IDENTITY

Name : Mr. S
Age : 46 years old
Sex : Male
Address : Distric Konda
Admission : February, 2nd
2017 (13.39 PM)
DPJP :
 HISTORY TAKING
Chief complain : Headache
Anamnesis :
Patient refferal from Konda Health Center with
complain headache since an hours before
admitted to the hospital. The patient comes
with a traffic accident.
Mechanism of trauma : the patient was a being
riding motorcycle, and suddenly hit another
motocycle in front of him while turned the street.
Patient used helmet.
There was history of syncope, There was
actived bleeding from nose, Ear bleeding and
vomiting was denied, There was history of
treatment in Konda Health Center.
 Primary survey
A Clear

RR 26x/min, spontaneous
thoracoabdominal type, symmetrical B
C BP 150/100 mmHg
Pulse =94x/min, regular, strong

GCS 15 (E4M6V5), pupil isochors,

: 2,5mm/2,5mm, light reflex +/+ D
E T = 36.50 C (axillary)
 SECONDARY SURVEY

Head : Normally
Face : Normally
Eyes : Normally
Nose : There was an active bleeding at right
nose and inactive bleeding at left nose
Mouth : There was an inactive bleeding by
incisor tooth that falled out
Ears : Normally
Neck : Normally
 SECONDARY SURVEY

Chest :
Inspection: there was deformity at region of
rigt clavicula, hematoma (+)
Palpation : Tendernes (+)
Percussion: Sonor
Auscultation: vesicular breathing
Abdomen : Normally
Ekstremity :
Upper : ROM of right humery : actived : limited
passive: limited
Lower: Normally
 Plan of Diagnostic
counting blood cell
X-ray skull region, AP/Lat view
X-ray right shoulder region,
AP/Oblique view
 Diagnosis

MILD HEAD INJURY GCS 15

+ Epistaxis + Fracture of
right clavicula
MANAGEMENT
IVFD
Analgetics
Antibiotics
Consult to general
surgery
Clinical Finding
X-ray skull regio n, AP /La t view
 Thank
You
BAGIAN ILMU
BEDAH