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    Patient Identity

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    Eka Ramadhani Darwanty
    Mrs. M, a 44-year-old female, was admitted to the hospital on May 19th, 2017 complaining of a headache following a motorcycle accident where she was not wearing a helmet. She had multiple lacerations to her head with exposed bone as well as abrasions on her right shoulder and hands. Her vital signs were stable. Diagnostic tests including bloodwork and x-rays of her skull and right shoulder were planned to further evaluate her mild head injury and injuries from the accident. She was started on IV fluids, pain medication, antibiotics, and wound care while consulting general surgery.

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    Patient Identity

    Uploaded by

    Eka Ramadhani Darwanty
    15 views9 pages
    Mrs. M, a 44-year-old female, was admitted to the hospital on May 19th, 2017 complaining of a headache following a motorcycle accident where she was not wearing a helmet. She had multiple lacerations to her head with exposed bone as well as abrasions on her right shoulder and hands. Her vital signs were stable. Diagnostic tests including bloodwork and x-rays of her skull and right shoulder were planned to further evaluate her mild head injury and injuries from the accident. She was started on IV fluids, pain medication, antibiotics, and wound care while consulting general surgery.

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    Mrs. M, a 44-year-old female, was admitted to the hospital on May 19th, 2017 complaining of a headache following a motorcycle accident where she was not wearing a helmet. She had multiple lacerations to her head with exposed bone as well as abrasions on her right shoulder and hands. Her vital signs were stable. Diagnostic tests including bloodwork and x-rays of her skull and right shoulder were planned to further evaluate her mild head injury and injuries from the accident. She was started on IV fluids, pain medication, antibiotics, and wound care while consulting general surgery.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    15 views9 pages

    Patient Identity

    Uploaded by

    Eka Ramadhani Darwanty
    Mrs. M, a 44-year-old female, was admitted to the hospital on May 19th, 2017 complaining of a headache following a motorcycle accident where she was not wearing a helmet. She had multiple lacerations to her head with exposed bone as well as abrasions on her right shoulder and hands. Her vital signs were stable. Diagnostic tests including bloodwork and x-rays of her skull and right shoulder were planned to further evaluate her mild head injury and injuries from the accident. She was started on IV fluids, pain medication, antibiotics, and wound care while consulting general surgery.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 9

    PATIENT IDENTITY

    Name : Mrs. M
    Age : 44 years old
    Sex : Female
    Address : Petoaha Distric, Nambo City
    Admission : May, 19th 2017
    DPJP : dr. Tedjo Arianto, Sp.B-KBD
    HISTORY TAKING
    Chief complain :

    Anamnesis :
    Patient presented to the hospital complaining of Headache that had been
    present since 1 hours before admitted to the hospital. The patient comes
    with a traffic accident.
    Mechanism of trauma : Patients are motorcyclists who drive at speed
    40km/h and then suddenly fell down because he could not control the
    motorcycle because he drove at cobblestone area. And the patients do not
    use a helmet while driving
    There was history of nausea. Sncope, vomiting, ear and nose bleeding was
    denied.
    Primary survey
    A Clear

    RR 20x/min, spontaneous
    thoracoabdominal type, symmetrical B
    C BP 110/60 mmHg
    Pulse = 64x/min, regular, strong

    GCS 15 (E4M6V5), pupil isochors,


    : 2mm/2mm, light reflex +/+ D
    E T = 36.80C (axillary)
    SECONDARY SURVEY

    Head : There were lacerated wound which was 10 cm in length


    and semicircular in shepe at the right frontoparietalis
    region with bone exposed, lacerated wound which was 5
    cm in length at the right parietalis region, and at the
    frontalis region which was 1 cm in length.
    Eyes : Normally
    Nose : Normally
    Mouth : Normally
    Ears : Normally
    Neck : Normally
    Chest : Normally
    Abdomen : Normally
    Extremity

    Upper: There were excoriated wound at right deltoid region and at


    the right and left manus region. ROM right shoulder joint was limited
    Lower: Normally
    Plan of Diagnostic

    counting blood cell


    X-ray skull region, AP/Lat view
    X-ray Right Shoulder joint AP view
    Diagnosis

    MILD HEAD INJURY GCS 15 + Multiple Lacerated


    wound at the right frontoparietalis region
    with bone exposed, right parietalis region,
    and at the frontalis region + Multiple
    excoriated wound at right deltoid region and
    at the right and left manus region.
    MANAGEMENT
    IVFD
    Analgetics
    Antibiotics
    Wound care
    Consult to general surgery
    Thank You

    Nurhidayah

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