No.

Name : Ch. L Sex : Female

Age : 4 years old No. Reg : 713643
Main complaint : Wound at face
Condition : The condition apparent for 9 hours before taken to
hospital due to traffic accident. There was no history of
vomiting and decrease consciousness. Prior medical
care at Sinjai Hospital.
Mechanism of : She was a passenger of motorcycle and when it
injury motorcycle on its way to stop, patient jumped from the
motorcycle and her head bumped to asphalt.
Sustained Injury : Head, Face
Symptom & sign : Headache,
Examination : Physical examination, Laboratory examination, Skull X-
Done Ray, Head CT-Scan, Chest X-Ray, Cervical X-Ray
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR: 28x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP: 100/70 mmHg, PR: 88 x/minute, regular, adequate

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

Reflex +/+
E: T (ax): 36,8 oC
Secondary Survey
Right Supraorbita Region :
I : Seen lacerated wound size 1,5 x 1
cm, there was no active bleeding
P : Crepitation (-) tenderness (+)

Left Supraorbita Region :

I : Seen lacerated wound size 1,5 x 0.5
cm, there was no active bleeding
P : tenderness (+) crepitation (-)

Nasal Region :
I : Seen exoriated wound size 0,5 x 0,2
cm, there was no active bleeding
P : tenderness (+) crepitation (-)
 Laboratory Result
WBC : 16,5 x 103 / L

RBC : 4,9 X 106 / L

HGB : 13 g/dL

HCT : 38,9 %

PLT : 485 x 103/ L

CT / BT : 800/300

Blood Sugar : 90 mg/dl

Ureum : 16 mg/dl

Creatinin : 0,60 mg/dl

GOT / GPT : 33 /16 /L

Skull X-Ray
Waters position X-Ray
Thorax X-Ray
WORKING DIAGNOSIS : - Traumatic Brain Injury GCS 15 (E4M6V5)
- Nasal fracture

MANAGEMENT : O2
IVFD
Medicaments
Consult to senior plastic surgeon
Advice: Plan for repotition