No. Name:Ch. ASex:MaleAge: 13 years oldNo. Reg:628035

Main complaint :HeadacheCondition:The condition had been apparent for 1 day due to traffic accident before the patient taken to the hospital. There were events of vomitting and unconsciousness. Previous medical care was carried out at Bantaeng Hospital. Mechanism of injury:The patient was carried by motorcycle, when suddenly another motorcycle going front direction struck him. He was thrown from the motorcycle and landed head first onto the road.Sustained Injury:HeadSymptom & sign:HeadacheExamination done:Physical examination, Head CT Scan, Skull AP/Lat, Thorax X-ray

PHYSICAL EXAMINATION Primary SurveyA:ClearB:RR: 24x/minutes, spontaneous, symmetric, thoraco abdominal type C:BP: 110/60 mmHg, PR: 96x/minute, regular, adequateD:GCS 15 (E4M6V5), pupil equal 2,5 mm/2,5 mm, Light Reflex +/+E:T (ax): 36,5 oC

Secondary SurveyRight olrbital region :I : Hematome (+), Edema (+)P : Tenderness (+), Crepitation (-)Mentalis region:I : Seen stitched wound size 1 cm, edema (-), hematome (-)P : Crepitation (-)

Laboratory ResultWBC: 18,11 x 103 / LRBC: 4,07 x 106 / LHGB: 12,5 g/dLHCT: 34,1 %PLT: 277x 103/ LCT / BT: 800 /200Blood Sugar: 115 mg/dlUreum: 25 mg/dlCreatinin: 0,7 mg/dlGOT / GPT: 59/29 /L

Skull X-Ray

Head CT scan

WORKING DIAGNOSIS :Mild head injury GCS 15 (E4M6V5)EDH at Right Temporofrontal RegionSDH at Right Temporofrontal Region

MANAGEMENT: O2 Apply IVFD Medicaments Consult to senior Neuro Surgeon Advice: Proceed Craniectomy

Operating ProcedurePatient laid supine under GADisinfection and drapping procedureExtend the incision from lacerated wound, deepen until pricraniumIdentificate, seen depressed fracture at parietal region with fracture segment break the duramaterPerform 1 burrhole, extend with knable tang, seen hematom 15 ccEvacuate hematom and fracture segment, bleeding control, hanging dura and apply fibrin glueClose wound layer by layer with 1 vacuum drainOperation finished

POST OP DIAGNOSIS :Mild Head Injury GCS 15 (E4M6V5)EDH at Right Temporofrontal RegionSDH at Right Temporofrontal Region

PROGNOSIS

FOLLOW UP:

:Good

Vital sign, GCS

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