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    Chief Complaint: History Taking: No. Name: Mr. H Sex: Male Age: 19 Years No. Reg: 653012

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    Mohamad Zulfikar
    1) A 19-year-old male presented with decreased consciousness for 8 days following a motorcycle accident where he lost control and hit his head on the ground. 2) Examination found a head injury with headache, CT scan showed a depressed skull fracture in the frontal area. 3) The patient underwent a craniectomy under general anesthesia to repair the depressed skull fracture.

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    Chief Complaint: History Taking: No. Name: Mr. H Sex: Male Age: 19 Years No. Reg: 653012

    Uploaded by

    Mohamad Zulfikar
    33 views8 pages
    1) A 19-year-old male presented with decreased consciousness for 8 days following a motorcycle accident where he lost control and hit his head on the ground. 2) Examination found a head injury with headache, CT scan showed a depressed skull fracture in the frontal area. 3) The patient underwent a craniectomy under general anesthesia to repair the depressed skull fracture.

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    tcr

    Original Title

    Harnes TCR

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    1) A 19-year-old male presented with decreased consciousness for 8 days following a motorcycle accident where he lost control and hit his head on the ground. 2) Examination found a head injury with headache, CT scan showed a depressed skull fracture in the frontal area. 3) The patient underwent a craniectomy under general anesthesia to repair the depressed skull fracture.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    33 views8 pages

    Chief Complaint: History Taking: No. Name: Mr. H Sex: Male Age: 19 Years No. Reg: 653012

    Uploaded by

    Mohamad Zulfikar
    1) A 19-year-old male presented with decreased consciousness for 8 days following a motorcycle accident where he lost control and hit his head on the ground. 2) Examination found a head injury with headache, CT scan showed a depressed skull fracture in the frontal area. 3) The patient underwent a craniectomy under general anesthesia to repair the depressed skull fracture.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 8

    No.

    Name : Mr. H Sex : Male


    Age : 19 years No. Reg : 653012

    Chief complaint : Decrease of consciousness

    History taking : This condition has been apparent for 8 days before
    admitted to the hospital due to head injury, he’s been
    awake in the last 4 days, History loss of consciousness
    (+) nausea (+) vomiting (-).
    Mechanism of : He was riding motorcycle in high speed, then he loose
    injury his balance and fall down with his head and face facing
    the ground.

    Injury sustain : Head, face


    Symptom & sign : Headache
    Examination : Physical examination, laboratory examination, head CT
    scan
    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear

    B: RR :18 x/minutes, spontaneous, symmetric, thoraco


    abdominal type

    C: BP :110/ 70 mmHg, HR :68 x/minute, regular, adequate

    D: GCS 14 (E4 M6 V4), pupil equal Ø 2,5 /2,5 mm , LR +/+

    E: T (ax) : 37,1 oC
    Secondary Survey
    Right zygoma region :
    I : Seen excoriated wound size 4x3 cm, edema(+), hematoma(+),
    active bleeding(-), deformity (-)
    P : Tenderness (+), Crepitation (-)
    Laboratory Result
    WBC : 15,5 x 103 / μL

    RBC : 4,18 x 106 / μL

    HGB : 12,6 g/dL

    HCT : 37 %

    PLT : 191 x103/ μL

    CT / BT : 78‘00” / 2 ’ 00”

    Blood Sugar : 71 mg/dl

    Ureum : 28 mg/dl

    Creatinin : 0,4 mg/dl

    GOT / GPT : 29/ 26 μ/L


    Thorax X-ray
    Head CT Scan
    WORKING DIAGNOSIS : Mild head injury GCS 14 (E4M6V4)

    MANAGEMENT : • O2
    • Medicaments
    • Report to senior neurosurgeon
    advice : Elective craniectomy

    PROGNOSIS : Good

    FOLLOW UP : Vital sign


    Operation Procedure
    • Patient laid supine under GA
    • Disinfection and draping procedure
    • Perform horseshoe incision and deepen until
    pericranium
    • Seen deppresed fracture in frontal area
    • Perform 1 burrhole and extend with knable
    tang

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