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8/18/2019 Mild Head Injury.ppt

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Morning ReportMorning ReportAugust, 20August, 20thth 20112011
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Patient Mr.R, male, 24 years old,came to AA Hospital on 18 August2011

Chie complain!

unconscious ater motorcycle accident
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Primary "ur#eyPrimary "ur#ey

Air$ay! clear %reathing! &reathing spontanly $ith

respiration rate 20 '(minute

Circulation! %P 110(80 mmHg, HR!88'(minute regular and $arm acral,capilery reillied )2 seconds

*isa&ility! +C" 1, pupil isochor Ф -

mm( -mm,light relect /(/. 'posure! pre#ent hipotermia $ith

co#er.
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"econdary "ur#ey"econdary "ur#ey Recent llness History

hours ago, patient dro#e a motorcycle no usinghelmet $hich speed $as 30m(h. 5hen he turn

to the let, suddenly a $omen passing through andhe crush her. 6hen, his motorcycle ell do$n to thelet and then he $as unconscious.

6hen, he $as &rought to AA hospital

At hospital he $as conscious and eel mild

headache,pain around his let shoulder. 6here $asno #omit,&lood rom ear and rom nose.
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Past illness history : no related

Family illness history: no related
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Physical 'aminationPhysical 'amination

Conciousness ! composmentis

7ital sign!

%P! 120(80 mmHg HR! 8 ' (minutes

RR! 1 '(minutes

6emp!-9,10C
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Head

nspection!

Vulnus e'coriatio at os.parietal- ' 4 cm

:o ;torea

:o Rhinorea

:o Raccoon eyes
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6horac ! :ormal

A&dominal ! :ormal
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Local Status

Left shoulder

=oo "$elling ?, laceration ?,

deormity ?,shortening ?,cyanosis ?
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Rontgen rom emergency unit
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'amination Planning'amination Planning

Rontgen AP and lateral let shoulder

that@s sho$ articulatio humeri

sinistra and cla#icula sinistra
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=a&oratory indings=a&oratory indings

Hb : 13 gr/dl

Ht ! 4 WBC : 19.000 (B=

P=6 ! 2-8.000 (B=
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6reatment6reatment

7
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6han Dou

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