IDENTITY

• NAME : MR. R
• Age : 21 years old
• Address : Paku Jaya
• Admision : Monday, 20th june 2016
• Responsible doctor : dr. Syamsul Rijal, Sp.B
 History taking
Chief complain : cephalgia
Anamnesis :
Suffered since 4 hours before admited to the
hospital after traffic accident.
Mechanism of trauma was Patient was ride a
motorcycle with a middle speed, he was using
helmet and suddenly, someone cross the road
and the patient trying to avoid her.
There wasn’t history of unconscious, there weren’t
nausea and vomit, dizzines (-), bleeding nose (+),
ears bleeding (-).
 PHYSICAL EXAMINATION : Primary Survey

• Clear
Airway

• RR: 20x/min, symmetrical, spontaneous, regular

Breathing
• BP: 120/80 mmHg , HR: 88x/min
Circulation regular, strong

• GCS 15 E4M6V5, pupils are equal size

Disability 2,5mm, light reflex +/+

• T: 36,5 C
Exposure
 Secondary Survey
Hematome at orbicularis oculi D

Hematome at frontal region

Deformitas (+), hematom (+), edema (+) krepitasi (+), krusta (+), aktif
bleeding (+)

Normally

Multiple exoriated wound at labialis superior and inferior

Normally
Next...
Normal

Normal

Upper extremity : - normal

Lower extremity : multiple exoriated wound at right genu
region size 2x1 cm, 2x2 cm
Multiple exoriated wound at right digitalis pedis size 2x2 cm
 Working diagnosis
• Mild head injury GCS 15
• Nose bleeding susp. Frakture os. Nasale
• Multiple exoriated wound regio genu dekstra
and digitalis pedis D
 Planning examination
• Plain foto Skull posisi ap/lateral
 therapy
• Intravenous Fluids
• Intravenous Antibiotics
• Intravenous Analgetic
• Consult to the general surgeon