2_november_2023_ICH_temporo_parietal_sinistra_dengan_volume_24_6

1. Mrs. JPS / 53 Years Old/01135827/BPJS
Attending: dr. Tondi SpBS
November, 2nd 2023
Filza
Handra
Dhon - Agung
Hamdan - Alex

2. VISI dan MISI Ilmu Bedah FK UNRI
• VISI
• Menjadi Pusat Pendidikan Dokter Spesialis Bedah Berbasis Riset yang Unggul dan Bermartabat dibidang
Teknologi Kedokteran dan Kesehatan Terutama Dalam Pelayanan “Acute Care Surgery” di Kawasan ASEAN
Pada Tahun 2035
• MISI
• Menyelenggarakan pendidikan dokter spesialis bedah yang mampu secara mandiri melayani kasus bedah
terutama dalam pelayanan “Acute Care Surgery “
• Menyelenggarakan penelitian berbasis riset yang unggul dibidang teknologi kedokteran dan kesehatan yang
berkontribusi dalam menyelesaikan masalah bedah terutama pelayanan “Acute Care Surgery”
• Menyelenggarakan pengabdian kepada masyarakat terutama dalam pelayanan “Acute Care Surgery”
• Menjalin kerjasama dengan institusi atau lembaga pendidikan lain dalam negeri dan dikawasan ASEAN
• Menyelenggarakan kepemimpinan dan tata kelola program studi spesialis ilmu bedah yang baik dan akuntabel

3. Trauma, Alert response
Primary Survey
Objective Assessment Action
Airway maintenance with
restriction of cervical
spine motion
Snoring (-), gurgling (-), stridor (-), saturation 99 %.
Tracheal deviation (-), Wound (-), Emphysema (-),
Laryngeal Tenderness / crepitus (-), Venous Distension
(-), Oesophageal injury (-), Carotid Bruits / swelling (-)
Patent airway Monitoring airway
Breathing and ventilation RR 22 x/minute, Bruise (-), Wound (-), symmetrical
chest wall movement, jugular venous distention (-),
trachea in the middle, Emphysema / Crepitus (-), Chest
wall tenderness (-), normal heart sound, normal breath
sound R = L, resonance percussion, saturation 99 %
Breathing and ventilation clear Monitoring breath rhythm
and O2 saturation
Circulation and
hemorrhagic control
warm (+), cyanotic (-), pulse 108 bpm, regular
adequate, CRT < 2’s, BP 119/60 mmHg
Hemodynamic Stable IVFD RL 1500 cc/24 hours
Disability (neurology
evaluation)
GCS 14 E3M6V5, round pupils, equal 2/2 mm, pupillary
light direct & indirect reflex +/+, lateralization (-)
Decrease of consciousness (-) Observation level of
consciousness, repeat the
examination
Exposure T: 36,7 C No hypothermia Covered with blanked
Mrs. JPS / 53 Years Old/01135827/BPJS
Attending: dr. Tondi SpBS

4. Mrs. JPS / 53 Years Old/01135827/BPJS
Attending: dr. Tondi SpBS
Secondary Survey:
• The patient came with complaints of headache since 30 minutes before admission to
the hospital after a traffic accident.
• The mechanism of trauma, the patient was riding a bicycle at a moderate speed,
then suddenly the patient fell while avoiding a passing cat. she fell with her head
hitting the asphalt, she was wearing a helmet. After the incident, the patient
complained of pain in the head, accompanied by swelling on the left forehead, open
wound (+) active bleeding (-), history of decreased consciousness (+) and tendency
to be sleepy. The patient also vomited (+) 2 times in the emergency room containing
food that was eaten before, not spraying.
• History of seizure (-), limb weakness (-)
• She was immediately taken to Arifin Achmad Hospital for further treatment.

5. Mrs. JPS / 53 Years Old/01135827/BPJS
Attending: dr. Tondi SpBS
History of past illness
• A : No history of an allergic
• M: Last medication (-)
• P : History of past illnesses (-)
• L : Last meal about 4 hours before admission
• E : Traffic accident

6. Physical Examination
• Awareness : GCS 14 E4M6V5
• Vital Sign
• VAS : 4-5 out of 1-10 scale
• BP : 124/78mmHg
• HR : 108 x/m reguler, adequate
• RR : 22 x/m, reguler,
• Temp : 36.6 oC
• SpO2 : 99 % Room air

7. Physical Examination
• Head: Localized Status
• Eyes: Anemic conjunctiva (-/-), hematoma
palpebra (-/+), icteric sclera (-/-), round pupils,
equal pupil : 2/2mm, pupillary light reflex direct
and indirect (+/+)
• Neck: normal, JVP not elevated, lesions (-)
• Chest :
- I : symmetric movement of chest walls,
- P : resonance percussion
- P : fremitus right and left are normal,
- A : vesicular sounds (+/+), rhales (-/-),
wheezing (-)
• Heart: normal heart sound regular, no gallop, no
murmur
• Abdomen:
- I : distended (-), bruise (-), wound (-)
- A : normal bowel sound
- P : Soepel, Muscle rigidity (-), tenderness(-),
defense muscular (-)
- P : tympani
• Extremity: Warm Acral, CRT <2’’, laceration (-)

8. Localized status of Head
Head:
• Look: hematome (+) in the left frontal region, imprint (-),
abrasions (-)
• Feel: tenderness (+), hematome with size 20x10 cm
Eyes:
• Racoon eyes (-/-)
• Round pupils, equal 2 mm/2 mm,
• Pupillary light direct and indirect reflex (+/+)
• Palpebral hematoma (-/+)
• Visual acuity normal, eyeball movement normal
• Subconjunctival bleeding (-/-)
Nose: deformity (-), Rhinorrhoea (-)
Ears: Otorrhea (-/-),battle sign (-/-)

9. Localized status of Head

10. Working Diagnosis
• Mild TBI GCS 14 E3M6V5
Performed
Emergency room therapy
- O2 10 lpm NRM
- Head Up
- IVFD NaCl 0,9% 16 dpm
- Manitol loading 200 cc
- Ceftriaxone 1 gr iv
- Ketorolac 30 mg iv
- Omeprazole 40 mg iv
Suggestion:
- Observation of GCS if it drops 2 points,
repeat Head CT Scan

11. Laboratory Result (November 2nd 2023)
Type Value Unit Normal Value
Haemoglobin 12.2 g/dL 13,0 - 16,0
Haematocrit 38.6 % 40,0 - 48,0
WBC 20.47 10^3/µl 5,00 - 10,00
Platelet 539 10^3/µl 150 - 400
PT 13.2 Second 11,6 – 14,5
APTT 24.9 second 28,6 – 42,2
Type Value Unit Normal Value
AST 41 U/L 10 – 40
APT 29 U/L 10 – 40
Glucose 110 mg/dL < 140
HIV Non-reactive Non-reactive Non-reactive
HBsAg Non-reactive Non-reactive Non-reactive

12. Chest X-ray (November, 2nd 2023)
• Airway: normal, trachea was at
middle site
• Bone : no discontinuity
• Cardiac: normal (CTR < 50%)
• Diaphragm: normal
• Field of the lung: normal

13. Head CT Scan (November, 2nd 2023)
• Left temporo-parietal ICH with a volume of
24.6 cc
• Left temporo-parietal SDH (9.2 mm)

14. Head CT Scan (November, 2nd 2023)
• No Discontinuity

15. Cervical X-Ray (November, 2nd 2023)
• Alignment
• Anterior vertebral line normal
• Posterior vertebral line normal
• Spinolaminar line normal
• Interspinosus line normal
• Bone : no discontinuity or dislocation
• Cartilage normal
• Disc normal
• Facet normal

16. Diagnosis
• Mild TBI GCS 14 E3M6V5
• Left temporo-parietal ICH with a volume of 24.6
cc
• Left temporo-parietal SDH (9.2 mm)
ICD X:
S00.93XA - Head injury of unspecified part of head, initial encounter
S06.35- Traumatic hemorrhage of left cerebrum
S06.5X0A · Traumatic subdural hemorrhage
Performed
Advice dr Tondi SpBS:
• Mannitol 4x125 cc
• Inj ceftriaxone 1x2 gr
• Inj ketorolac 2x30 mg
• Lansoprazole 1x30
• Close observation / 3 hours

17. THANK YOU