Severe Head injury GCS 10

+ Contusio frontal regio + Multiple excoriated wound

 IDENTITY

Name : Mrs. T
Age : 42 years old
Adress : konawe
Occupation : Laborers
Admission : August, 4th 2017
DPJP : dr. H. Syamsul Rijal, Sp.B
 HISTORY TAKING
Main complaints : decrease of conciousness
Anamnese : the patient was reference from konawe hospital, she came
with decrease of consciousness since about 7 hours before entering the
hospital that caused by a single accident.
Mechanism of trauma : the patient was a second man of a motorcycle.
Her friend ride the motorcycle with an average speed and no helmet.
And then they got an accident because hitting a hole at the road. The
patient through away about 1 meter. And finnaly the patient goy syncope.
There were history of syncope, vomit (-), nose bleeding (+)
There was history of treatment at konawe primary health care :
ketorolac, ranitidine, and ceftriaxone
PRIMARY SURVEY
A Clear

RR 20x/min regular, spontaneous,

thoracoabdominal type, symmetrical B
BP 110/80 mmHg
C HR = 60 x/min regular

GCS 10 (E2V5M3), isochoric pupil,

: 2,5 mm/2,5 mm, light reflex slow response D
E T = 36.60 C (axillary)
 secondary survey
General State
Head :
There was contusio at frontal regio, excoriated wound at frontal occipital
regio post hecting, and excoriated wound at maxilla regio
Eyes : Normally
Nose : Epistaksis
Mouth : Normally
Ears : Normally
Neck : Normally
Chest : Normally
Abdomen : Normally
Extremity superior : Excoriatum wound at manus regio post hecting
Extremity Inferior : Excoriatum wound at genu regio left/right
Clinical Finding
D
I
A
G Severe Head injury GCS 10
Contusio frontal regio + Multiple excoriated wound
N
O
S
E PLANNING EXAMINATION :
X-Ray skull Ap/AL
Routine blood

THERAPY :
O2, Fluid therapy, Antibiotic drugs, Analgesic
drugs, Consul Surgeon

7
L/O/G/O

Thank You

BAGIAN ILMU
BEDAH