No.

Name : Mr. L Sex : Male

Age : 20 years old No. Reg : 741022
Chief complaint : Decrease of consciousness
History taking : Suffered since 5 hours before admitted to
Wahidin General Hospital due to motor vehicle
accident. There were history of vomiting

Mechanism of : Patient was riding a motorcycle and get hit by

injury another motorcycle from opposite direction. The
next mechanism was unclear
Injury sustain : Head
Symptom & sign : Decreased of consciousness
Examination : Physical examination, laboratory examination,Thorax X-
Ray, head CT scan
PHYSICAL EXAMINATION
Primary Survey
A: clear

B: RR : 18 x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP : 110/70 mmHg, HR : 92 x/minute, regular, adequate

D: GCS 13 ( E3M6V4), pupil isokor 3mm/3 mm , LR +/+

E: T (ax) : 36,9oC
Secondary Survey

left periorbital region

I : seen periorbital hematom, edema
(+), active bleeding(-)
P: tenderness(+), crepitation (-)
 Laboratory Result
WBC : 20,3 H x 103 / L

RBC : 4,43 x 106 / L

HGB : 12,8 g/dL

HCT : 38%

PLT : 165 x 103/ L

CT / BT : 700 / 3 00

Blood Sugar : 147 mg/dl

Ureum : 24 mg/dl

Creatinin : 0,66 mg/dl

GOT / GPT : 65 / 28 /L
WORKING DIAGNOSIS : Moderate head injury GCS 13 ( E3M6V4)
Epidural hematome at left
temporoparietal region

MANAGEMENT :
O2
IVFD
Medicaments
Report to Senior Neuro Surgeon
advice : immediate craniotomy EDH
evacuation