Cedera Kepala Sedang

Wulan Yuniarti
2118012184

Perceptor:
dr. Fidha Rahmayani, Sp.S

KEPANITERAAN KLINIK ILMU PENYAKIT SARAF

RSUD ABDUL MOELOEK KOTA BANDAR LAMPUNG
FAKULTAS KEDOKTERAN
UNIVERSITAS LAMPUNG
2023
 IDENTITAS PASIEN
Nama Tn. MRP
Jenis kelamin Laki-laki
Umur 21 tahun
Pekerjaan Guru
Alamat Bandar Lampung
No.. RM 73.10.50
 ANAMNESIS
Keluhan utama Keluhan tambahan

Muntah-muntah sejak 10 jam Pusing, nyeri kepala

SMRS
Riwayat Penyakit Sekarang

Pasien mengeluh muntah-muntah hingga 10-15 kali sejak 10 jam SMRS

setelah terpeleset di kamar mandi 12 jam SMRS. Muntah
menyemprot (+). Pasien mengaku sedang tidak enak badan sehingga
lemas dan lantai kamar mandi licin sehingga terpeleset. Kepala belakang
dan sebelah kanan membentur dinding. Pasien masih sadarkan diri setelah
kepala terbentur, tetapi pasien muntah-muntah. Pasien lalu ke Puskesmas
dan diberi obat anti mual, tetapi keluhan tidak membaik, pasien masih
muntah-muntah. Pasien saat ini juga mengeluh nyeri kepala hilang
timbul di seluruh kepala dan pusing seperti bergoyang. Pasien sadar
penuh, tidak pernah penurunan kesadaran. Kejang (-), keluar cairan atau
darah dari hidung (-), telinga (-), mulut (-), mual (+).
Riwayat Penyakit
Riwayat Penyakit Keluarga
Dahulu
- Keluhan sama (-)
Hipertensi (-), diabetes (-), penyakit
lainnya (-)
 PEMERIKSAAAN FISIK
Keadaan umum : Tampak sakit sedang
Tingkat kesadaran : compos mentis
GCS: E4V5M6
TD: 90/50 mmHg
HR: 50 kali/menit
RR: 20 kali/menit
T: 36,8 C
Spo2: 100% room air
 Status generalis
Kepala : normocepal
Mata : konjungtiva anemis (-/-), sklera ikterik (-/-)
Hidung : epiktasis (-), NCH (-)
Mulut : pucat (-), sianosis (-)
Telinga : sekret (-), battle sign (-)
Leher: pembesaran KGB (-), JVP 5-1, pembesaran tiroid (-)
 Status Generalis
Thoraks Abdomen
I : simetris, normochest I : datar, tidak terdapat lesi
P : NT (-), Ekspansi dada simetris A : BU (+)
P : Sonor P : timpani
A : Vesikuler (+/+), rh (-/-), wh (-/-) BJ 1 dan P : nyeri tekan (-)
2 (reguler), murmur (-), gallop (-)

Ekstremitas
superior dan inferior : Akral hangat,
CRT <2 detik, edema (-/-)
 Status Neurologis
Fungsi Luhur Fungsi Otonom
• Fungsi bahasa : baik Miksi : +
• Fungsi orientasi : baik Defekasi : +
• Fungsi memori : baik Berkeringat : +
• Fungsi emosi : baik
Refleks fisiologis Refleks patologis
Hoffman : -
Bisep : +/+
Tromner : -
Trisep : +/+
Babinski : -
Patella : +/+
Chaddock : -
Achilles : +/+
Gordon : -
Gonad : -
Oppenheim : -
Rangsang meningeal Schaeffer : -
Kaku kuduk (-), brudzinski I, II, III, IV (-),
kering sign (-), laseque sign (-)
Saraf kranial
• N.I : fungsi penghidu normal
• N.II : visus normal
• N.III, IV, VI : ptosis (-/-), enoftalmus (-/-), eksoftalmus (-/-), pupil isokor,
refleks pupil direk indirek (+/+), gerakan bola mata normal
• N.V : motorik & sensorik normal, refleks kornea (+/+), refleks masseter (-/-)
• N.VI : Inspeksi, motorik, dan sensorik dalam batas normal
• NVII : Tes Rinna (-), tes Weber lateralisasi (-), tes Swabach memanjang (-)
• N.IX, N.X : fungsi pengecapan normal, uvula di tengah, refleks muntah (+),
mampu menelan
• N.XI : M.Sternocleidomastoideus normal, M.Trapezius normal
• N.XII : Deviasi lidah (-)
Fungsi Sensoris
Fungsi Sensoris Superior Inferior
Rasa raba Dalam batas normal Dalam batas normal
Rasa nyeri Dalam batas normal Dalam batas normal
Rasa getar Dalam batas normal Dalam batas normal
Suhu panas Dalam batas normal Dalam batas normal
Suhu dingin Dalam batas normal Dalam batas normal
Fungsi Motorik
Trofi Eutrofi/eutrofi
Eutrofi/eutrofi
Tonus Normotonus/normotonus
Normotonus/normotonus
Gerak Aktif/aktif
Aktif/aktif
Kekuatan otot 5555/5555
5555/5555
Klonus (-)
 PEMERIKSAAN PENUNJANG :
DARAH LENGKAP
Pemeriksaan Hasil Nilai Normal Satuan

Hemoglobin 13,0 13,2 – 17,3 g/dL

Leukosit 8.100 3.800 – 10.600 /uL

Eritrosit 4,2 4,4 – 5,9 juta/uL

Hematokrit 38 40 – 52 %

Trombosit 310.000 150.000 – 440.000 /uL

MCV 89 80 – 100 fL

MCH 31 26 – 34 pg

MCHC 35 32 – 36 g/dL
 PEMERIKSAAN PENUNJANG :
DARAH LENGKAP
Pemeriksaan Hasil Nilai Normal Satuan

Basofil 0 0–1 %

Eosinofil 0 2–4 %

Batang 0 3–5 %

Segmen 65 50 – 70 %

Limfosit 26 25 – 40 %

Monosit 9 2–8 %

LED 9 0 – 10 mm/jam

GDS 65 < 140 mg/dL

Kesan : Dalam batas normal

 PEMERIKSAAN
PENUNJANG : CT SCAN

Tanpa kontras

Kesan:
• Tidak tampak perdarahan intrakranial
• Tidak tampak fraktur calvaria
• Sinusitis maksilaris kanan
 PEMERIKSAAN
PENUNJANG : EKG
 Diagnosis

Klini Topis Etiologi

s
s
Projectile vomitting CKS
 Tatalaksana

• IVFD NaCl 0,9% 24 • Ranitidine ampul

tpm 01 02 50mg/24 jam
• Paracetamol tablet • Sucralfat syrup 10ml/8
500mg/8 jam jam

Betahistine tablet 6mg/8

jam 04 03 Dexamethasone ampul
5mg/8jam (tappering
off)
 PROGNOSIS

Quo Ad Quo Ad
Quo Ad Functionam
Vitam
Ad bonam Ad bonam
Sanationam
Ad bonam
ANALISIS KASUS
 KEY ACCOMPLISHMENTS
• Pasien mengeluh muntah-muntah hingga
10-15 kali sejak 10 jam SMRS setelah
terpeleset di kamar mandi 12 jam SMRS.
Muntah menyemprot (+).
• Terpeleset karena sedang tidak enak
badan sehingga lemas
• Nyeri kepala hilang timbul di seluruh kepala
• Pusing seperti bergoyang.
• Pasien sadar penuh, tidak pernah
penurunan kesadaran. Kejang (-), keluar
cairan atau darah dari hidung (-), telinga (-),
mulut (-)
PATIENT SATISFACTION

95%
Big numbers catch your audience’s attention
 INNOVATIONS

JUPITER MARS NEPTUNE

INNOVATION 1 INNOVATION 2 INNOVATION 3

Jupiter is the biggest planet in Despite being red, Mars is a very Neptune is the farthest planet
the Solar System cold place from the Sun
 QUALITY IMPROVEMENT
MEASURES

MERCURY VENUS MARS

Mercury is the closest planet Venus is the second planet Despite being red, Mars is
to the Sun from the Sun actually a very cold place

JUPITER SATURN NEPTUNE

Jupiter is the biggest planet Saturn is composed of Neptune is the farthest planet
of them all hydrogen and helium from the Sun
OUR CENTERS

MARS
Despite being red, Mars
is a cold place

VENUS
Venus is the second
planet from the Sun
 TESTIMONIALS

JENNA DOE JOHN JAMES

“Venus is the second planet “Jupiter is the biggest planet in
from the Sun” the Solar System”

FRED BLOGGS TIMMY JIMMY

“Despite being red, Mars is “Saturn is a gas giant and has
actually a cold place” several rings”
 OUR AWARDS
Despite being red, Mars
01 is a cold place

OUR Saturn is a gas giant and

02 has several rings
AWARDS
Venus is the second
03 planet from the Sun
A PICTURE IS WORTH A
THOUSAND WORDS
WEBSITE
DEMO
You can replace the image on the
screen with your own work. Just
right-click on it and select “Replace
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 OUR DOCTORS

JENNA DOE TIMMY JIMMY

You can speak a bit about this person You can speak a bit about this person
here here
TERIMA KASIH!
ICON PACK
 ALTERNATIVE RESOURCES
VECTORS:
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 RESOURCES
VECTORS:
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PHOTOS:
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ICONS:
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