NEUROLOGYCAL CASE

SEVERE HEAD
INJURY
By Eufrasia Victa Swastika Anggriasti , 030.11.090 - FK TRISAKTI
Preceptor : dr. Ronny Yoes, Sp.S

This presentation is performed as one

requirement to pass the clinical
clerkship of neurology station

PATIENT IDENTITY

 Name : Mr. S
Age

: 15 years old

Sex

: Male

Marital Status : Single

Education Background
Address

: Junior High School

: Petamburan

Date of Entry : March, 17th 2016

Number of Medical Record

: 15.28.XX

ANAMNESA
Anamnesa was done by alloanamnesa in March 17th, 2016 at Numfor ward room D2,
Dr.Mintohardjo Navy Hospital

CHIEF COMPLAINT

Patient present with consciousness declining since

1 hour before hospital admission

History of Present Illness

History of seizure, ear or nose bleeding, and drinking alcohol was denied

Medical Past
History

Family Medical
History

Past trauma history (-)

Seizure (-)

Seizure (-)

Diabetes Melitus (-)

Diabetes Melitus (-)

PHYSICAL
EXAMINATION

Vital Signs
Consciousness

: Sopor, E hematoma M 4 V 2

Blood Pressure

: 150 / 80 mmHg

Pulse

: 92x / min, regular, strong, equal

Breathing

: 28x / min

Temperature

: 27,3o Celsius

Generalist Status

NEUROLOGICAL
STATUS

 MENINGEAL SIGN
Brudzinsky I
Brudzinsky II
Laseque
: (-)
Kernig
: (-)

: Not Examined
: Not Examined

HEAD
Shape
: Normocephal
Tenderness : (+)
Pulse
: (+)
Symmetrical
: (+)

NECK
Posture
: Normal
Movement : (+)
APHASIA
Motoric Aphasia : Difficult to asses
Sensory Aphasia : Difficult to asses
Dysarthria
: Difficult to asses

Cranial Nerves
N. I - Olfactory Nerve

N. VI Abducent Nerve

N. II Optic Nerve

N. VII Facial Nerve

Pupil Isochor : Difficult to asses

Light Reflex : Difficult to asses

N. III Oculomotor Nerve

N. IV Troclear Nerve
N. V Trigeminal Nerve

N. VIII Vestibulocochlear Nerve

N. IX Glossopharyngeal Nerve
N. X Vagus Nerve
N. XI Accessory Nerve
N. XII Hypoglossal Nerve

Upper Extremities
SENSORY

PHYSIOLOGICAL REFLEX

Pain
Temperature

: Not Examined

Point Discrimination

: Not Examined

: Not Examined

Biceps
Triceps

: +2 / +2

Radius
Ulna

: +1 / +1

: +2 / +2
: +1 /+1

MOTORIC
Movement
Power

: +/+

Trophy
Tonus

: -/-

:5555/5555
: +/+

PATHOLOGICAL REFLEX
Hofman Tromner

:-/-

Lower Extremities
SENSORY

PHYSIOLOGICAL REFLEX

Pain
Temperature

: Not Examined

Point Discrimination

: Not Examined

: Not Examined

MOTORIC

Patella
Achilles

: +2 / +2
: +2 / +2

PATHOLOGICAL REFLEX

Movement
Power

: +/+

Trophy
Tonus

: -/-

:5555/5555
: +/+

Babinsky
Chaddock

:-/:-/-

Schaeffer
:-/ Oppenheim : - / Gordon
:-/-

 COORDINATON, GAIT, AND BALANCE

Walking
Romberg Test
Examined
Dysdiadokinetic

: Not Examined

Ataxia
Dissymmetrical

OTONOM REFLEX
Micturition
Defecation

; by Dauer Catheter
: Not Examined

: Not Examined

Anal Reflex
Cremaster Reflex

: Not Examined

Bulbocavernosus Reflex : Not Examined

: Not

: by Diaper
: Not Examined

: Not Examined

ABNORMAL MOVEMENT
Tremor
Athetose

:-/-

Myoclonic
Chorea

:-/-

:-/:-/-

LASEQUE
Patrick
Contra Patrick

: Not Examined
: Not Examined

RESUME

 Mr.S, male, 15 years old came to emergency room of Dr. Mintohardjo Navy
Hospital with complaint of consciousness declining since 1 hour before
hospital admission after traffic accident. The patient was driving a
motorcycle with 2 other friends. The patients motorcycle was slipping off
and his head hit the road. He didnt use a safety helmet and got
consciousness declining directly that was not able to communicate. During
in the emergency room, he got blood vomiting.

 Physical examination showed that consciousness spoor, E hematoma M4 V2, blood

pressure 150/80 mmHg, pulse 92x/min, breathing 38x/min, temperature 37,3 o
Celsius.
Eyes : Palpebral hematoma +/+, Lesion (+) in forehead, nose, lips, and cheeks.
Lung : Vesicular breathing sound +/+, rhonchi +/+ , wheezing -/-.
Neurological Status : Meningeal Sign (-), Cranial Nerves Lesion (-), Sensory :
Normal,
Motoric 5555 / 5555, Autonom : Normal.
5555 / 5555
Physiological Reflex : Biceps +2/+2, Triceps +2/+2, Patella +2/+2, Achilles +2/+2.
Pathological Reflex : Hofman-Tromner -/-, Babinsky -/-, Chaddock -/-.

SUPPORTING
EXAMINATION

Head CT Scan
without contrast
Image :
Anterior Intra- cerebral hemorrhage
Whitish of both maxillaries and
ethmoidalis sinuses
Fracture of Nasals bone

Bone Window
CT Scan
Image :
Fracture of Frontals and Nasals bone

3D Head CT Scan
Image :
Fracture of Right and Left
Zygomaticus, Frontals, and Nasals
Bone

Thorax Rontgen AP
Image :
Suspect TB?
Laboratorium?

Laboratorium

Complete Blood Count on March 18th, 2016

Leucocyte

16,800 / L

Erythrocyte

3,95 million / L

Hemoglobin

9,6 g / dL

Hematocrit

28 %

Thrombocyte

278,000 / L

Erythrocyte Sedimentation Rate

28 mm / hour

Laboratorium

Differential Count on March 18th, 2016

GLUCOSE TEST
Basophils

0%

Eosinophils

1%

Band Neutrophils

0%

Segmented Neutrophils

78 %

Lymphocytes

16 %

Monocytes

3%

246 mg / dL

ASSESMENT

Dx 1
Clinical

: Loss of Consciousness

Etiology

: Severe Head Injury

Topical

: Right and Left Brain Hemisphere

Pathological : Intra Cerebral Anterior Hemorrhage

Dx 2
Fracture of Right and Left Zygomaticus, Frontals, and Nasals Bone

Therapy
Citicoline inj. 2 x 250 mg
Ceftriaxone inj. 2 x 2 gr
Manitol inf. 4 x125mg
Ringer Lactate inf. / 12 hours

Prognosis

Ad Vitam

: Dubia ad Malam

Ad Functionam

: Ad Malam

Ad Sanationam

: Ad Malam

THANK YOU