Bedah Saraf

Mild head injury + depress fracture at the frontal region

Patient identity
Name : Rusdi
Age : 41 years old
Sex : Male
Address : Desa.Neusu, Kec. Darul Kamal, Kab
Aceh besar
CM : 98 59 12
Phone : 085358848600
Driving licence : (+)
Chief complain:
Headache with Pain and difficulty to move of the left upper arm.

Patient illnes history
The patient come to the emergency room Zainoel Abidin hospital
with a chief complaint Headache with Pain and difficulty to move of
the left upper arm.after trauma for 2 hour ago. The patient was
standing beside the car dam truck, suddenly he fell down from truct,
and his head hit the aspalt. History of unconsciousness (-) ,vomitting
(-).

Physical examination
Primary survey
A: clear
B: spontaneous, RR: 22 breaths/ minute
C: Blood Pressure: 130/80 mmHg Pulse 90 beats/minute,
D: GCS: 15 (E4 M6 V5); isochoric pupil (L/R) 3mm/3mm, lateralization(-)
E:
L/S at the left frontal region
L: wound (+) size 8 cm,Swelling (+),bone expose (+), pulp
cerebri (-), LCS (-)
F: Pain (+), discontinuity of bone (+)

L/S at the left shoulder Joint
L: wound (+) 6 cm , swelling (+)
F: Pain (+)

L/S at the left upper arm
L: Sweling (+), deformity (+)
F: Pain (+), NVD (-)
M:Rom Limited

Assessment:
Mild Head Injury + Open depress fracture at the frontal region
+ Close fracture of the left of Upper arm

Management:
Head up 30
0

Oxygen 2 L/i via nasal canule
IVFDNaCl 0,9 % 20 drips/minute
Ceftriaxone inj. 1 gr
Ketorolac inj 30 mg
Tetagam 250 iu
Blood routine laboratory
Radiology examination

Laboratory result
Hb :12.3 gr/dl
White blood count :15.300 /ul
Platelet :220.000 /ul
CT :9 minute
BT :3 minute
Ht :36 %
Blood glucose random :157 mg/dl

Radiology result:
Head CT Scan :
No SCALP hematome
There was depress fracture of the frontal region > 1 tabule
Sulcus and gyrus in normal limit
Ventricle and systerna system in normal limit
No mid line shift

Wide Thorax :
Fracture of the costae 2
nd
,3
rd
,4
th
of the left hemi thorax +
contusio of the left lung

Brachii AP/L :
Fracture of the upper third of the left humeri

Assesment:
Mild head injury (ICD-10-CM S09.90) + depress fracture at the frontal
region (ICD-10-CM S02.91) +Close Fracture of the upper third of the
left humeri + close of the costae 2
nd
,3
rd
,4
th
of the left hemi thorax +
contusio of the left lung

Consult to neurosurgery division
Elevation depress fracture emergency

Consult to Orthopedic surgery Division
Perform U Slab
Perform Orif electif

Consult to Thorax Cardio Vascular surgery Division
Perform WSD