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    Main Complaint: Condition

    Uploaded by

    Myra Miera
    A 13-year-old male patient presented with a headache after a traffic accident where he was thrown from his motorcycle after being struck from behind. He had events of vomiting and unconsciousness before arriving at the hospital. A physical exam revealed tenderness and hematoma on the right orbital region. Head CT scan showed an extradural hematoma and subdural hematoma on the right temporofrontal region. The patient underwent a craniectomy procedure to evacuate the hematomas and address a depressed skull fracture. His post-op diagnosis was mild head injury and hematomas on the right temporofrontal region. His prognosis was good and he was to be monitored for vital signs and Glasgow Com

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    Main Complaint: Condition

    Uploaded by

    Myra Miera
    43 views12 pages
    A 13-year-old male patient presented with a headache after a traffic accident where he was thrown from his motorcycle after being struck from behind. He had events of vomiting and unconsciousness before arriving at the hospital. A physical exam revealed tenderness and hematoma on the right orbital region. Head CT scan showed an extradural hematoma and subdural hematoma on the right temporofrontal region. The patient underwent a craniectomy procedure to evacuate the hematomas and address a depressed skull fracture. His post-op diagnosis was mild head injury and hematomas on the right temporofrontal region. His prognosis was good and he was to be monitored for vital signs and Glasgow Com

    Original Description:

    EDH

    Original Title

    EDH

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    A 13-year-old male patient presented with a headache after a traffic accident where he was thrown from his motorcycle after being struck from behind. He had events of vomiting and unconsciousness before arriving at the hospital. A physical exam revealed tenderness and hematoma on the right orbital region. Head CT scan showed an extradural hematoma and subdural hematoma on the right temporofrontal region. The patient underwent a craniectomy procedure to evacuate the hematomas and address a depressed skull fracture. His post-op diagnosis was mild head injury and hematomas on the right temporofrontal region. His prognosis was good and he was to be monitored for vital signs and Glasgow Com

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    43 views12 pages

    Main Complaint: Condition

    Uploaded by

    Myra Miera
    A 13-year-old male patient presented with a headache after a traffic accident where he was thrown from his motorcycle after being struck from behind. He had events of vomiting and unconsciousness before arriving at the hospital. A physical exam revealed tenderness and hematoma on the right orbital region. Head CT scan showed an extradural hematoma and subdural hematoma on the right temporofrontal region. The patient underwent a craniectomy procedure to evacuate the hematomas and address a depressed skull fracture. His post-op diagnosis was mild head injury and hematomas on the right temporofrontal region. His prognosis was good and he was to be monitored for vital signs and Glasgow Com

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 12

    No.

    Nam
    : Ch. A
    Sex
    : Male
    e
    13 years No.
    Age :
    : 628035
    old
    Reg
    Main complaint : Headache
    Condition
    : The condition had been apparent for 1 day due to traffic
    accident before the patient taken to the hospital. There
    were events of vomitting and unconsciousness. Previous
    medical care was carried out at Bantaeng Hospital.
    Mechanism of
    injury

    : The patient was carried by motorcycle, when suddenly


    another motorcycle going front direction struck him. He
    was thrown from the motorcycle and landed head first
    onto the road.
    Sustained Injury : Head
    Symptom & sign : Headache
    Examination
    : Physical examination, Head CT Scan, Skull AP/Lat,
    done
    Thorax X-ray

    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear
    B: RR: 24x/minutes, spontaneous, symmetric,
    thoraco abdominal type
    C: BP: 110/60 mmHg, PR: 96x/minute, regular,
    adequate
    D: GCS 15 (E4M6V5), pupil equal 2,5 mm/2,5
    mm, Light Reflex +/+
    E: T (ax): 36,5 oC

    Secondary Survey
    Right olrbital region :
    I : Hematome (+), Edema (+)
    P : Tenderness (+), Crepitation (-)
    Mentalis region:
    I : Seen stitched wound size 1 cm,
    edema (-), hematome (-)
    P : Crepitation (-)

    Laboratory Result
    WBC

    18,11 x 103 / L

    RBC

    4,07 x 106 / L

    HGB

    12,5 g/dL

    HCT

    34,1 %

    PLT

    277x 103/ L

    CT / BT

    800 /200

    Blood Sugar

    115 mg/dl

    Ureum

    25 mg/dl

    Creatinin

    0,7 mg/dl

    GOT / GPT

    59/29 /L

    Skull X-Ray

    Head CT scan

    WORKING
    DIAGNOSIS

    : - Mild head injury GCS 15

    MANAGEMENT

    : O2

    (E4M6V5)
    - EDH at Right Temporofrontal
    Region
    - SDH at Right Temporofrontal
    Region

    Apply IVFD
    Medicaments
    Consult to senior Neuro
    Surgeon
    Advice: Proceed Craniectomy

    Operating Procedure
    Patient laid supine under GA
    Disinfection and drapping procedure
    Extend the incision from lacerated wound, deepen
    until pricranium
    Identificate, seen depressed fracture at parietal
    region with fracture segment break the duramater
    Perform 1 burrhole, extend with knable tang, seen
    hematom 15 cc
    Evacuate hematom and fracture segment, bleeding
    control, hanging dura and apply fibrin glue
    Close wound layer by layer with 1 vacuum drain
    Operation finished

    POST OP
    DIAGNOSIS

    : - Mild Head Injury GCS 15

    PROGNOSIS

    : Good

    FOLLOW UP

    : Vital sign, GCS

    (E4M6V5)
    - EDH at Right Temporofrontal
    Region
    - SDH at Right Temporofrontal
    Region

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