IDENTITY

Name
:
Age
:
Adress
:
Admission
DPJP
:

Mr. R
26 years old
Sampara
: May, 2nd 2016
dr. Faruly WSL, Sp.B

HISTORY TAKING
Chief Complaint : headache

Anamnesis : The patient was referred from PKM

sampara after a traffic accident 12 hrs before.
He felt such headache after falling from his
motorcycle when he tried to avoid road holes in
high speed. He doesnt wear helmet and so his
head was hit. Then, he was unconscious and
couldnt remember the moment after that in detail.
He also confirmed feeling dizziness, but didnt
remember any vomiting. He got few stitches on
his right supraorbital region. He had difficulties in
moving his right arm

 General state: moderately ill, GCS 15

VS: BP 130/80, HR: 80, RR: 20, T: 36,8 c
No abnormality in Neck, thorax, abdomen

Clinical Finding

Wounds region
Hematom in R orbital:
Laceration
supraorbital region (already stitched) 5cm
Excoriation:
L Nasal 4x3 cm
D Nasal 5x2 cm
R parietal 3x2
L oralis 6x 1 cm
L Antebrachii 14x3 cm
R deltoid region 10x4 cm
Auricular 4x0,5 cm

DIAGNOSIS

Mild head injury GCS

15+ Susp. Right
shoulder
dislocation+ multiple
excoriation wound

Planning Diagnostic

Complete blood count

Skull X-Ray Ap/Lat
Shoulder xray ap/lat

CBC

wbc: 13.92
Rbc: 5.41
Plt: 180
BT: 230
CT: 930

Skull Ap/lat

THERAPY PLAN

Intravenous Fluids
Intravenous Antibiotics
Intravenous H2 antagonist
Intravenous Analgetic
Consult to the general surgery

L/O/G/O

Thank
You
BAGIAN ILMU
BEDAH