Coass : 1.

Junarto Butar Butar

2. Janet Himber
3. Gluh Deca
6. Rina Panggaribuan

Consultant : dr. Tommy, Sp.BS

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Ernos Hugi/Male/ 24 y.o/ 451371
 Chief complaint : weakness of left extremity
 Present illness :
Patient was hit on his right head using a rock 5 days
before admitted to emegency unit. Then the patient
was fall to the ground and his suppressed his left
hand. After that the patient feels weaknes on the left
arm, nausea (+), Vomiting (+) 2 times in, dizzines (-),
Seizures (-).
 History of ilness : -
Cognita Manu Melia Cultu Neurosurgery Division
 Physical examination :
• VS, BP:130/100 : HR : 82 bpm, RR : 18 x/m, T: 36,5˚C, SpO2: 96%
• GCS: E4V5M6
• Normocephal , light reflex +/+, corneal reflex +/+, Cranial nerve: palsy (-)
racoon eyes -/- battle sign -/-, otorrhagia -/-, bloody rhinorhea -/-
• Cervical: bruise (-), rigid cervical collar (-)
• Thorax: cor and pulmo within normal limit
• Abdomen: normal
• Extremities: lateralisation (+) in left hand

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Ernos Hugi/Male/ 24 y.o/ 451371
 Clinical Diagnosis : weakness of left extremity
 Topical Diagnosis : Right Hemisphere
 Etiological Diagnosis : Post trauma capitis.

Further examination :
• Laboratory examination
• Chest X-ray, EKG, Non-Contrast Head CT scan

Cognita Manu Melia Cultu Neurosurgery Division

Laboratorium Examination

examination value examination value

HB 11,2 Basofil 0,1
HCT 33,5 eosinofil 0,3
RBC 4,0 neutrofil 71,5
WBC 14.45 limfosit 15,1
PLT 250 monosit 13,4
DDR Neg
GDS 174
PT 10,4
APTT 24,9

Cognita Manu Melia Cultu Neurosurgery Division

 Plan
 IVFD RL 500cc /8hour  Whole blood 1 bag
 Inj. Cephalosporins 3rd Generation  Pro debridement + correction open
1gr/12 hours/iv fracture depressed regio parietal
 Inj. Piracetam 800mg/12hours/iv dextra. CITO!
 Neuroactive peptide drops 2 gtt/12  CBC, prepare for operation
hours
 Consul anesthest
 Inj. Citicolin 500mg/12 hours
 Inj. Ketorolac 30mg/8hours/iv
 Metronidazol drip 500mg/8hours/iv
 Inj. Antagonist histamine receptor
50mg/12 hours

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Ernos Hugi/Male/ 24 y.o/ 451371
Head Ct Scan Results
without Contrast

Cognita Manu Melia Cultu Neurosurgery Division

 Thank You

Cognita Manu Melia Cultu Neurosurgery Division