3. IDENTITY
• Name : NKIM
• Gender : Female
• Age : 6 years old
• Nationality : Indonesian
• Religion : Hindu
• Address : Karangasem
• Medical record : 22042515
• Date of admission : August 24th , 2022 at 07.00 p.m
4. HISTORY TAKING
Chief complaint: Headache
Present History
• Patient referred from BM Karangasem hospital with fully consciousness and
chief complained with headache after a traffic accident since 8 hours
before admitted to hospital. The patient was hit by a motorbike while
walking. Her head hit the pavement. Patient did not had any history of
syncope. Patient has non-projectile vomited 1 time containing about 50 cc
of food. Seizure was denied. After the accident, the patient was
immediately taken to the BM Karangasem Hospital. Patient also had an
open wound on her left head, already got 3 times of changing wound
dressing.
• At emergency room Prof Ngoerah hospital, the patient fully consciousness,
headache said was improved, vomiting and seizure was denied. Complaint
of double vision was denied.
5. HISTORY TAKING
Past History
• Patients did not have any similar complaint before.
Family Medical History
• There were no history of chronic diseases within the family
6. HISTORY TAKING
• Got treatment at BM Karangasem Hospital
• IVFD Nacl 0,9%
• Ceftriaxone 300mg intravena, Paracetamol 200mg intravena
Treatment History
Social History
• The second child of 2 siblings, her sibling was healthy
7. HISTORY TAKING
Immunization History
• BCG (+), Polio (+) 5 times, Pentavalen (+) 4 times, MR (+) 2 times
• Patient was spontaneous delivered helped by midwife with birthweight of
3700 grams, length and the head circumference was forgotten. There was
no history of delivery complication.
• Patient was cried immediately after birth.
Intranatal History
8. Exclusive breastfeeding : breastfeeding since born until 13 months old, on
demand
Formula : formula milk since 13 months, on demand
Milk porridge : since 6 months , three times daily
Softened rice : since 10 months, three times daily
Adult Food : since 12 months , three times daily
Food Recall
Rice 1 portion
Spinach soup 1 portion
Fried chicken 1 portion
Fried egg 1 portion
Formula milk 1 glass
Total calories ~ 467 kcal~ 25% RDA
Nutritional History
HISTORY TAKING
9. Gross motor:
• Head up : 3 months
• Turning around : 4 months
• Sitting with support : 6 months
• Crawling : 8 months
• Stand : 12 months
• Walking : 14 months
• Talking : 12 months
The patient is currently in1st grade of elementary school, no learning difficulty
at school.
HETEROANAMNESIS
Developmental History
10. • Surgery : No history
• Allergy : No History
• Transfusion : No History
HETEROANAMNESIS
Others
11. Present Status
General condition : Moderately ill
GCS : E4V5M6 (15/15)
Blood Pressure : 100/70 mmHg (P50-P90)
Pulse : 126 beats per minute, regular, adequate
Respiration : 24 times per minute, thoracal type
Temperature : 36.6 ºC
O2 saturation : 99% in room air
Pain scale (WBS) : 4
Pemeriksaan Fisis
PHYSICAL EXAMINATION
P50 93/55
P90 107/68
P95 110/72
P95+12 122/84
12. General Status
• Head : normocephalic, head nodding (-), rash (-)
symmetrical face.
Eye : pale conjunctiva (-/-), jaundice sclera -/-, periorbital
hematom -/-, isochoric pupils 3 mm/3 mm, positive
pupil reflexes on both sides, sunken eyes -/-.
• ENT
– Ears : no discharge
– Nose : no nostril breath, no secrete, nasal flare (-)
– Mouth : no cyanosis
– Throat : difficult to examination
– Tongue : cyanosis (-), oral thrush (-)
– Lips : ulcer (-), cyanosis (-), crackly lips (-)
– Neck : JVP is not examined, no inflammation sign, no wound.
PHYSICAL EXAMINATION
13. Thorax : Symmetrical, retraction (-), no wound
Cor : S1S2 normal regular, murmur -/-
Pulmo : Vesicular breath sounds on both side, rales -/- ,
wheezing -/-
Abdomen : Distension (-), ascites (-), no tenderness, bowel sound
is normal, normal skin turgor.
Extremities : Warm extremities, edema pitting (-), CRT < 2 seconds, redness on
both palms of hands and foot (-), petechiae (-),
Skin : Cutis marmorata (-) cyanosis (-) yellowish in face (-)
Genitalia : Female, M1P1
Pemeriksaan Fisis
PHYSICAL EXAMINATION
14. Neurological Status :
Power : 5555 | 5555
5555 | 5555
Tonus : normal | normal
normal | normal
Trophy : normal | normal
normal | normal
Biceps reflects : ++/++
Triceps reflects : ++/++
Patela reflects : ++/++
Pathological reflects : -/-
Pemeriksaan Fisis
PHYSICAL EXAMINATION
15. Status Localized :
At regio parietal sinistra : cephal hematoma with diameter 3 cm , vulnus
appertum regio parietal sinistra with wound 2x1 cm (tissue wound
base)
Pemeriksaan Fisis
PHYSICAL EXAMINATION
16.
17.
18.
19. • Weight : 17 kilograms
• Length : 116 centimeter
• Length/age : < 0 SD
• Weight/age : < -1 SD
• IMT : 12,6
• IMT/U : < -2 SD
• Ideal body weight : 21 kg
• Nutritional status : Mild protein energy malnutrition
Pemeriksaan Fisis
ANTROPOMETRIC STATE
22. Blood Chemical and Swab Antigen
BM Karangasem Hospital
Parameter (24/08/2022) Unit Reference value
BT 1’30” minute 1’ – 3’
CT 9’00” minute 5’ – 15’
Swab Antigen SARS COV 2 Negative
23. SUMMARY
• Patient female 6 years old, chief complained headache after a
traffic accident since 8 hours and her left head was hit to the
pavement before admitted to hospital, the patient has non
projectile vomiting once containing about 50 cc of food
• GCS still compos mentis (E4 V5 M6), blood pressure 100/70
mmHg, heart rate 126 beats per minute, respiratory rate 24
times per minute
• Status Localized : At regio parietal sinistra : cephalhematoma
with diameter 3cm , vulnus appertum regio parietal sinistra
with wound 2x1 cm (tissue wound base)
• Non contrast head CT –scan : epidural hematom regio
parietal, depressed skull fracture parietal
24. WORKING DIAGNOSIS
Mild head injury (S09.90) + Epidural hematoma regio parietal
(S06.4) + Depressed skull fracture parietal sinistra (S02.91) + Mild
protein energy malnutrition (E43)
25. PLAN OF CARE
No Problems Intervention Target
1. • Mild head injury
• Epidural
hematoma regio
parietal
• Depressed skull
fracture parietal
sinistra
• Head elevation
• Preoperative laboratory
examination
• EDH evacuation craniotomy
with reconstruction
elevation fracture
depressed
• Monitoring for clinical
deterioration, elevated
intracranial pressure signs,
vital signs
• Post surgical PICU
admission with back up
ventilator
• No elevated intracranial
pressure
• No active bleeding
• Fracture corrected
