Emergency Case Report July 11-12th 2015Resident on Duty: dr. Zacky FauzieChief : Evi Febriana Hafisah

Co-ass:Rasdita NurhidayatiMiranti Rahmi ApriliaJefry Albari TribowoAlvita Fani Yulita

Patients List

NoIdentityAdmission to E.R.DiagnosisTreatment1.Mrs. Ernawati/40 y.o July 11th 2015 at 15.50 WITAHidrocephalus Acute + Meningoencephalitis Obs. Vital signOxygenationHead up 30AntibioticAnalgeticH2 Blocker

Consult to neurosurgery :Pro PV ShuntPatient discharged by request

2.Mr.Supriyanto/23 y.oJuly 11th 2015 at 22.00 WITAModerate head injury E3V4M5 + EDH 60 cc + closed fr frontalis dex + closed fr Zygoma dex + closed fr zygomatic process dexObs. Vital signOxygenationHead up 30AntibioticAnalgeticH2 BlockerX ray thoraxCT Scan

Consult to neurosurgery :Pro Craniotomy Evacuation

Patients List

NoIdentityAdmission to E.R.DiagnosisTreatment3.Mrs. Saugiah/47 y.o July 12th 2015 at 01.10 WITAMild head injury GCS E3V5M6 + Cerebral Edema + Lefort I & II + CF Zygomatic Process Sinistra + CF Sphenoid Sinistra Obs. Vital signOxygenationHead up 30AntibioticAnalgeticH2 BlockerCT Scan, XrayConsult to Neuro surgery : pro conservativeConsult to Plastic surgery : pro ORIF

Mrs. Ernawati/ 40 y.o/July 11th 2015/ 15.50 WITAChief Complain : decrease of consciousness

History: The patient has decreased her consciousness about 1 wee ago. About 1 month before, she complained about headache with vomitus and nausea. The headache worsen by the time. Headache didnt decrease by analgetic. About 2 weeks ago she looked for medication to Kotabaru Hosp but then she dismissed after decreasing of consciousness 1 week ago. She was brought to Millenia Clinic at Banjarmasin. She was getting better and conscious in Millenia Clinic for 2 days but getting decreased her conciousness back. Because of that, she was referred to Suaka Insan and warded at ICU for 3 days. After that she treated at Woman ward for 4 days then referred to Ulin hosp for further treatment. History of fever 2 weeks before headache. History of seizure (-). History of hypertension (+).

Vital Sign

General Status

Patological reflects :

Brudzinskis signs (-)Babinskis signs (+/+)Chaddocks signs (+/+)Hoffmans signs (-/-)Tromners signs (-/-)Gordons signs (+/+)Rossolimos signs (+/+)Schaffers signs (+/+)

Cornea reflects : (-/-)Pupil size (5mm/5mm)Pupil reflects (-/-) Neurological status

Motoric+3 +3+3 +3Sensoric +++ +Tonus