2. • Name : Mr. GN
• Age : 18 years old
• Gender : Male
• Date. MRS : 23-07-22
• Address : latuhalat
• Religion : Christianity
• Marital Status : not married
PATIENT IDENTITY
3. • Airway : clear without collar neck
• Breathing: symmetrical chest expansion, RR: 24x/min,
SpO2 99% without O2
• Circulation: BP 140/80 mmHg, HR 115x/min CRT <2
seconds
• Disability : GCS 15 : E4 V5 M6 , pupil isocor, RC (+/+)
• Exposure : R. capitis, R. manus dextra, R. patella
dextra, R. cubiti sinistra
Primary survey
4. • Chief complaint: tear on right knee
• Current medical history:
The patient came with complaints of lacerations on his right knee, and
abrasions on his left elbow and right hand. The patient admitted that
he fell from the motorcycle due to hitting another motorcyclist from the
front while turning back at high speed. The patient fell to the right and
the patient's head hit the road. The patient claimed to be dizzy but not
nauseated and vomiting. After the accident the patient had time to go
home after 30 minutes at home the patient was getting dizzy and was
rushed to the hospital by the family.
ANAMNESIS (autoanamnesis)
5. • Allergic :-
• Medication :-
• Past Illness :-
• Last Meals: ± 5 hours before entering the hospital
• Events/Environments : Highway
ANAMNESIS (autoanamnesis)
