injury
    with Contucio cerebri on the left frontal and
    temporal pole.
    (ICD-10: S06.2X)
    Sub Galleal hematom on the right temporoparietal region
    (ICD-10: S00.T88)

    Pregnant 6 months (G3P1A1)

    (ICD-10: 000.09A)

    Treatment

    Antibiotic, Analgesic
    Anti odema cerebri
    Conserfative tratment of neuro Surgery
    Obsevation, If decrease of consciousness evaluation
    Re-Head CT Scan
    (Z51.81)

    Consultation to OBSGIN Depatement :


    good condition of her prengnacy
    (Z34.0)
    Anti uterus contraction : Duvadilan 2x1/2 tabets

    Today Condition :

    Stable condition, no dizzy , no vomite


    Pain score : 2

    Plan:

    Discharge to day

    Thank you

    GCS

    Indication CT Scan in Head Injuries


    Selection of adults for CT scan
    (NICE Clinical guideline (Jan 2014))

    CT scan of the brain within one hour (with a written radiology report
    within one hour of the scan being undertaken):
    Glasgow Coma Scale (GCS) <13 when first assessed or GCS <15 two
    hours after injury Suspected open or depressed skull fracture
    Signs of base of skull fracture*
    Post-traumatic seizure
    Focal neurological deficit
    >1 episode of vomiting
    All patients with a coagulopathy or on oral anticoagulants should have a
    CT brain scan within eight hours of the injury, provided there are no other
    identified risk factors, as listed above. Again, a written radiology report
    should be available within one hour of the scan being undertaken.

    Selection of children (under 16 years) for CT scan

    CT scan of the brain within one hour (with a written radiology report within one hour of the scan being undertaken):
    Clinical suspicion of non-accidental injury
    Post-traumatic seizure (no past medical history of epilepsy)
    GCS <14 on initial assessment or, if <1 year, GCS <15
    GCS <15 two hours after injury
    Suspected open or depressed skull fracture or tense fontanelle
    Signs of base of skull fracture*
    Focal neurological deficit
    Aged <1 - bruise, swelling or laceration >5 cm on the head
    If none of the above are present then CT brain scan within one hour if more than one of the following are present (with a written
    radiology report within one hour of the scan being undertaken):
    Witnessed loss of consciousness >5 minutes
    Amnesia (antegrade or retrograde) >5 minutes
    Abnormal drowsiness
    3 Discrete episodes of vomiting
    Dangerous mechanism of injury (high-speed RTA, fall from >3 m, high-speed projectile)
    If only one of the aforementioned risk factors is present then observe for a minimum of four hours - CT scan of the brain within
    one hour if any of the following occur (with a written radiology report within one hour of the scan being undertaken):
    GCS <15
    Further vomiting
    Abnormal drowsiness

    You might also like