Patient List

No Identity Admission Diagnosis Treatment

to E.R.
3. Mr. Erwin April 4th Mild Head Injury GCS 15 VS Obs
Nahumuri/ 2015 at 01.45 (E4V5M6) + Susp Fr. Basis Cranii IVFD NS
Fossa Media Dextra + VL a/r Head up 30
45yo/1-14 WITA frontalis Dextra Inj analgesic
-61-20 Inj. Antibiotic
Inj H2Blocker
Wound Toilet
Primary Suture

CTSCAN The
patient refused
Dismissed by request

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5. Mr. Erwin Nahumuri/ 45yo/1-14 -61-20
April 4th 2015 at 01.45 WITA
Chief Complain :
Decreasing level of consciousness
History :
3 hours before admission patient had accident while
riding motorcycle around Gang Veteran Banjarmasin. The
patient was bumped by other motorcycle and fell head hit
the road first. History of fainted (+), Bleeding from
mouth/nose/ear (-/-/+). The patient got no other injuries
on his body. He admitted had drink alcoholic beverages
before riding. His friend rushed him to Ulin Hospital for
treatment.

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Primary Survey
Clear, snoring (-), gurgling (-), C-spine
A
control (-)

Clear, RR= 20 bpm, symmetric

B
respiratory movement, VBS

Blood Pressure: 130/80 mmHg

C
Pulse rate : 88 bpm, reguler, strong
lifted
GCS E4V5M6 (15), Round and symmetric
D pupils diameter (3mm/3m), Light
reflexes (+/+), BH (-/-), BS(-/)

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A -

M -

P -

7 hours before
L admission

E On road

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Secondary survey
Head : VL a/r frontalis size 4 cm with subcutan base,
irregular ridge
Head/Nec Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane
k Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)

I : symmetric respiratory movement, retraction (-),

wound (-)
Chest P : symmetric VF
P :sonor
A : VBS, Rh (-/-), Wh (-/-)

I : Wound (-), distension (-), hematoma (-)

A : Normal bowel sound
Abdomen P : H/L/M not palpable, tenderness (-), rebound
tenderness (-), muscular defense (-)
P : Tympanic in all quadrants

Extremities Warm
Warm extremities,
extremities, parese
parese (-),
(-), edema
edema (-)
(-)
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Neurological Status
GCS E4V5M6 (15), Round and
symmetric pupils diameter
(3mm/3m), Light reflexes (+/+), Brill
hematom (-/-), Battles sign (-/-),
parese (-), lateralization (-)

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Clinical Pictures

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 Local Status

a/r Head :
VL a/r frontalis size 4 cm with subcutan base,
irregular ridge

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Laboratory Result April 1 2015 st

Items Result Normal Value Unit

Hemoglobine 11,3 11.00 - 16.00 g/dl

Leukocyte 8,9 4.0 10.5 thousand/ul

Eritrocyte 5,08 4.00 5.50 million/ul

Hematocrit 36,1 32.00 44.00 Vol%

Thrombocyte 260 150 450 Ribu/ul

RDW-CV 17,5 11.5 14.7 %

MCV 71,2 80.0 97.0 Fl

MCH 22,2 27.0 32.0 Pg

MCHC 31,3 32.0 38.0 %

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 Items Result Normal Value Unit

Gran% 75,6 50.0-70.0 %

Lymphosite% 15,5 25.0-40.0 %

MID% 8,9 4.00-11.00 million/ul

Gran# 6,70 2.50-7.00 Billion/ul

Limfosit # 1,4 1.25-4.0 Billion/ul

MID# 0,8 Billion/ul

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 Items Result Normal Value Unit
GDS 129 <200 Mg/dL

SGOT 46 0-46 U/l

SGPT 20 0-45 U/l

Ureum 12 10-50 mg/dL

Creatinin 1,1 0,7-1,4 mg/dL

Natrium 141,2 135-146 mmol/L

Kalium 3,7 3,4-5,4 mmol/L

Chloride 104,2 95-100 mmol/L

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Working Diagnosis
Mild Head Injury GCS 15 (E4V5M6) + Susp Fr.
Basis Cranii Fossa Media Dextra + VL a/r
frontalis Dextra

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Management
VS Obs
IVFD NS
Head up 30
Inj analgesic
Inj. Antibiotic
Inj H2Blocker
Wound Toilet
Primary Suture
CTSCAN The patient refused
Dismissed by request
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