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TCR Samsurijal

Mr. S, a 33-year-old male, presented to the hospital with a 4-day history of headaches following a traffic accident where another motorcycle hit him from the right side causing him to fall and hit his head and face on the asphalt. On examination, he had excoriation wounds on his right zygoma and obicularis oris regions with tenderness and crepitus on the zygoma. A head CT scan was performed. He was diagnosed with mild head injury and multiple excoriation wounds and was treated with oxygen, medications, and wound care. His prognosis was good and he was followed up by monitoring his vital signs.

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Mohamad Zulfikar
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23 views5 pages

TCR Samsurijal

Mr. S, a 33-year-old male, presented to the hospital with a 4-day history of headaches following a traffic accident where another motorcycle hit him from the right side causing him to fall and hit his head and face on the asphalt. On examination, he had excoriation wounds on his right zygoma and obicularis oris regions with tenderness and crepitus on the zygoma. A head CT scan was performed. He was diagnosed with mild head injury and multiple excoriation wounds and was treated with oxygen, medications, and wound care. His prognosis was good and he was followed up by monitoring his vital signs.

Uploaded by

Mohamad Zulfikar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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No.

Name : Mr. S Sex : Male


Age : 33 years No. Reg : 659598

Chief complaint : Headache

History taking : This condition has been apparent for 4 days before
admitted to the hospital due to traffic accident. History
loss of consciousness (-) nausea (+) vomiting (+). Prior
medical care at Ajjapangge hospital, Soppeng.
Mechanism of : He was riding a motorcycle then suddenly another
injury motorcycle hit him from his right side, then he fell with
his head and face to the asphalt

Injury sustain : Head, face


Symptom & sign : Headache
Examination : Physical examination, head CT scan
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR 15 x/minutes, spontaneous, symmetric, thoraco


abdominal type

C: BP :100/ 60 mmHg, HR :78 x/minute, regular, adequate

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

E: T (ax) : 37,1 oC
Secondary Survey
Right zygoma region :
I : Seen excoriation wound, size 1x0,5 cm
P : Tenderness (+), Crepitatation (+)

Obicularis oris region


I : Seen excoriation wound size 2x1 cm
P : Tenderness (+), Crepitation (-)
Head CT
Scan
WORKING DIAGNOSIS : Mild head injury GCS 15 (E4M6V5)
Multiple excoriation wound
MANAGEMENT : O2
Medicaments
Wound care

PROGNOSIS : Good

FOLLOW UP : Vital sign

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