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  • Name: Mrs. S Age: 63 ID: 01422313 ADM: National Health Insurance

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    syaiful_sn
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    Mrs. S, a 63-year-old woman, presented to the emergency department with persistent headache after falling off her bicycle 10 hours prior. On examination, she was conscious with a Glasgow Coma Scale of E4V5M6 and an equal-sized pupil reaction. A CT scan showed edema in her brain. She was diagnosed with a mild brain injury and cerebral edema. Her treatment plan included oxygen, intravenous fluids, pain medication, observation of her vital signs and Glasgow Coma Scale, and admission for further monitoring.

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    Semoga nermanffat

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    Mild Brain

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    Mrs. S, a 63-year-old woman, presented to the emergency department with persistent headache after falling off her bicycle 10 hours prior. On examination, she was conscious with a Glasgow Coma Scale of E4V5M6 and an equal-sized pupil reaction. A CT scan showed edema in her brain. She was diagnosed with a mild brain injury and cerebral edema. Her treatment plan included oxygen, intravenous fluids, pain medication, observation of her vital signs and Glasgow Coma Scale, and admission for further monitoring.

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    12 views9 pages

    Name: Mrs. S Age: 63 ID: 01422313 ADM: National Health Insurance

    Uploaded by

    syaiful_sn
    Mrs. S, a 63-year-old woman, presented to the emergency department with persistent headache after falling off her bicycle 10 hours prior. On examination, she was conscious with a Glasgow Coma Scale of E4V5M6 and an equal-sized pupil reaction. A CT scan showed edema in her brain. She was diagnosed with a mild brain injury and cerebral edema. Her treatment plan included oxygen, intravenous fluids, pain medication, observation of her vital signs and Glasgow Coma Scale, and admission for further monitoring.

    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 9

    Name : Mrs.

    S
    Age : 63
    ID : 01422313
    ADM : National Health Insurance
    Chief complaint:
    Persistent headache after falling

    Present illness:

    Ten hours prior to admission, while the patient was riding


    bicycle, the bicycle was slipped and he fell down in unknown
    position. Unconsciousness (+), vomit (-), seizure (-). After the
    accident, patient complained persistent headache. By the
    helper, he was brought to Panti Waluyo Hospital. Because of
    limited facility, he was brought to Moewardi Hospital.
    Primary survey

    A : Clear

    B : I : Equal chest expansion, RR : 20 x/mnt

    P : crepitation (-/-)

    P : Sonor/sonor

    A : Vesicular breathing sound (+/+), additional sound (-/-)

    C : HR : 94 x/mnt, BP : 130/80 mmHg

    D : GCS E4V5M6, equal pupil width (3 mm/3 mm), light reflexes (+/+)

    E : T : 36,6o C
    Secondary Survey

    Head : Hematom R. Parietal (D) (+)

    Eyes : no abnormality

    Nose : no abnormality

    Mouth : no abnormality

    Face : no abnormality

    Ear : no abnormality

    Neck : no abnormality

    Chest : no abnormality

    Abdomen : no abnormality

    Extremity : no abnormalilty
    1st Assessment :
    Mild Brain Injury GCS E4V5M6 with persistent headache

    1st Plan :
    O2 3 lpm
    Head Up 30°
    IVFD NaCl 0.9% 1500 cc/24 hours
    Metamizole inj. 300 g/8 hours
    Laboratory
    Head Ct scan
    Head ct scan from Moewardi
    2nd Assesment:
    Mild Brain Injury GCS E4V5M6 (ICD X S06.2)
    Oedema Cerebri (ICD X G93.4)

    2nd Plan:
    Inward
    Observation VS, GCS and lateralization.
    Arrival Time 16.10

    Triage Time 16.15

    Surgery Dept. Time 16.20

    Radiology Time 16.35-17.30

    Diagnose Time 17.35

    Inward Time 17.40

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