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  • Ridwan Brachial Plexus

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    Christophore Santoso
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    This document summarizes a patient's admission to the emergency room. A 56-year-old male was admitted after a motorcycle accident, complaining of headaches for 3 hours. His initial examination found him conscious with stable vitals. Secondary examination revealed multiple excoriated wounds and swelling on his face and neck, with tenderness and limited range of motion in his right shoulder. Lab results and radiology findings were pending. The diagnoses included mild head injury, multiple wounds, and possible left brachial plexus injury. The management plan included IV fluids, analgesics, a neck collar, consulting orthopedics for a cervical CT scan and IV methylprednisolone.

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    This document summarizes a patient's admission to the emergency room. A 56-year-old male was admitted after a motorcycle accident, complaining of headaches for 3 hours. His initial examination found him conscious with stable vitals. Secondary examination revealed multiple excoriated wounds and swelling on his face and neck, with tenderness and limited range of motion in his right shoulder. Lab results and radiology findings were pending. The diagnoses included mild head injury, multiple wounds, and possible left brachial plexus injury. The management plan included IV fluids, analgesics, a neck collar, consulting orthopedics for a cervical CT scan and IV methylprednisolone.

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    6 views22 pages

    Ridwan Brachial Plexus

    Uploaded by

    Christophore Santoso
    This document summarizes a patient's admission to the emergency room. A 56-year-old male was admitted after a motorcycle accident, complaining of headaches for 3 hours. His initial examination found him conscious with stable vitals. Secondary examination revealed multiple excoriated wounds and swelling on his face and neck, with tenderness and limited range of motion in his right shoulder. Lab results and radiology findings were pending. The diagnoses included mild head injury, multiple wounds, and possible left brachial plexus injury. The management plan included IV fluids, analgesics, a neck collar, consulting orthopedics for a cervical CT scan and IV methylprednisolone.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
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    of 22

    MORNING REPORT

    September 15th , 2012 EMERGENCY ROOM WAHIDIN SUDIROHUSODO GENERAL HOSPITAL MAKASSAR
    FW/SM/ND

    Name Age Admission

    :R : 56 years old / Male : September 15th, 2012 at 15.34 Wita Registration : 56 87 42 Status : Jamkesda

    Autoanamnesa (at 15.34) :


    Headache, suffered since 3 hours before admitted to Wahidin Sudirohusodo hospital due to traffic accident. He was riding a motorcycle than fall down with unknown mechanism. History of prior treatment at Gowa hospital History of unconsciousness (+), vomit (-), nausea (-)

    PRIMARY SURVEY
    (at 15.39)

    A B

    : Patent : RR = 20 x/min, symmetric, spontaneous, thoracoabdominal type. C : BP: 120 / 80 mmHg, HR: 96 x/min, reguler, strong D : GCS 15 (E4M6V5), light reflex +/+ , pupil isochors, : 2 mm / 2 mm, E : T = 36.5 C

    SECONDARY SURVEY
    (at 15.44)

    Facial Region :
    I : Excoriated wound sized 6 cm x 10 cm at left frontal, swelling (+), hematoma (-) Swelling (+), hematoma(+) at left eye Excoriated wound sized 8 cm x 8 cm at left zygoma, swelling (+), hematoma (-) : Tenderness (+)

    Neck Region :
    I P : Excoriated wound sized 6 cm x 10 cm edema (+), hematoma (-). : Tenderness (+)

    Right Shoulder Region :


    I
    P ROM NVD

    : Hematoma (+) at posterior aspect sized 3 cm x 3 cm, swelling (-), deformity (-)
    : Tenderness (+) : Active and passive motions of the shoulder joint is difficult to evaluate due to pain : Sensibility is hypoesthesia in axillary, median, ulnar and radial nerves, radial artery is palpable, CRT<2

    2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

    2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

    2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

    2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

    Any anal sensation N

    0 Absent 1 Impaired 2 Normal NT Not testable

    LABORTORY FINDINGS
    (at 16.00)

    WBC RBC HGB HCT PLT BS Ureum Creatinin SGOT SGPT CT BT HBs Ag

    15.25 x 103 /uL 4.61 x 106 /uL 12.9 g/dL 39.6 % 301 x 103 /uL 133 mg/dl 26 mg/dl 0.7 mg/dl 28 u/l 36 u/l 8 00 2 00 negative

    RADIOLOGY FINDINGS
    (at 16.10)

    DIAGNOSIS

    Mild head injury GCS 15 Multiple excoriated wound Left brachial plexus injury

    DD. Burner syndrome

    MANAGEMENT

    IVFD Analgesic Apply collar neck Report to orthopedic senior, advice: - CT-scan cervical - Metilprednisolon 1 vial/8 hours/IV

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