No.

1
Name : Mr. Ramlan Sex : Male
Age : 50 years old No. Reg : 44 97 51

Chief complaint : Decreased of consciousness

History taking : Suffered since 3 hours before admitted to the hospital
due to traffic accident. There was history of vomiting.
Prior medical care at Sungguminasa Hospital
Mechanism of : He was riding motorcycle, suddenly struck by another
injury motorcycle from right direction. The next mechanism
was unknown
Injury sustain : Head
Symptom & sign : Decreased of consciousness
Examination : Physical examination, laboratory examination, x ray,
Head CT Scan
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR : 20 x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP : 140/90 mmHg, HR: 78x/minute, regular, adequate

D: GCS 11 (E3M5V3), pupil unequal 4mm/3 mm , LR +/+

E: T (ax) : 36,7oC
Secondary Survey
Orbita region :
I : Seen hematoma, edema (+),wound(-)
P : Tenderness (+), Crepitating (-)

Occipital region :
I : Seen edema, hematoma(+), excoriated wound (+)
P : Tenderness (+), Crepitating (-)
 Laboratory Result
WBC : 17,36x 103 / L

RBC : 4,76 x 106 / L

HGB : 12 g/dL

HCT : 39,4%

PLT : 316 x103/ L

CT / BT : 800 / 3 00

Blood Sugar : 99 mg/dl

Ureum : 29 mg/dl

Creatinin : 0,9 mg/dl

GOT / GPT : 19/13 /L

 Head CT
Scan

EDH at right frontalis region

EDH at occipital region
Closed Line fracture at occipital bone
Chest X - Ray
WORKING DIAGNOSIS : Moderate head injury GCS 11 (E3M5V3)
EDH at right Frontal Region
EDH at occipitale region
Fracture linier at occipitale bone

MANAGEMENT : O2
IVFD
Medicaments
Report to senior neurosurgeon
advice : immediate trepanation
 Operating Procedure
Patient laid supine under GA
Disinfection and draping procedure
Perform linier incision at occipital region, deepen
until periosteum
Perform 4 burr holes, continue craniotomy with
craniotom
Seen EDH 30 cc, evacuated hematoma and
hanging duramater
Close the wound layer by layer and apply 1
vacuum drain
Operation finished
DIAGNOSIS POST OP : Moderate head injury GCS 11 (E3M5V3)
EDH at right Frontal Region
EDH at occipitale region
Fracture linier at occipitale bone

PROGNOSIS : Fair
FOLLOW UP : Vital sign and