assessment of hematoma

7/27/2019 Assessment of Hematoma

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PRESENT HEALTH HISTORY

A case of Patient T.D. , female, 68 y.o., Single, from Cabuburan,Calape,Bohol was amitte to !icente Sotto "emorial "eical Center last December #,$%, ue to complains of se'ere pain speci(cally, on the left temporal area.

Patient was iagnose with )Acute *piural +ematoma, Seconary to aDepresse fracture on the eft Temporal lobe- an has unergone )Debriement,Craniectomy an *'acuation of hematoma- in !S""Cs /perating 0oom lastDecember 1, $%.

HISTORY OF PATIENTS ILLNESS

2 ays prior to amission, while the patient was playing with his guitar, hisfrien, who was uner the in3uence of alcohol, hac4e him at his left temporalarea.

Pain in the area hit ble an became unbearably painful, thus, prompteimmeiate hospitali5ation. Patient was then amitte to the Pro'incial +ospitalan there he was gi'en meications he was unable to recall.

Patient was then referre to !icente Sotto "emorial "eical Center for

further management.

FAMILY, PSYCHOSOCIAL, AND PERSONAL HISTORY

Patient is a male, was born on anuary &7, &27$ in "inanao. +e is a ilipinociti5en, currently li'ing in Cabuburan,Calape, Bohol. Patient is 9 feet an 7 inches,weighs 62 4ilograms. Patient wor4s as a coconut har'ester in Bohol.

Patient was born 'ia :ormal Spontaneous eli'ery on anuary &7, &27$ withno signi(cant abnormalities after birth. Patient has not been in any past in;uriesuring chilhoo.

+e is the elest chil among 7 chilren. +e has four other brothers an $sisters, who are all marrie.

Patient family health history< Paternal sie =>? +ypertension, an Bronchialasthma@ "aternal sie =>? +ypertension.


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Patient smo4es cigarette occasionally, consuming $# pac4s ay. +e also rin4salcoholic be'erages, consuming $#. Patient is often seen with cousins in theneighborhoo.

DEVELOPMENTAL HISTORY

Erik Ericsons Psychosocial Sa!"# enerati'ity 's. Stagnation

Patient +.+. who is now 1# years ol, is uner the enerati'ity 's.Stagnationof *ri4 *ric4sons Psychosocial Stage. Aults nee to create or nurturethings that will outlast them, often by ha'ing chilren or creating a positi'echange that bene(ts other people. Success leas to feelings of usefulness anaccomplishment, while failure results in shallow in'ol'ement in the worl. hosewho are successful uring this phase will feel that they are contributing to theworl by being acti'e in their home an community.

Those who fail to attain this s4ill will feel unproucti'e an unin'ol'e in theworl. Being prou of your accomplishments, watching your chilren grow intoaults, an e'eloping a sense of unity with your life partner are importantaccomplishments of this stage.

Si!$%n& Fr"%&s Psychos"'%al Sa!"#Genital

During the (nal stage of psychoseual e'elopment, the ini'iual e'elopsa strong seual interest in the opposite se. This stage begins uring puberty butlast throughout the rest of a personEs life.
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HEALTH ASSESSMENT

PHYSICAL APPEARANCE.Patient ha a meium buit, an appears neat but wasseen half na4e upon inter'iew.

EYES.Patient oes not ha'e any reness or swelling in the eyes. :o ecessi'ewatering or tearing of the eye. "inimal ischarges note, greenish white in color.

The upper li margin is between the upper margin of the iris an the uppermargin of the pupil. The upper an lower lis close easily an meet completelywhen close.

*yelashes are e'enly istribute along the li margins. S4in on both eyelisis without reness, swelling or lesions. The eyeballs are symmetrically aligne inthe soc4ets without protruing or sin4ing. The iris is roun, 3at an e'enly colore=ar4 brown?. The pupil is centere in the iris an are eFual in si5e.

EARS.The auricle aligns with the corner of each eye. *arlobes are free. The s4inis smooth with no lesions, lumps are lesions@ slightly oily. Color is consistent withfacial color. The auricles are not tener upon palpation.

NOSE.Patients nose is consistent with facial color@ nasal structure is smooth ansymmetrical@ no pain an tenerness note on palpation@ with no ischargesnote.

LIPS, MOUTH and TEETH.The patients lips are ry@ has a complete set ofteeth, an oes not wear any prosthesis or entures. ums are pin4, moist an(rm without any lesions.


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TONGUE.Tongue is pin4, moist an moerate in si5e. Patient rin4s alcohol.Patient brushes his teeth $# a ay, usually after meals.

SHOULDERS, ARMS, and ELBOWS. Shoulers are symmetrically roun, noreness, swelling or eformity note. "uscles are fully e'elope. Cla'icles anscapulae are e'en an symmetric.

WRISTS.Grists are symmetric@ no reness an note,no pain with etension ofthe wrist against resistance note.

HANDS, FINGERS and NAILS.+ans an (ngers are symmetric@ no tenernessan slight swelling note both hans. The client has full 0/" against resistance.Patient has long an irty nails.

KNEES.Both 4nees ha'e no swelling or eformities note@ nontener anmuscles are (rm, no pain or clic4ing soun note.

ANKLES and FEET.Toes on both feet pointe upwar an lie 3at. Toes an feetare in alignment with the lower leg. S4in is smooth, no lesions note.

SKIN.Patient has a goo s4in turgor@ no lesions note on etremities. S4in isintact, with no ryness or swelling an reness note@ ecept for the temporalarea which was the site of the surgery.


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Cranial Nere!

OLFACTORY NERVE (CN I)

Remarks:

Hntact. Client was able to ientify scent correctly =bath soap?.

OPTIC NERVE (CN II)

Note: Snellen chart not available.

Remarks:

Client was able to rea (ne prints without iIculty using newspaper. Peripheral

'ision intact.

OC*LOMOTOR NERVE (CN III)

Remarks:

P*00A = Pupils *Fually 0oun, 0eacti'e to ight an Accommoation ?

TROCHLEAR AND A+D*CENS NERVES (CN IV VI)

Remarks:


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Hntact carinal ga5e. Patients eye mo'ement is smooth an symmetricthroughout all si irections. Client was able to mo'e each eye upwar,ownwar, iagonally an laterally. Hlluminate pupils constrict simultaneously.

TRI-EMINAL NERVE (CN V)

Remarks:

Hntact motor function. Positi'e contraction of the temporal an masseter muscleswhen client clenche his teeth.

Hntact sensory function. Client was able to correctly ientify sharp an ull stimulian light touch to the forehea, chee4s an chin.

FACIAL NERVE ( CN VII)

Remarks:

Hntact motor function. Client was able to smile, frown, wrin4le forehea, showteeth, puJ out chee4, purse lips, raise eyebrows an close eyes with resistance.

Hntact sensory function. Client was able to correctly ientify the 3a'or of "ilo.

ACO*STIC NERVE (CN VIII)

Remarks:

Hntact cochlear component. Client was able to hear whispere wors at a istanceof $ feet.

=? 0omberg test. Client was able maintain staning position for $% secs withminimal swaying with feet together an arms on the sies an eyes open an


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then close.

Note: Weber and Rinne Tests not done. Tuning fork not available.

-LOSSOPHARYN-EAL NERVE (CN I.)

0emar4s

assessment of hematoma

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