Scribd Logo
Upload

Welcome to Scribd!

  • Chief Complaint: History Taking

    Uploaded by

    Mohamad Zulfikar
    4 views4 pages
    Ms. Z, a 19-year-old female, presented to the emergency department with a headache after being involved in a traffic accident where a car struck the motorcycle she was riding. On examination, she had an excoriation wound on her glabella region but was otherwise stable with a Glasgow Coma Scale of 15. She was diagnosed with a mild head injury and managed conservatively with oxygen, medications, and follow up by the neurosurgeon. Her prognosis was determined to be fair.

    Original Description:

    tcr

    Original Title

    Tcr

    Copyright

    © © All Rights Reserved

    Available Formats

    PPT, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    Ms. Z, a 19-year-old female, presented to the emergency department with a headache after being involved in a traffic accident where a car struck the motorcycle she was riding. On examination, she had an excoriation wound on her glabella region but was otherwise stable with a Glasgow Coma Scale of 15. She was diagnosed with a mild head injury and managed conservatively with oxygen, medications, and follow up by the neurosurgeon. Her prognosis was determined to be fair.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as ppt, pdf, or txt
    4 views4 pages

    Chief Complaint: History Taking

    Uploaded by

    Mohamad Zulfikar
    Ms. Z, a 19-year-old female, presented to the emergency department with a headache after being involved in a traffic accident where a car struck the motorcycle she was riding. On examination, she had an excoriation wound on her glabella region but was otherwise stable with a Glasgow Coma Scale of 15. She was diagnosed with a mild head injury and managed conservatively with oxygen, medications, and follow up by the neurosurgeon. Her prognosis was determined to be fair.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as ppt, pdf, or txt
    of 4

    No.

    Name : Ms.Z Sex : Female


    Age : 19 years No. Reg : 664931

    Chief complaint : Headache

    History taking : This condition has been apparent for 30 minutes before
    admitted to the hospital due to traffic accident. Nausea
    (-) vomiting (-).
    Mechanism of : She was riding a motorcycle then suddenly a car struck
    injury her then she fell down because the rider lost his balance
    balance and hit her head and face to the asphalt

    Injury sustain : Head, face


    Symptom & sign : Headache
    Examination : Physical examination
    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear

    B: RR 16 x/minutes, spontaneous, symmetric, thoraco


    abdominal type

    C: BP :110/ 60 mmHg, HR :68 x/minute, regular, adequate

    D: GCS 15 (E4 M6 V5), pupil equal 2,5 /2,5 mm , LR +/+

    E: T (ax) : 36,7 oC
    Secondary Survey
    Glabella region :
    I : Excoriation wound 2x1 cm, active bleeding (-)
    P : Tenderness (-), Crepitatation (-)
    WORKING DIAGNOSIS : Mild head injury (E4M6V5)

    MANAGEMENT : O2
    Medicaments
    Report to senior neurosurgeon
    advice : conservative

    PROGNOSIS : Fair

    FOLLOW UP : Vital sign

    You might also like