Scribd
Upload
30 views

Name: Mr. T Age: 31 Years Old Sex: Male Address: Lambuya DPJP: Dr. Syamsul Rijal, SP.B Admission: November, 6th 2017

Mr. T, a 31-year-old male, presented to the hospital with a headache after being in a motorcycle accident where he swerved to avoid an oncoming car. He reported vomiting, nausea, and syncope after the accident. On examination, he was conscious with normal vital signs except an elevated heart rate of 112. A CT scan showed no abnormalities and he was diagnosed with a headache after trauma. He was given IV fluids, analgesics, and antacids and monitored until his symptoms resolved.

Uploaded by

Muhammad Safaat
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
30 views

Name: Mr. T Age: 31 Years Old Sex: Male Address: Lambuya DPJP: Dr. Syamsul Rijal, SP.B Admission: November, 6th 2017

Mr. T, a 31-year-old male, presented to the hospital with a headache after being in a motorcycle accident where he swerved to avoid an oncoming car. He reported vomiting, nausea, and syncope after the accident. On examination, he was conscious with normal vital signs except an elevated heart rate of 112. A CT scan showed no abnormalities and he was diagnosed with a headache after trauma. He was given IV fluids, analgesics, and antacids and monitored until his symptoms resolved.

Uploaded by

Muhammad Safaat
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
You are on page 1/ 7

IDENTITY

Name : Mr. T
Age : 31 years old
Sex : Male
Address : Lambuya
DPJP : dr. Syamsul Rijal, Sp.B
Admission : November, 6th 2017
HISTORY TAKING

Main complain : pain at head


Anamnesis
The patient come to hospital with a pain at head since 5 hours ago after a
traffic accident
Mechanism of trauma :
The patient a rider at motorcicle at medium speed use of a helmet,
suddenly, the car at medium speed going in the opposite direction, the
patient avoided the collision and fell from the motorcicle
There was history of vomiting (+) syncope (+),nausea (+), alkoholism (-),
drugs (-).
Primary survey
A Clear

RR 20 x/min, spontaneous
thoracoabdominal type, symmetrical B
C BP 110/70 mmHg
Pulse =112x/min, regular, strong lift

GCS 15 (E4M6V5), pupil isochors D


E T = 36.8 C (axillary)
General state
Head : Normally Chest : Normally
Face : Normally Abdomen : Normaly
Eyes : Normally Lower limb : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Neck : Normally
DIAGNOSIS

TCS GCS 15
Management
pharmacology Non-pharmacology
education
IVFD
Analgetic
H2RA

Surgeon Consult
Thank You

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy