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MR VL 30 Sept 3014
MR VL 30 Sept 3014
Name
: A.B
Age : 42 years old
Sex : Male
Address : Fatululi
Cheif
Compain:
Unconsciousness
: clear, patent
B : RR 25 x/m, spontan,
C : BP 120/90 mmHg Pulse 94 x/m,
D : voice
GCS
: E3V5M6
Head : 1 VE (+) regio occipital 3 x 3 cm, bottom
of the wound is skin, active bleeding (-)
hematom (-)
Eye : anemic (-/-), light reflex (+/+), icteric (-),
racoon eyes +/+
Ear : clot(+/-)
Nose : clot (+/+)
Neck : enlargement (-)
Left Shoulder : deformity (+), swelling (+),
crepitation (+), tenderness (+)
Inspection
Look
normal
Feel
normal
Move
normal
WBC
RBC
HGB
PLT
: 12,63 x 103/uL
: 4,99 x 106/uL
: 14,3 g/dL
:260 x 103/uL
Head
up 30 o
IVFD RL 20 tpm
Ketorolac 3 x1 amp IV
Ranitidin 2 x 1 amp. IV
Ceftriaxon 2 x 1 amp IV
Bandage
Head CT scan