Lah Bin Hassan
B699966

65/M U/L HPT

Working on replacing his home iron gate at 10 am.
Gate fell on him and fell onto the floor
Trauma not witnessed by anyone but wife noticed he was seated on the ground about 10 minutes later

Post trauma, had brief moment of LOC with retrograde amnesia of that duration. C/o headache with giddiness, nauseated, no vomiting at home, but vomited x 1 at ed. Otherwise, no diplopia, no ent bleed, no hearing or visual impairement.

Initially brought to Hosp Tengku Anis - Referred to USM TRO ICB

On arrival to HUSM
BP 177/77
PR88
T 36.5

Pupils 2/2 reactive
e4v5m6

Raccoon eye over left eye
No battle sign
No visual impairement 
extraocular muscle intact - no diplopia
no facial numbness
hearing intact
gag reflex present


Motor examination
Tone Normal
Power 5/5 bilaterally
Babinsky downgoing
reflex intact
sensation intact and equal

Ct brain

Right temporal contusion with SDH and SAH
Multiple right frontal contusion
tentorial SDH
left subgaleal haematoma

Imp : Right temporal burst lobe with multiple contusions


Plan
Load Iv Phenytoin 
IV Mannitol 100mg stat and tds
GCS and pupil monitoring
Fit chart
If drop in gcs or fitting, for emergency decom. craniotomy and clot evacuation
NBM
IVD 5 pints with NS


Underwent Craniectomy and evacuation of clot