F/M/15yo

855127
Chief complaint : pain in the head

The patient has had headaches since 6 hours ago, the patient fell from
a motorcycle without a helmet, History of decreased consciousness (-)
vomiting (-) seizures (-) weak limbs (-)
Primary Survey :
A : Clear
B : Spontaneus, RR: 22x/I SpO2: 99%
C : HR : 82x/i, BP: 122/72 CRT <2”
D : GCS 15, pupil isochor 3mm/3mm
E : T 36,5C
AMPLE
•A : no history of allergy
•M : no history of medication
•P : no history of past illness
•L : no history last meal
•E : kecelakaan lalu lintas
Secondary Survey :
• Head & Neck : there is an injury to the face
• Back : no abnormality was found
• Chest : no abnormality was found
• Abdomen : no abnormality was found
• Extremities : no abnormality was found
• Genitalia : Male, no abnormality was found
• Head and Neck : there is vulnus excoriasi on
the frontal and zygomaticum on the face, active
bleeding (-) contaminated (+)
Laboratory Finding
• Hb / Hct / WBC / PLT : 13/38/11.100/255.000
Chest X-Ray
Cervical AP Lateral
PELVIS
FAST
CT Scan
Working Diagnosis
Treatment