IDENTITY

Name
: Mrs. D
Age : 34 y.o
Address : Lambusa Residence
Admission : October 14rd, 2016
DPJP
: dr. Syamsul Rijal, Sp. B

HISTORY TAKING
Main Complain : unconsiousness
A patient was brought to emergency unit after had a traffic
accident 3hours ago. As long the way to hospital, Patient have
a decreased consiousness. There was a historical of sincope,
no seizzure and vommiting.
Mecanism of Trauma : the patient was riding motorcicles with
her friend then suddenly fell down to the ground when turn the
corner way.

PRIMARY SURVEY

Clear
RR 26 breath/min regular, spontaneous
thoracoabdominal type, symmetrical

BP 120/70 mmHg
PR = 82 beat/min regular, strong
GCS 11 (E3V3M5), isochoric pupil,
: 2.5 mm/2.5 mm, light reflex +/+

T = 36,60 C (axillary)

Secondary Survey
normal
Hematom and Lacerated wound at
parietal region
normal
bleeding

Normal
Normal
Normal

Normal

Multiple excoriated wound at knee region

Clinical Diagnose

Moderate Head Injury GCS 11 +

hematom and laceration wound at
parietal region

Planning Examination

Skull X Ray
Routine Blood

Therapy

IVFD
Analgesic
antibiotic
consult surgeon

Thank You

Elisabeth Grety