mr head injury
DESCRIPTION
Morning reprtTRANSCRIPT
Morning report
28 Oktober 2015
Patient identity (1)
• Name : Miss N• Sex : Female• Age : 16 years old • Address : Gg. Budiman
Chief complaint
• Headache
Present illness history
Patient come to the hospital with complaint of headache approximately 90 minutes before enter emergency room. This complaint is felt after she got into an accident. Her motorcycle hit another vehicle and then she fell down to left side and her head hit the ground. According to her, after the accident she was fainted for about 3 minutes. Nausea (+), vomiting (-), visual disturbance (-). There is no bleeding from nose or ears.
Past medical history
•History of hypertension (-) •History of DM (-)
Physical examination
Vital sign• GCS : 15 (Compos Mentis)• Blood pressure : 120/70• Hate rate : 92 x / min • Respiratory rate : 20 x / min• Temperature : 36,5°C
Physical examination
• Head: normosefali• Eyes: anemic conjunctiva (-/-), icteric sclera (-/-), • Pulmonary: Normochest, breath sounds basic:
Vesicular (-/-), Wz (- / -), Rh (- / -)• Heart: Regular S1S2, Galoop (-), Murmur (-)• Abdomen: flat, nontender, turgor (+), bowel
sounds (+) normal• Extremities: CRT <2”
Localized Status
• vulnus excoriatum 4 cm x 3 cm a/r antebrachii sinistra
• vulnus excoriatum 2 cm x 1 cm a/r pedis dextra
• vulnus excoriatum 2 cm x 1 cm a/r pedis sinistra
• Contusio a/r temporal sinistra
X-Ray
Diagnosis
• Mild brain injury
Therapy Head up 30° Oxygen 3 lpmNaCl 20 dpmPiracetam 1 ampCiticolin 1 ampKetorolac 1 ampRanitidin 1 amp
Prognosis
• Ad vitam : bonam• Ad functionam : bonam• Ad sanactionam : bonam
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