In Patient

Male patient, 40 years old, was admitted to ER ,with :

Chief complaint :
Decreased of consciousness after traffic accident since 12
hours before admission

PRIMARY SURVEY :
A : clear
B : spontan, RR 18x/minute
C : HR : 96x/minute BP : 110/70 mmHg
D : GCS 14 (E3M6V5), Pupil isochor 3 mm/3mm, light
reflex (+)
Secondary Survey

• Decreased of consciousness after traffic accident since 12

hours before admission

• Patient was riding motorcycle and then strucked by

another motorcycle and her head bumped to the asphalt.

• Vomit (-), seizure (-)

• Rhinorhea (-), otorhea (-)

• No associated trauma
Physical Examination
• General Appearance : Moderately illness
• Consiousness : GCS 14 (E3 M6 V5 )
• HR : 96 x/ minute
• BP : 110/70 mmHg
• RR : 18 x/ minute
• Temp : 370 C

Generally State
Eyes : Conjunctive was not anemic
Thorax and abdomen no abnormally detected
Locally state

Head region
Ins : Wound (-), hematome (-)
Pal : Depressed fracture (-)
Working diagnose :
Traumatic Brain injury GCS 14 (E3M6V5)

Laboratorium :
Hb : 13,6 gr%
Leu : 8.390 mm3
CT Scan
Diagnose :

Traumatic brain injury GCS 14 ( E3M6V5)

Patient’s conditions this morning :
Patient in ward
S/ Patient is conscious
No vomitus and seizure

O/ BP : 120/ 70 mmHg, HR : 86 x/ minute

RR : 18x/ minute T : 36,8oC
GCS : 15 E4M6V5

A/ Traumatic brain Injury GCS 14

P/ Conservative