No.

3
Name : Ms. MA Sex : Female
Age : 18 years No. Reg : 653026

Chief complaint : Decreased of consciousness

History taking : Suffered since 5 hours before admitted to the hospital
due to traffic accident. There was history of vomiting .
Prior medical care at Gowa hospital
Mechanism of : She was riding motorcycle as a passanger, and suddenly
injury the motorcycle stopped and she fell down, with her head
face the ground
Injury sustain : Head
Symptom & sign : Decreased of consciousness
Examination : Physical examination, laboratory examination, cervical x-
ray, chest x-ray, head CT scan
PHYSICAL EXAMINATION
Primary Survey
A: Partial obstruction → oropharyngeal tube and apply ETT

B: RR : 12 x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP : 110/70 mmHg, HR : 80 x/minute, regular, adequate

D: GCS 3X ( E1M2VX ), pupil unequal Ø 3/4,mm , LR +/+

E: T (ax) : 37,5oC
Secondary Survey

Left frontal region :

I : Seen excoriated wound size 4 x 2
cm, edema (+), hematoma(-)
P : Tenderness difficult to evaluated
 Laboratory Result
WBC : 29,7 x 103 / μL

RBC : 4,11 x 106 / μL

HGB : 12,3 g/dL

HCT : 37 %

PLT : 272 x 103/ μL

CT / BT : 8‘00” / 3’ 00”

Blood Sugar : 128mg/dl

Ureum : 17 mg/dl

Creatinin : 0,5 mg/dl

GOT / GPT : 36 / 20 μ/L

Head CT
Scan
WORKING DIAGNOSIS :  Severe Head injury GCS 3X ( E1M2VX )

MANAGEMENT :
 O2
 IVFD
 Medicaments
 Report to senior neurosurgeon
advice : immediately trepanation