Scribd Logo
Upload

Welcome to Scribd!

  • Mr. L-23yo-TCR+Multiple Vulnus Excoriated

    Uploaded by

    Fine Farhani
    36 views10 pages
    1) A 24-year-old male was admitted to the hospital on November 4th, 2017 following a motorcycle accident where he was not wearing a helmet and crashed into a parked car. 2) He presented with a headache lasting 7 hours, bleeding from his ear, loss of consciousness, nausea, and vomiting. 3) On examination, he had excoriated wounds on his head and was conscious with a GCS of 15 but tenderness was noted on his head.

    Original Description:

    Morning report

    Original Title

    Mr. L-23yo-TCR+Multiple vulnus excoriated

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    1) A 24-year-old male was admitted to the hospital on November 4th, 2017 following a motorcycle accident where he was not wearing a helmet and crashed into a parked car. 2) He presented with a headache lasting 7 hours, bleeding from his ear, loss of consciousness, nausea, and vomiting. 3) On examination, he had excoriated wounds on his head and was conscious with a GCS of 15 but tenderness was noted on his head.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pptx, pdf, or txt
    36 views10 pages

    Mr. L-23yo-TCR+Multiple Vulnus Excoriated

    Uploaded by

    Fine Farhani
    1) A 24-year-old male was admitted to the hospital on November 4th, 2017 following a motorcycle accident where he was not wearing a helmet and crashed into a parked car. 2) He presented with a headache lasting 7 hours, bleeding from his ear, loss of consciousness, nausea, and vomiting. 3) On examination, he had excoriated wounds on his head and was conscious with a GCS of 15 but tenderness was noted on his head.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pptx, pdf, or txt
    of 10

    IDENTITY

    Name : Tn. L
    Age : 24 years old
    Sex : Male
    Admission : November, 4th 2017
    Doctor in charge : dr. Syamsul Rijal, Sp.B
    HISTORY TAKING

    •Main complain : Pain of the head


    •Anamnesis :
    Patient referred from Buton Utara Hospital with pain of the head since 7
    hours ago after traffic accident
    •Mechanism of trauma : The patient was riding a motorcycle with
    high speed, didn’t use a helmet, the patient crashed into a parked car
    • There was history of bleeding from the ear
    • History loss of consciousness (+) nausea (+) and vomiting (+).
    •History of alcohol (+)
    Primary survey

    A Clear

    RR 20x/min regular, spontaneous, thoracoabdominal type B


    C BP 130/100 mmHg
    Pulse = 89x/min, regular, strong

    GCS 15 (E4V5M6), pupil isochors,


    Ø : 2,5mm/2,5mm, light reflex +/+ D
    E T = 36.60 C (axillary)
    SECONDARY SURVEY

    Head : There was Excoriated wound at left frontal region size 5x4 cm
    Face : Normally
    Eyes : Normally
    Nose : Normally
    Mouth : Normally
    Ears : Normally
    Neck : Normally
    Chest : Normally
    Abdomen : Normally
    Extremity : There was Excotiated wound
    LOCALIS STATUS

     HEAD
    I : Vulnus excoriated at right frontal region size 7 cm x
    2 cm
    P : Tenderness (+)
    CLINICAL FINDING
    PLANING EXAMINATION

    Skull X-RAY AP/Lat View


    DIAGNOSIS

    Mild Head injury GCS 15 + Multiple vulnus excoriated


    MANAGEMENT

    IVFD
    ANALGETIC
    ANTIBIOTIC
    CONSULT SURGEON
    Thank You

    BAGIAN ILMU
    BEDAH

    You might also like