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Case Report Thursday 25.08.2022.pptx
- 1. MORNING REPORT THURSDAY, AUGUST 25th 2022
- 2. CASE REPORT
- 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 尊C 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
- 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
- 20. Head CT Scan at BM Karangasem Hospital (24/8/22)
- 21. COMPLETE BLOOD COUNT AT BM KARANGASEM HOSPITAL Parameter (24/08/2022) Unit Reference value WBC 14.75 103/袖L 4.1-17.0 NE% 70 % 47.0-80.0 LY% 41.3 % 13.0-40.0 MO% 3.7 % 2-11 NE# 4.0 103/袖l 2.5-7.5 LY# 6.09 103/袖L 1.0-4.0 MO# 1.53 103/袖L 0.10-1.20 RBC 5.12 106/袖L 4.5- 5.9 HGB 13.9 g/dL 13.5- 17.5 HCT 42.3 % 34 - 40 MCV 82.5 fL 86.0-110.0 MCH 27.1 pg 26 - 34 MCHC 32.9 g/dL 31-36 RDW 11.8 % 11.6-14.8 PLT 492 103/袖L 150-450
- 22. Blood Chemical and Swab Antigen BM Karangasem Hospital Parameter (24/08/2022) Unit Reference value BT 130 minute 1 3 CT 900 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
- 26. COMPLETE BLOOD COUNT AT PN HOSPITAL Parameter (24/08/2022) 20.35 Unit Reference value WBC 18.60 103/袖L 6.0 14.0 NE% 85.50 % 18.30 47.10 LY% 11.30 % 30.00 64.30 MO% 3.10 % 0.0 7.10 NE# 15.90 103/袖l 1.10 6.60 LY# 2.10 103/袖L 1.80 9.00 MO# 0.58 103/袖L 0.00 1.00 RBC 4.62 106/袖L 4.10 5.3 HGB 12.60 g/dL 12.0 16.0 HCT 37.90 % 36.0 49.0 MCV 82.00 fL 78.0 102.0 MCH 27.30 pg 25.0 35.0 MCHC 33.20 g/dL 31-36 RDW 12.80 % 11.6-18.7 PLT 445 103/袖L 140-440
- 27. BLOOD CHEMISTRY TEST AT PN HOSPITAL Parameter (24/08/2022) Unit Reference value PPT 16.7 Second 10.8-14.4 INR 1.18 0.9-1.1 APTT 25.7 Second 24-36 SGOT 36.4 U/L 5-34 SGPT 12.80 U/L 11.00-34.00 Blood Sugar 89 mg/dL 60-100 BUN 8.20 mg/dL 8.00-23.00 Creatinine 0.61 (GFR 104) mg/dL 0.57- 1.11 Sodium 141 Mmol/L 136-145 Potassium 4.7 Mmol/L 3.50-5.10 Chloride 107.0 Mmol/L 94-110
- 28. WORKING DIAGNOSIS Mild head injury (S09.90) + Epidural hematom regio parietal sinistra (S06.4) + Depressed skull fracture parietal sinistra (S02.91) + Mild protein energy malnutrition (E43)
- 29. INSTRUCTION Therapy : Primary survey : Airway, Breathing, Circulation, Disability, Exposure Head up 30属 Face mask O2 6 LPM Fluid requirement 1350 ml/day ~ IVFD D5 遜 NS 56 ml/hours ~ fasting Paracetamol 10-15 mg/kg/time ~ 250 mg every 4-6 hours if pain with VAS<4 Phenytoin 60 mg every 12 hours intravenously ~ Neurosurgeon Monitoring vital sign, increased intracranial pressure Ceftriaxone 50 mg/kg/dose ~ 850 mg IV 30 minute before procedure ~ Neurosurgeon Pro craniotomy EDH evacuation + Reconstruction elevate depressed fracture Post surgical PICU admission
- 30. FOLLOW UP
- 31. Subjective Patient was fully alert, pain in the post operation area (+), minimal pain on surgical site, no vomiting, no fever. Objective GCS : E4V5M6 Pulse : 120 beats per minute, regular, adequate Blood pressure : 90/60 (P50) Respiration : 24 times per minute Temperature : 36.7 尊C O2 saturation : 99% oxygen with face mask 6 lpm General Status Eye : edema palpebra (-), pale conjunctiva (-) Thorax : Symmetrical, retraction (+) subcostal minimum Cor : S1S2 normal, murmur (-) galop (-) Lungs : Vesicular, rales -/-, wheezing -/- Abdomen: not distended, normal peristaltic Extremities : warm, CRT < 2 seconds, edema (-) Skin : not cyanotic 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 : -/- Fluid balance (3.00 am-6.00 am) BC -212,3 ml UO 1.96 ml/kg/hour FOLLOW UP 18/08/2022, 06.00 AM
- 32. ASSESMENT Post elevation reconstruction depressed fracture + Mild head injury (S09.90) + Epidural hematoma regio parietal sinistra (S06.4) + Depressed skull fracture parietal sinistra (S02.91) post reconstruction elevate depressed fracture + Craniotomy epidural hematoma evacuation + Mild protein energy malnutrition (E43)
- 33. INSTRUCTION Therapy : O2 facemask 5 lpm Fluid requirements 1350 ml/day~drink ability 170 mL~IVFD RL+D40% 2 flass 49 ml/hours TF Standard Formula 10ml/kg/day~22ml every 3 hours Phenytoin 60mg every 12 hours oral Paracetamol 250 mg every 6 hours oral Ceftriaxone 50mg/kg/times~850mg every 12 hour~Neurosurgeon Phentanyl 100 mcg in 20 Ml NaCl 0,9% ~ 0,6 mL/hours~ Anesthesiology field
- 36. THANK YOU