Coass : 1.

Abdul M Kastella
2. Benyamin Kalapadang
3. Ester Kayame
4. Nurfitria
Consultant : dr. Tommy, Sp.BS

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Isaskar Ronsumbre/Male/ 21 y.o/ 194737
 Chief complaint : Stabbed wound on the head
 Present illness :
Patient comes to the emergency room with complaints of headaches, the chronology
of the patient was initially stabbed by someone who was known when he was consuming
alcohol. The patient was stabbed because the offender was offended by the words of the patient
so the perpetrator took sickle machetes and straight machetes to hit the victim. The first blow
was received at the head using a sickle machete, then the perpetrator tried to hit the victim's
hand using a straight machete, but the victim tried to fend off and catch the machete. When
catching the machete the perpetrator tried to pull the machete from the patient's grasp. The
patient immediately fled to the rocky mountain so that patient's leg was injured by a stone.
Nausea (-) vomiting (-) fainting (-), blurred vision (-)

History of illness : Nothing like this before, history of hypertension, Diabetes Mellitus, Uric
Acid, easy bleeding wounds, bleeding is difficult to stop being denied by the patient.

Cognita Manu Melia Cultu Neurosurgery Division

Mr. Isaskar Ronsumbre/Male/ 21 y.o/ 194737
 Physical examination :
• VS, BP:110/60 : HR : 92 bpm, RR : 21 x/m, T: 36,2˚C, SpO2: 99%
• GCS: E4V5M6
• Normocephal , light reflex +/+, corneal reflex +/+, Cranial nerve: palsy (-) racoon
eyes -/- battle sign -/-, otorrhagia -/-, bloody rhinorhea -/- edema palpebra -/-
• Cervical: bruise (-), rigid cervical collar (-)
• Thorax:
I: symmetrical, Follow the breathing, Injury (-), Bruised (-).
P: chest pain on right side of ICS II,
P: sonor
A: Vesicular breath sounds, smooth wet rhonki on both lungs.
Cor: dbn
Cognita Manu Melia Cultu Neurosurgery Division
• Abdomen: Injury in the iliaca dextra
• Extremities: Vulnus excoriation on interdigiti 3-4 and 4-5, swollen of the
right hand, V. Excoriatum in the right and left of regio anterior patella.

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Isaskar Ronsumbre/Male/ 21 y.o/ 194737
 Clinical Diagnosis : Vulnus laceratum regio parietal sinistra with
fracture linear cranial
 Topical Diagnosis : Extracranial
 Etiological Diagnosis : Post trauma capitis.

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

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Laboratorium Examination

examination value
HB 14,9
HCT 44,0
RBC 6,01
WBC 22,48
PLT 301
DDR Neg
APTT 20,4
PT 11,5

Cognita Manu Melia Cultu Neurosurgery Division

 Planning
 IVFD Nacl 0,9% 2000cc /24 hour
 Inj. Cephalosporins 3rd Generation
2gr/12 hour
 Metronidazol drip 500mg/8hour
 Inj. Metamizole 1gr/8 hour
 Inj. Antagonist histamine receptor
50mg/12 hour
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 Pro CT scan skull 3D and thorax
 Pro debridement + correction
fracture
 Check DL, PT, APTT
 Consul anesthest
 Observation GCS and VS per hours
Neurosurgery Division
Instruction post op.

 IVFD RL 28 tpm
 Inj. Cephalosporins 3rd Generation 1 gr/ 12 hours
 Inj. Inj. Antagonist histamine receptor (Ranitidin) 50 mg/12 hours
 Inj ketorolac tromethamine 30 mg/ 8 hours
 Inj. Asam Tranexamat 500 mg/8 hours

Cognita Manu Melia Cultu Neurosurgery Division

Xray Thorax and Manus

Cognita Manu Melia Cultu Neurosurgery Division

Mr. Isaskar Ronsumbre/
Head Ct Scan Results
without Contrast

Cognita Manu Melia Cultu Neurosurgery Division

Mr.Isaskar Ronsumbre/Male/ 21 y.o/ 194737
Head Ct Scan Results without Contrast
• There is no abnormal hypodens area Sulci
and bilateral sylvii fissure and bilateral
interhemister fissures did not widen

• It appears that the ventricular system does

not widen, ventricles 3 and 4 are normal

• Invisible midline structure deviation

• There is no fracture in the bone window

scan

• Impression: No bleeding, No fracture,

Edema cerebral

Cognita Manu Melia Cultu Neurosurgery Division

 Thank You

Cognita Manu Melia Cultu Neurosurgery Division