IDENTITY

Name : Mrs. A
Age : 32 years old
Sex : Female
Address : East Kolaka
Admission : March, 4th 2017
DPJP : dr. Syamsul Rijal,
Sp.B
 HISTORY TAKING
Chief complaint : Headache
Anamnesis :
Patient presented to the hospital with
complaint of headache since 4 hours before
entering hospital because traffic accident.
Mechanism of trauma : the patient is a
motorcycles passenger. Suddenly the motorcycle
hit by a car that stop abruptly, so the patient
felt . Patient didnt use helmet.
There were history of syncope and vomiting.
History of nose and ear bleeding denied .
 Primary survey
A Clear

RR 20x/min, spontaneous
thoracoabdominal type, symmetrical B
C BP 120/70 mmHg
Pulse 68x/min, regular, strong

GCS 15 (E4M6V5), pupil isochors,

: 2,5mm/2,5mm, light reflex +/+ D
E T = 36,50 C (axillary)
 SECONDARY SURVEY
Head : There was hematoma at right
temporoparietal region with size 2 cm.
Eyes : Normally
Nose : Normally
Ears : Normally
Mouth : There was lacerated wound at the
upper lip with size 1x0,4x0,3 cm
Neck : Normally
Chest : Normally
Abdomen : Normally
Extremity : Normally
Plan of Diagnostic

Counting blood cell

Skull Xray AP/Lat
 Diagnosis

Mild Head Injury GCS 15 +

Hematoma right
temporoparietal region +
lacerated wound at oralis
region
Therapy
IVFD
Antibiotics
Analgetics
Consult to general surgery
Clinical Finding
 Thank You

BAGIAN ILMU
BEDAH
stavita Maria Bandong