Department of SurgeryFebruary 23, 2015

Name : M Rifky E Age : 14 y.o Sex : Male Address : Kawistolegi Karanggeneng

Lamongan Date examination: Feb 23, 2015

Chief complaint :

Headache

MOI :

Patient complained headache post felt in his house

about 2 days before admission. He felt alone when the

accident was happened. His head hat a floor. His headache in

back side. Its not refered to the neck. Decrease of

consiousness -, vomiting 1x when he was on the road,

Miction and defecation was normally, PTA (-). He was

medicated in Puskesmas 2 days before admission.

Airway and spine control : clear (+), snorring (-), gargling (-), potensial obstruction (-)

Breathing : spontan, simetric (+), RR x/minutes, ves/ves, rh-/-, wh-/-

Circulation : PR 79x/minutes, acral warm dry red, CRT < 2 , Sp02 distal 99%, blood presure 114/80 mmHg

Disability : GCS 456, LP +/+, isocor pupil 3mm/3mm, lateralisasi-

Exposure : temp 36.4

History past illness same complained denial History of social, economic :- Status Generalis Head and neck : anemic (-), icteric (-), cyanosis

(-), dyspneu (-), jejas - Thorax : simetric (+), retraction (-)

Pulmo : ves/ves, rh-/-, wh-/-Cor : S1S2 single, murmur (-), gallop (-),

lession - Abdomen : flat (+), soepel (+), tympani (+),

liver and spleen were not palpable, bowel sound (+), lession-, injury -

Extremities : acral warm, dry, red, lession-

Clue and cue

◦ Male, 14 y.o◦ Headache post trauma◦ Vomiting

Mild Head Injury

• CBC• RBG• CT-Scan without contras

Eritrosit : 4,87 Hb : 12,4 LED : 28/51 Limposit : 21,2 Basofil : 2,8 Eusinopil : 3,9 Hct : 39,2 Leu : 6.300 MCH : 25,50 MCHC : 31,60 MCV : 80,50 Trombosit : 431 GDA : 96

Mild Head Injury with minimal EDH

• Ivfd Asering 1500 cc/24 h• Inj. Ranitidin 2x50 mg iv• Inj. metamizole 3x500 mg iv• Inj. piracetam 4x1,5 gr iv• Inj. Ondansentron 2 x 4 mg iv• c/ dr. Suharianto Sp.BS observation

Subjective complaint Vital sign GCS

Explain to the patient’s family about the diagnosis, etiology, intervention of therapy, complication, and prognosis.