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    Surgery Department: Emergency Case Reports

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    Mohamad Zulfikar
    This emergency case report summarizes a patient visit to the emergency room. A 30-year old male was admitted with wounds to the face and pelvis after a traffic accident where he was thrown from a motorcycle without a helmet. He was evaluated and found to have lacerations to the head and pelvis with bleeding and swelling. He was given oxygen, medications, and wound care. His prognosis was determined to be good.

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    Surgery Department: Emergency Case Reports

    Uploaded by

    Mohamad Zulfikar
    4 views7 pages
    This emergency case report summarizes a patient visit to the emergency room. A 30-year old male was admitted with wounds to the face and pelvis after a traffic accident where he was thrown from a motorcycle without a helmet. He was evaluated and found to have lacerations to the head and pelvis with bleeding and swelling. He was given oxygen, medications, and wound care. His prognosis was determined to be good.

    Original Description:

    simple wound

    Original Title

    Simple Wound at Face

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    This emergency case report summarizes a patient visit to the emergency room. A 30-year old male was admitted with wounds to the face and pelvis after a traffic accident where he was thrown from a motorcycle without a helmet. He was evaluated and found to have lacerations to the head and pelvis with bleeding and swelling. He was given oxygen, medications, and wound care. His prognosis was determined to be good.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    4 views7 pages

    Surgery Department: Emergency Case Reports

    Uploaded by

    Mohamad Zulfikar
    This emergency case report summarizes a patient visit to the emergency room. A 30-year old male was admitted with wounds to the face and pelvis after a traffic accident where he was thrown from a motorcycle without a helmet. He was evaluated and found to have lacerations to the head and pelvis with bleeding and swelling. He was given oxygen, medications, and wound care. His prognosis was determined to be good.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
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    You are on page 1of 7

    EMERGENCY CASE REPORTS

    Sunday, November 19th, 2010


    SURGERY DEPARTMENT

    EMERGENCY ROOM
    WAHIDIN SUDIROHUSODO
    GENERAL HOSPITAL
    MAKASSAR
    Sunday, November 19th 2010

    Ambulation : 1 Patients

    Hospitalized : 5 patients

    Observation : 1 Patients
    Operated : 2 Patients
    Death : Patient

    Total : 6 patients
    No. 4
    Name : Mr. Mundus Sex : Male
    Age : 30 years old No. Reg : 44 82 49

    Chief complaint : Wound at the face


    History taking : Suffered since 30 minutes before admitted to the
    hospital due to traffic accident. History loss of
    consciousness (+) vomiting (-), convulsion (-).
    Mechanism of : She was passenger a motorcycle suddenly feel down
    injury because drowsiness and she not using a helmet and
    than her head bumped to the asphalt

    Injury sustain : Head, face, pelvis


    Symptom & sign : Headache
    Examination : Physical examination
    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear

    B: RR :24 x/minutes, spontaneous, symmetric, thoraco


    abdominal type

    C: BP :120/ 60 mmHg, HR :84 x/minute, regular, adequate

    D: GCS 15 (E4 M6 V5), pupil equal 2,5 /2,5 mm , LR +/+

    E: T (ax) : 36,7 oC
    Secondary Survey
    Right temporofrontal region :
    I : Seen lacerated wound size 3 x 0,5 cm, edema(+),
    hematoma(+), wound (-), active bleeding(-), deformity (-)
    P : Tenderness (+), Crepitating (-)

    Right pelvis region :


    I : Seen lacerated wound size 4 x 4 cm, edema(+), hematoma(+),
    wound (-), active bleeding(-), deformity (+)
    P : Tenderness (+), Crepitating (-)
    ROM : Active and passive motion of hip joints was limited due
    to pain.
    NVD : Sensibility was good, pulse of dorsalis pedis artery was
    palpable, capillary refill < 2
    WORKING DIAGNOSIS : Multiple excoriated wound

    MANAGEMENT : O2
    Medicaments
    Wound care

    PROGNOSIS : Good

    FOLLOW UP : Vital sign

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