No.

Name : Mr. I Sex : Male

Age : 13 years old No. Reg : 625554

Chief complaint : Headache

History taking : Suffered since 4 hours before admitted to the hospital

due to traffic accident. There was no history of loss
consciousness. No history of vomiting
Mechanism of : He was riding motorcycle, suddenly struck by another
injury motorcycle from behind. The next mechanism was
unknown. She was using a helmet.
Injury sustain : Head
Symptom & sign : Decreased of consciousness
Examination : Physical examination, laboratory examination, Head CT
Scan, Chest X-Ray
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR : 22 x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP : 110/80 mmHg, HR: 78x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal 3mm/3 mm , LR +/+

E: T (ax) : 36,6oC
Secondary Survey
Right frontal region :
I: Seen lacerated wound size 2x0,5 cm. Udem
(+), hematome (-)
P: Tenderness (+)
 Laboratory Result
WBC : 13,3 x 103 / L
RBC : 4,49 x 106 / L
HGB : 12,3 g/dL
HCT : 37,1 %

PLT : 254 x103/ L

CT / BT : 800/300

Blood Sugar : 111 mg/dl

Ureum : 15 mg/dl
Creatinin : 0,5 mg/dl
GOT / GPT : 22/7 /L
Head CT Scan
WORKING DIAGNOSIS : - Mild head injury GCS 15 (E4M6V5)
- Open depressed fracture at frontal bone
MANAGEMENT : O2
IVFD
Medicaments
Report to senior neurosurgeon
advice : Craniectomy
 Operating Procedure
Patient laid supine under GA
Disinfection and draping procedure
Perform linier incision at occipital region, deepen
until periosteum
Perform 4 burr holes, continue craniotomy with
craniotom
Seen EDH 30 cc, evacuated hematoma and
hanging duramater
Close the wound layer by layer and apply 1
vacuum drain
Operation finished
DIAGNOSIS POST OP : - Mild head injury GCS 15 (E4M6V5)
- Open depressed fracture at frontal bone

PROGNOSIS : Good

FOLLOW UP : Vital sign and GCS