IDENTITY

Name
: Mr. F
Age
: 22 years old
Admission
: September, 19th
2016
DPJP
: dr. H. Syamsul Rijal,
Sp.B

HISTORY TAKING

Chief complain : Headache

Anamnesis
: (alloanamnesis dan
autoanamnesis)
Reference from Konawe hospital. Suffered
since 3 hours before admitted to the
hospital due to traffic accident.
Mechanism of trauma : the patient was a
driver of motorcycle using helmet with
high speed suddenly falling down hit a
pedestrian who was drunk alcohol. There
was history of unconscious, no history of

Primary survey
A

Clear
RR 20x/min regular, spontaneous
thoracoabdominal type, symmetrical

BP 120/70 mmHg
Pulse = 78x/min, regular, strong
GCS 15 (E4V5M6), pupil isochors,
: 2mm/2mm, light reflex +/+

T = 36.80 C (axillary)

secondary
survey
Head: Normal
Face : Hematoma (+) lacerated wound at the
frontalis region, excoriated
wound at the
frontalis region.
Eyes : Hematoma d/s (+)
Nose : Excoriated wound at nasalis region. Blood
clot after epistaksis (+)
Mouth : swelling of the lips (+)
Ears : Normal
Neck : Normal
Chest : Normal
Abdomen: Normal
Extremity: Superior : Excoriated wound at left
antebrachii, Excoriated
wound at
right manu.s
Inferior
: Normal

PLAN OF DIAGNOSTIC

X-ray skull region,

ap/lat view

Radiological finding

CLINICAL
FINDINGS

DIAGNOSIS
Mild Head Injury GCS 15 +
Lacerated wound at
frontalis region + Multiple
Excoriated wound

MANAGEMENT
IVFD RL 20 tpm
Wound care
Antibiotic
Analgesic
Consul an surgeon

Thank
You

BAGIAN ILMU
MeiBEDAH
Asrina Demara