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A: clear
B : RR: 22 times in a minute
C : Blood preasure : 130/70 mmHg , Pulse: 89
times/minute, reguler.
D : GCS E1V1M3, pupil ishokor, 3mm/3mm
E : vulnus laseratum regio frontalis dextra, supra
orbita dextra with bone expose, regio zygomaticum
dextra
Vulnus laseratum regio patela cruris dextra, vulnus
escoriatum cruris dextra
Secondary Survey
Head : vulnus laseratum regio frontalis dextra with bone
expose, supra orbita dextra, regio zygomaticum dextra
Eye : anemic (-/-), pupil isokor (+/+), icteric (-/-)
Ear : blood clot at left ear, ottorea (-/-)
Nose : blood clot (-/-), rhinnorea (-/-)
Mouth : smell alcohol
Thorax
Inspection : chest expansion bilateral simetric,
pattern of respiration is abdominothoracal
Palpation : vocal fremitus R=D
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchie (-/-),
wheezing (-/-)
Abdomen
Inspection : distended (-)
Auscultation : peristaltics (+) still normally
Palpation : tenderness pain (-), mass (-)
Percusion : timpany sound (+)
Extremity
Look : normal
Feel : pain on the right leg (+), bruised (-)
Move
ROM : normal
Laboratorium
CBC :
Hb 12,7 gr/dL
WBC 32,3 x 10^3/uL
Plt 295 x 10^3/uL
Planning Diagnosis
Head CT Scan
Assessment
Severe Head Injury
Vulnus laseratum regio frontalis dextra, supra orbita
dextra with bone expose, regio zygomaticum dextra
Vulnus laseratum regio patela cruris dextra, vulnus
escoriatum cruris dextra
Planning therapy
O2 2-4 lpm
Wount Toilet
Hecting
IVFD NaCL 0,9% 20 tpm
KCT 2x30 mg
Ranitin 2x50 mg
Consul Sp. BS