Emergency Report

th-11th
th, 2015
February 10th

Resident on duty:
dr. Alma Wijaya

PATIENT LIST
Oncology surgery

Digestive surgery

Thorax cardiovascular surgery :

Plastic surgery

Urology surgery

Neurosurgery

:1

Pediatric surgery
Orthopedic
Total

:
:

:1

Patients List
N
o

Identity

Admissio
n to E.R.

Diagnosis

Ch
Widya, 5
yo/

February
10th ,
2015 at
17.15

Mild
Head
Injury GCS 15
+
Linear
fracture
at
occipital
region

Management

Consult to neurology
surgery:
-Obsv. Vital sign
-Head up 30 degree
-IVFD NS mainteanance
-H2 Blocker
-Analgetic

1. Mr. Fajar, 26 yo/ December

22nd, 2014 at 15.15
Chief complain: Headache
History : about 1 hour before admission when the

patient was playing around her house suddenly

then a car passed away beside the patient, the
patient fall with the head hit the road. History of
fainting + less than 5 minutes, vomiting - , seizure
- , bleeding from ear nose and mouth -. After the
accidet the patient concious and just felt pain on
the back of her head. The patient directly brought
to ULIN hospital by the family to get further
treatment

Primary Survey

A
B

Clear (-) with ETT , snoring (-), gurgling(-), stridor (-)

Clear, RR : 24 tpm, simetric respiratory movement,

VBS simetry, Rh

Pulse 92 tpm, reguler, lift strong, the extremities warm

BP: 110/70 mmHg

GCS E4V5M6, P 3mm/3mm, light reflex +/+, parese -/-

Secondary Survey
Head/Nec
k

Chest

Abdomen

Extremitie
s

Eyes : racoon eyes (-/-), anemic conjungtivae (-/-)

Nose : rhinohargia (-)
Ear : otohargia (-), battle sign (-)
Mouth : wet mucosa, bleeding Neck : Lymph nodes enlargement (-), JVP enhancement
(-),
hematome at occipital region (+) crepitation (-)
I : symmetric respiratory movement,
P : symmetric VF (+/+)
P : sonor at all lung
A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)
I : distention (-) injury (-)
A : normal Bowel sound
P : Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-) , rebound tenderness (-)
P : Tympani

Warm, see status localized Within normal limit

(-)

(-)

(-)

1 hour before admission

On the road

Localized Status

Localized Status
Eyes : racoon eyes (-/-),
anemic conjungtivae
(-/-)
Nose : rhinohargia (-)
Ear : otohargia (-),
battle sign (-)
Mouth : wet mucosa,
bleeding Neck : Lymph nodes
enlargement (-), JVP
enhancement (-),
hematome at occipital
region (+) crepitation (-)

Skull X-Ray February, 10th 2015

Ct Scan February, 10th 2015

LABORATORY FINDING

13,5
Result

HEMATOLOGY
Parameter

Normal Value

December 22nd, 2014

Hemoglobin

13,6

14,0-18,0 g/dl

Lekosit

14,1

4,0-10,5 ribu/ul

Eritrosit

4,31

4,5-6,0 juta/ul

Hematokrit

31,4

42-52 vol %

Trombosit

354

150-450 ribu/ul

14

Working Diagnosis
Mild Head Injury GCS 15 + Linear
fracture at occipital region

Management
Consult to neurology surgery:
- Obsv. Vital sign and GCS
- Head up 30 degree
- IVFD NS maintenance
- H2 Blocker
- Analgetic
- Hospitalized