Department of Surgery

February 23, 2015

Name : M Rifky E
Age
: 14 y.o
Sex
: Male
Address : Kawistolegi Karanggeneng
Lamongan
Date examination: Feb 23, 2015

Chief complaint :

Headache

MOI :
Patient complained headache post felt in his house about
2 days before admission. He felt alone when the accident
was happened. His head hat a floor. His headache in back
side. Its not refered to the neck. Decrease of consiousness -,
vomiting 1x when he was on the road, Miction and defecation
was normally, PTA (-). He was medicated in Puskesmas 2
days before admission.

Airway and spine control : clear (+),

snorring (-), gargling (-), potensial
obstruction (-)
Breathing : spontan, simetric (+), RR
x/minutes, ves/ves, rh-/-, wh-/Circulation : PR 79x/minutes, acral warm dry
red, CRT < 2 , Sp02 distal 99%, blood
presure 114/80 mmHg
Disability : GCS 456, LP +/+, isocor pupil
3mm/3mm, lateralisasiExposure : temp 36.4

History past illness same complained denial

History of social, economic :Status Generalis
Head and neck : anemic (-), icteric (-), cyanosis
(-), dyspneu (-), jejas Thorax : simetric (+), retraction (-)
Pulmo : ves/ves, rh-/-, wh-/Cor : S1S2 single, murmur (-), gallop (-),
lession Abdomen : flat (+), soepel (+), tympani (+),
liver and spleen were not palpable, bowel sound
(+), lession-, injury Extremities : acral warm, dry, red, lession-

Clue and cue

Male, 14 y.o
Headache post trauma
Vomiting

Mild Head Injury

CBC
RBG
CT-Scan without contras

Eritrosit : 4,87
Hb : 12,4
LED : 28/51
Limposit : 21,2
Basofil : 2,8
Eusinopil : 3,9
Hct : 39,2
Leu : 6.300
MCH : 25,50
MCHC : 31,60
MCV : 80,50
Trombosit : 431
GDA : 96

Mild Head Injury with minimal EDH

Ivfd Asering 1500 cc/24 h

Inj. Ranitidin 2x50 mg iv
Inj. metamizole 3x500 mg iv
Inj. piracetam 4x1,5 gr iv
Inj. Ondansentron 2 x 4 mg iv
c/ dr. Suharianto Sp.BS observation

Subjective complaint
Vital sign
GCS

Explain to the patients family about the

diagnosis, etiology, intervention of therapy,
complication, and prognosis.