IDENTITY

Name : Mr. S
Age : 57 year old
Adress : Beringin street
Admission : July, 16th 2017
DPJP : dr. H. Syamsul Rijal,
Sp.B
HISTORY TAKING
Main complain : Unconsciousness
Anamnesis :

Patient referrals from the Bhayangkara

Hospital with complain unconsciousness
suffered since 4 hour after a traffic accident.
Mechanism of trauma : The patient was a
driver of motorcycle. The patient fall when hit
a truck crossing. Patients are not using
helmet. Pasients fell position and actually
accident is unknwon.
There was history of unconsciousness after
accident, There was history nausea and
 PRIMARY SURVEY
Unclear
A Gurgling insert of oropharyngeal
airway (gudel) Airway Clear
RR 32x/min , spontaneous,
abdominalthoraco type, symmetrical
using an oxygen mask 10 l/m
B
C BP 100/50 mmHg
Pulse = 68x/min, iregular

GCS 3 (E1V1M1) D
E T = 37,10 C (axillary)
 SECONDARY
SURVEY

GENERALIZED STATE

Neck : Normally
Chest : Normally
Abd : Normally
Extremity
superior : Normally
inferior : Normally
 SECONDARY
SURVEY
LOCALIZED STATE
Head : Hematom at parietal region,
laseratum wound at parietal region
zise 4 cm
Face: Excoriatum wound at frontalis
and zygomatica sinistra region
Eyes : Hematom at orbitalis dextra
sinistra region, : 3mm/2,5mm, light
reflex -/-
Nose : Active bleeding
Mouth : Active bleeding
Ears : Active bleeding
Laboratory
Laboratory
CLINICAL FINDING
PLANING EXAMINATION

Complete Blood Count

SKULL X-RAY AP
CT- scan Skull
 DIAGNOSIS

Severe Head Injury GCS 3 (E1M1V1) +

Hematom At Parietal Region + Laseratum
Wound At Parietal Region + Excoriatum
Wound At Frontalis And Zygomatica Sinistra
Region + Hematom At Orbitalis Dextra Sinistra
Region
 MANAGEMENT

IVFD
Head Up 300
Insert of oropharyngeal airway (gudel )
Oxygen Mask 10 l/m
Antipiretic
Analgetic
Antibiotic
Antihemorragic
CONSULT SURGEON
 Thank You

BAGIAN ILMU
BEDAH
a Ramadhani Darwanti