Trauma Case Presentation

7/26/2019 Trauma Case Presentation

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CASE REP RT

BRAGASTIO SIDHARTA



Patient Identity

• Name : Mr. S• Age : 13 y

• MR n. : !1."3.#!.$$• O%%&'atin : (t&dent

• Addre(( : Peni Pa)*a'ang Bant&)

• Date + ,i(ite : A'ri)- " "!!



Anamne(i(

• C/ie+ Cm')aint: Pain n t/e rig/t eye(

• Hi(try + 're(ent i))ne((:

T/ree /&r( *e+re admi((in- /e 0ent a)ngmtr%y%)e 0it/&t /e)met. He +e)t d0n. He

/ad /it gr&nd. He +e)t 'ain in /i( eye. T/ere

0a( &n%n(i&(ne((-na&(e and ,mit. He %amet Bant&) /('ita) and re+ered t Sarit

/('ita)



Genera) E2aminatin

• Genera) %nditin : &n%n(i&(ne((

• B)d 're((&re : 11!4! mmHg

• P&)(e : 5! 2min&te

• Re('iratin : "! 2min&te

• Tem'erat&r : 34 C





%)ear )en( %)ear

%)ear

de+ine margin

a,:"3-%d:!-3*rig/t re+)e2 ;<

n

=&nd&(media

'a'i)

ma%&)a

Retina

%)ear

de+ine margin

a,:"3-%d:!-3*rig/t re+)e2 ;<

n

nrma) IOP nrma)+ree)y MO +ree)y



• B>N : #-4 mgd)• Creatinin : !-#• B)d E2aminatin : G)&%(a : 11! gd)• ?BC : 3"-$• H* : 11-@ gd) T/ra2 PA : ?N9• P9T : 3#!• BT : "

• CT : • NaC) : 1@$ @-3 1!3• TP : 4-3@• A)*&min : 3-4$ gd)





RESULT:

Fraktur calvaria/ os frontalis dextra until orbital rim dekstra





S+t ti((&e (0e))ing in +rnt 'arieta) de2tra

=rat&r (.+rnta)e de2tra-'en +rat&r and t/e )atera) 0a)) r*ita

Brain 'r)a'( in de+e%t (.+rnta)e and *)eeding intra)e(i and'ne&men%e'/a)%e)e









OPERATO! REPORT

• Se'ti% and a(e'ti% n t/e 'eratin area

0it/ *etadine ()&tin

• 9%a) (&*%&tan ana(te(i 0it/ )id%ain "

• ?&nd ti)et de*ridemant

• S&t&ring )ayer *y )ayer 0it/ %&tgat $.!

• S&t&red (&* %&tane&()y 0it/ 'r)en $.!

• S+trat&)e 0a( 'er+rmed

• C/)ram'/eni%) EO a'')ied

• Bandage





P)ea(e gi,e me (me (&gge(tin( and

ad,i%e( +r +&rt/er management

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Trauma Case Presentation