No.

Name : Mr.TT Sex : Male

Age : 22 years ago No. Reg : 672382

Main complaint : Headache

Case : The condition had been apparent for 3 days before the
patient admitted to the hospital.There were no history of
nausea, vomiting and lost of conciousness

Mechanism of : She was hit by a bottle that was thrown by her sister due
injury to a brawl.
Sustained injury : Head
Symptom & sign : Wound
Examination : Physical examination
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR : 14x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP : 110/70 mmHg, PR : 84x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal 2,5 /2,5 mm, Light Reflex

+/+, all motoric muscle function are normal
E: T (ax) : 37,1 oC
Secondary Survey
Left parietal region:
I : Seen lacerated wound size 1x0,3 cm. Active
bleeding (-)
P : Tenderness (+), Crepitation (-)
WORKING DIAGNOSIS : - Lacerated wound on left parietal region

MANAGEMENT : Medicament
Proceed Wound Care
Patient discharged