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
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
N wound
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