Identity

Name Age Gender Address Job Medical Record

: RP : 14 years old : Male : Petapahan : student : 789958

Primary Survey

Airway Stridor (-), gurgling(-), cervical spine control (-) Breathing Simetris, RR 20X/minutes Circulation BP 130/80 mmHg, HR: 84 x/minutes regular and capillary refilling time <3 seconds Disability GCS E3V5M6, pupil isochor 3mm/ 3mm, light reflect (+/+) Exposure Undressed the patient and put the blanket on him

Primary Survey
Airway Evaluation Patient conscious, able to speak clearly Assessment: airway clear

Breathing Evaluation Inspection: there is an increased effort to breath, breath frequency of 22 times / min, symmetrical chest movement Palpation: left fremitus same as the right Percussion: sonor Auscultation: vesiculer Assessment: breathing not disturbed

Circulation Evaluation Pulse rate 84 beats / min, acral warm, CRT <2 seconds, blood pressure 120/80 mmHg, temperature 360C. Assessment: circulation not disturbed

Disability Evaluation GCS 15, pupil isochor, right 3 mm, left 3 mm, positive light reflex right and left Assessment: disability not disturbed

Exposure Evaluation Found hematom on the patient's temple and has wound on his chin Action: cleaning the wound and blanketed the patient to prevent hypothermia

Secondary Survey

Patient RR, male, 14 years old, was admitted to AA General Hospital on November 26th, 2012. Chief Complain : vomit 3 times after got traffic accident because fallen from his motorcycle since 8 hours before admitted to the hospital

Present illness history

A 8 hours before admitted to the hospital, patient got traffic accident because fallen from his motorcycle. He used helmet. Patient said that he didnt remember the mechanism of the accident. He got headache after the accident. pain is felt continuous, lesion in head area (-), he got vomit 3 times before come to the hospital. hematom in his palpebra sinista Then, he was transferred to the hospital. He woke up at the hospital. There was no blood emit from his ears and the patient was not vomit at the time.

Past History Illness : No related ilnesses Family history : -

Physical examination
Generalized condition : moderate illness Conciousness : composmentis GCS E4M6V5 Vital sign :

BP : 120/80 mmHg HR : 84 x/minute RR : 22x/minute Temp : 36 C

Head : localized status Neck : normal Thorak : normal Abdomen : normal Extremity : normal

Locally Status
Head Inspection : hematom on palpebra the wound in his

sinistra, didnt found head GCS : 15 Motorik : 5/5/5/5

Working Diagnosis: Contusio + mild head injury + linear fracture

Examination planning
1. 2. 3.

Routine blood examination Head CT-Scan 3D scan of head

Routine Blood Examination

Hb Platelet Ht WBC

: 14,4 gr/dl : 309.000/l : 43,3 %. : 25.900/l

Rontgen

Manegement

Conservative:
Bedrest with Fowler position Ranitidin iv 2 x 1 amp Ceftriaxone iv 2 x 1 mg Tramadol 3 x 1 g Control the symtom of increase intracranial pressure