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Emergency ReportFebruary 10th-11th, 2015

Resident on duty:dr. Alma Wijaya1Patients ListNoIdentityAdmission to E.R.DiagnosisManagement1Ch Widya, 5 yo/February 10th , 2015 at 17.15Mild Head Injury GCS 15 + Linear fracture at occipital regionConsult to neurology surgery:Obsv. Vital signHead up 30 degreeIVFD NS mainteananceH2 BlockerAnalgetic31. Mr. Fajar, 26 yo/ December 22nd, 2014 at 15.15Chief complain: HeadacheHistory : about 1 hour before admission when the patient was playing around her house suddenly then a car passed away beside the patient, the patient fall with the head hit the road. History of fainting + less than 5 minutes, vomiting - , seizure - , bleeding from ear nose and mouth -. After the accidet the patient concious and just felt pain on the back of her head. The patient directly brought to ULIN hospital by the family to get further treatment4Primary Survey5Secondary Survey67Localized Status

8Localized Status

Eyes : racoon eyes (-/-), anemic conjungtivae (-/-)Nose : rhinohargia (-)Ear : otohargia (-), battle sign (-)Mouth : wet mucosa, bleeding -Neck : Lymph nodes enlargement (-), JVP enhancement (-), hematome at occipital region (+) crepitation (-)

9Skull X-Ray February, 10th 2015

Ct Scan February, 10th 2015

13,514LABORATORY FINDING HEMATOLOGYParameterResultNormal ValueDecember 22nd, 2014Hemoglobin13,614,0-18,0 g/dlLekosit14,14,0-10,5 ribu/ulEritrosit4,314,5-6,0 juta/ulHematokrit31,442-52 vol %Trombosit354150-450 ribu/ulWorking DiagnosisMild Head Injury GCS 15 + Linear fracture at occipital region15ManagementConsult to neurology surgery:Obsv. Vital sign and GCSHead up 30 degreeIVFD NS maintenanceH2 BlockerAnalgeticHospitalized

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