IDENTITY

Name : miss H
Age : 18 years old
Admission : September, 19th 2017
DPJP : dr. Syamsul Rijal , Sp.B
 HISTORY TAKING
 Main complain : headache

 Anamnesis :
Patient came to the hospital with headache since 1 hours ago after got
accident.
 Mecanism of trauma :
 patients riding motorcycles at speeds of 20-40 km / h. the patient hit
the motor that stopped in front of her. patients do not use helmets
 There was history of syncope less then 5 minutes, there was vomit.
there was no bleeding from nose (-), mouth (-), ears (-).
 Primary survey
A Clear

RR 20x/min, spontaneous,
symmetrical B
C BP : 120/80 mmhg, HR = 88x/min, regular, strong

GCS 15 (E4M6V5), pupil isochors, D

E T = 36.70 C (axillary)
 Secondary Survey

Head :
Hematoma at occipitalis region
Plan of Diagnostic

 Routine blood cell

Head x ray
Diagnosis

mild head injury

 MANAGEMENT
 IVFD
 Analgetics
 H2RA
Consult to general surgery
 Thank You

BAGIAN ILMU
BEDAH