IDENTITY

Name
:
Age
:
Adress
:
Admission
DPJP
:
Sp.B

Child R
5 years old
Kampus Baru
: April, 06th 2016
dr. H. Syamsul Rijal,

HISTORY TAKING
Chief Complain : Headache
Heteroanamnesis : suffered since 30 minute hours before
admitted to the hospital by accident. History of vomiting
one times containing food mixed with blood,brown. There
was history of bleeding from the nose and right ear. There
was not history of sinkop (-). Mechanism of trauma : the
patient was hit by the car was pulling from the front.
Previous treatment history : patient referal Abunawas
hospital, patients get treatment : IFVD RL, Ondansentro
Inj, Citicolin Inj,Asam Tranexamid Inj.

PRIMARY SURVEY

Clear
RR 39x/min regular, spontaneous
thoracoabdominal type, symmetrical

BP 100/50 mmHg
HR = 116 x/min, heave reguler
GCS 15 (E3V5M4), pupil : isokor with
diameters,
: 2.5 mm/2.5 mm, light reflex +/+

T = 36,70 C (axillary)

Secondary Survey

Next...

Clinical Finding

DIAGNOSIS

Mild head injury GCS

15 + excoriated
wound at left
axillaris regio + right
auriculer bleeding

Planning Diagnostic

Counting blood cell

Skull X-Ray Ap/Lat

THERAPY PLAN

O2 1-2 liter
Intravenous Fluids
Intravenous Antibiotics
Intravenous Analgetic
Antibleeding
Tampon ear
Consult to the general surgeon

Radiological Finding

L/O/G/O

Thank
You
BAGIAN ILMU
BEDAH