Scribd Logo
Upload

Welcome to Scribd!

  • 24 views

    Primary Survey: A: Clear B: RR 24x/m Adecuate, Simetris D/S C: HR 88x/m Reguler, Adecuate D: Verbal Respons E: Head

    Uploaded by

    lie anto
    - A 41-year-old man was admitted to the hospital unconscious after a motorcycle accident where he was not wearing a helmet and lost control at high speed. - On examination he was somnolent with stable vital signs and moderate head injuries on the right side including hematomas. - CT scan showed an intracranial hemorrhage on the right side measuring 33cc as well as a skull fracture and pneumoencephalus. - The diagnosis was a moderate head injury from the trauma and plans were made for monitoring, treatment, and additional diagnostic tests.

    Copyright:

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

    Primary Survey: A: Clear B: RR 24x/m Adecuate, Simetris D/S C: HR 88x/m Reguler, Adecuate D: Verbal Respons E: Head

    Uploaded by

    lie anto
    24 views17 pages
    - A 41-year-old man was admitted to the hospital unconscious after a motorcycle accident where he was not wearing a helmet and lost control at high speed. - On examination he was somnolent with stable vital signs and moderate head injuries on the right side including hematomas. - CT scan showed an intracranial hemorrhage on the right side measuring 33cc as well as a skull fracture and pneumoencephalus. - The diagnosis was a moderate head injury from the trauma and plans were made for monitoring, treatment, and additional diagnostic tests.

    Original Description:

    kasus

    Original Title

    up1

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    - A 41-year-old man was admitted to the hospital unconscious after a motorcycle accident where he was not wearing a helmet and lost control at high speed. - On examination he was somnolent with stable vital signs and moderate head injuries on the right side including hematomas. - CT scan showed an intracranial hemorrhage on the right side measuring 33cc as well as a skull fracture and pneumoencephalus. - The diagnosis was a moderate head injury from the trauma and plans were made for monitoring, treatment, and additional diagnostic tests.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    24 views17 pages

    Primary Survey: A: Clear B: RR 24x/m Adecuate, Simetris D/S C: HR 88x/m Reguler, Adecuate D: Verbal Respons E: Head

    Uploaded by

    lie anto
    - A 41-year-old man was admitted to the hospital unconscious after a motorcycle accident where he was not wearing a helmet and lost control at high speed. - On examination he was somnolent with stable vital signs and moderate head injuries on the right side including hematomas. - CT scan showed an intracranial hemorrhage on the right side measuring 33cc as well as a skull fracture and pneumoencephalus. - The diagnosis was a moderate head injury from the trauma and plans were made for monitoring, treatment, and additional diagnostic tests.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 17

    Primary Survey

     A : clear
     B : RR 24x/m adecuate, simetris D/S
     C : HR 88x/m reguler, adecuate
     D : Verbal respons
     E : Head
    History Taking
     A man, 41 years old, admitted to hospital with a chief complaint:
    unconsciousness after an accident.
     4 hours before admission, the patient was riding a motorcycle and
    he was not wearing a helmet. The rider rode the motorcycle with
    high-speed and loses control and the patient fell down, head
    bumped asphalt road, he was found unconscious on the side of the
    road.
     He looks sleepy. Unresponse when his family called him
     There were vomiting 1 times of the patient, not projectile, contain
    food and yellow fluid.
     Blood from nose (-), blood from ears(-),
     Seizure (-),Fever(-), Slurred Speech(-), Weakness of one side of
    the body(-), alcohol (-)
     After that, he was taken to Kandou Hospital for the first aid and
    treatment
    History of Past Illness
    Hypertension (-)
    Cholesterol (-)
    Heart Disease (-)
    DM (-)
    Kidney (-)
    Physical Examination
     General examination:
     General condition: Moderate, Consciousness : Somnolen
     BP: 110/70 mmHg, MABP: 83, HR: 88 times per minute reg, RR: 24
    times per minute , T: 36,4°C, SaO2 : 98%
     Conjunctiva: pale (-/-), sclera ikteric (-/-)
     JVP : normal
     Thorax : Rale -/-, Wh -/-, heart sound I/II normal, gallop -, murmur –
     Abdomen : Flat, normal turgor, peristaltic normal
     Extremities : warm acral
    Neurological Examination
     GCS E3M5V2. Pupil round ø 2/2 mm. Direct light Reflex +/+
    Indirect Light Reflex +/+
     Meningeal Sign: nuchal rigidity not evaluated. Lasegue (>70/>70)
    Kernig (>135/>135)
     Cranial Nerves: impression of paresis (-).
     Motoric examination : hemiparesis impression (-).
    MT : N N PhyR : ++/++/++ ++/++/++ PathR : - -
    N N ++/++ ++/++ - -
     Sensoric exam : can’t be evaluated
     Autonomic state : urination via catheter
    Localized Examination
     Otorrhea - / -
     Rhinorrhea - / -
     Racoon eye - / -
     Battle sign - / -
     Hematome r/ temporoparietal dekstra 4x5 cm
     Hematome r/ temporoparietal sinistra 4x4 cm
    WDx
    Moderate head injury
    Planning
     Bed rest + C Spine control
     Family CIE
     Pro NGT+catheter ( family approval)
     O2 nasal canule 2-4 lpm
     IVFD NaCl 0,9% 500 cc 20gtt /m
     Paracetamol 3x500mg NGT
     Vitamin C 2x200mg NGT
     Zink 2x20mg NGT
     Observe GCS/Pupil/O2 per hour.
    Diagnostic Planning
     Blood exam: hematology, blood sugar, electrolyte, renal
    function, liver function.
     Brain CtScan + BW
     Cervical X-ray AP/lat.
    Laboratory Examination 8 September 2017
     Hb : 13.8
     Ht : 42.3%
     WBC : 21.420
     PLT : 280.000
     RBC : 5.18 x 10^6
     SGOT : 30
     SGPT : 38
     Ureum : 23
     Creatinine : 1.0
     Random Blood sugar : 165
     Na : 137
     K : 3.60
     Cl : 106.0
     OSM : 293 mOsm/L
    Cervical X-ray AP/ Lat
    Brain CT
    Brain CT Scan (zoomed)
    Bone
    Window
    WDx
    ICH r/ temporoparietal dekstra vol 33 cc
    SAH traumatical
    Fracture linear r/ temporoparietal dekstra
    Pneumoencephal
    Additional Therapy
     Tranexamat acid 4x1gr IV
     Nimodipin 4x60 mg via NGT if BP>130/80
     Manitol loading dose 300cc, next 4x 150 cc 6
    hours after loading if BP> 110/80
     Ceftriaxone 2x2 gr IV
    THANK YOU

    You might also like