Professional Documents
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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 (-)
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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 (-/-)
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
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Items Result Normal Value Unit
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Items Result Normal Value Unit
GDS 129 <200 Mg/dL
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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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ECG