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Name : Mrs.

S
Age : 63
ID : 01422313
ADM : National Health Insurance
Chief complaint:
Persistent headache after falling

Present illness:

Ten hours prior to admission, while the patient was riding


bicycle, the bicycle was slipped and he fell down in unknown
position. Unconsciousness (+), vomit (-), seizure (-). After the
accident, patient complained persistent headache. By the
helper, he was brought to Panti Waluyo Hospital. Because of
limited facility, he was brought to Moewardi Hospital.
Primary survey

A : Clear

B : I : Equal chest expansion, RR : 20 x/mnt

P : crepitation (-/-)

P : Sonor/sonor

A : Vesicular breathing sound (+/+), additional sound (-/-)

C : HR : 94 x/mnt, BP : 130/80 mmHg

D : GCS E4V5M6, equal pupil width (3 mm/3 mm), light reflexes (+/+)

E : T : 36,6o C
Secondary Survey

Head : Hematom R. Parietal (D) (+)

Eyes : no abnormality

Nose : no abnormality

Mouth : no abnormality

Face : no abnormality

Ear : no abnormality

Neck : no abnormality

Chest : no abnormality

Abdomen : no abnormality

Extremity : no abnormalilty
1st Assessment :
Mild Brain Injury GCS E4V5M6 with persistent headache

1st Plan :
O2 3 lpm
Head Up 30°
IVFD NaCl 0.9% 1500 cc/24 hours
Metamizole inj. 300 g/8 hours
Laboratory
Head Ct scan
Head ct scan from Moewardi
2nd Assesment:
Mild Brain Injury GCS E4V5M6 (ICD X S06.2)
Oedema Cerebri (ICD X G93.4)

2nd Plan:
Inward
Observation VS, GCS and lateralization.
Arrival Time 16.10

Triage Time 16.15

Surgery Dept. Time 16.20

Radiology Time 16.35-17.30

Diagnose Time 17.35

Inward Time 17.40