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The patient came with complaints of decreased consciousness since 2 days ago, after the patient was in a car and
was hit from behind, after the incident the patient experienced a decrease in consciousness, no nausea, vomiting,
no seizures, no fever. BAK is smooth, has not had bowel movements since this morning There is no history of
bleeding from the nose. There is no history of bleeding from the ears. There is no history of hypertension. There
is no history of DM.

The patient was referred from Batara Siang Pangkep Hospital and received therapy: Piracetam 3 gr/IV/extra
Ketorolac 30mg/8jam/iv
Ranitidine 50mg/12jam/iv

Mechanism of trauma: The patient was in the car as a passenger in the second row behind the driver, suddenly
the car was hit by a large truck from behind, then the patient's head hit the right door of the car

Summary of Past Diseases:

The patient came with complaints of decreased consciousness since 2 days ago, after the patient was in a car and
was hit from behind, after the incident the patient experienced a decrease in consciousness, no nausea, vomiting,
no seizures, no fever. BAK is smooth, has not had bowel movements since this morning There is no history of
bleeding from the nose. There is no history of bleeding from the ears. There is no history of hypertension. There
is no history of DM.

The patient was referred from Batara Siang Pangkep Hospital and received therapy: Piracetam 3 gr/IV/extra
Ketorolac 30mg/8jam/iv
Ranitidine 50mg/12jam/iv

Mechanism of trauma: The patient was in the car as a passenger in the second row behind the driver, suddenly
the car was hit by a large truck from behind, then the patient's head hit the right door of the car

Primary survey:A: clear, patent, c spine controlB: RR: 20 beats per minute, symmetricalC: HR: 80
beats per minute, lifting force, BP: 130/80 mmHg,D: GCS 13 (E3M6V4), Pupil isochor 2mm /2mm,
RCL +/+ , RCTL +/+, Motor lateralization (-) E: Temperature: 37 degrees Celsius

Neurological Status: GCS 13 (E3M6V4) Pupil isochor 2mm/2mm, RCL +/+, RCTL +/+,

N. Cranialis: difficult to assess Motor: K 5/5 Sensory: difficult to assess R. Physiological : +/+

R. Pathological: -/-Autonomous: BAB has not been running smoothly since this morning

RESULTS
An MSCT scan of the head without contrast axial slices of coronal and sagittal reform has
been carried out with the following results:

- Differentiation of gray and white matter within normal limits

- There is a hyperdense lesion (52 HU) on the left side of the posterior pons
- Normal sulci and gyri
- The midline doesn't shift
- Subarachnoid space and ventricular system within normal limits
- Physiological calcifications in bilateral choroid plexus, pineal body and falx cerebri
- Cerebellum within normal limits
- Inclusion (14 HU) in the right sphenoid sinus. Other paranasal sinuses and mastoid air cells
scanned within normal limits
- The scanned bulbus oculi and retrobulber structures were within normal limits
- The scanned bones are intact

IMPRESSION
- Hyperdense lesion of posterior pons on left side, suspected bleeding
- Sinusitis sphenoid kanan
- Intact bones

PROPOSAL
MRI Brain