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ER Cases: Mild Head Injuries and Treatments

The document describes two patient cases seen in the emergency room. The first case is a 26-year-old male who arrived at 5:50pm with head wounds after a motorcycle crash. He was experiencing nausea, vomiting, dizziness and nosebleeds. Examination found lacerations on his head and bruising on his abdomen. The second case is a 42-year-old male who arrived at 8:05pm with head wounds after being beaten with wood. Examination found a laceration on his head but no other injuries. Both patients received IV fluids and pain medications.

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43 views23 pages

ER Cases: Mild Head Injuries and Treatments

The document describes two patient cases seen in the emergency room. The first case is a 26-year-old male who arrived at 5:50pm with head wounds after a motorcycle crash. He was experiencing nausea, vomiting, dizziness and nosebleeds. Examination found lacerations on his head and bruising on his abdomen. The second case is a 42-year-old male who arrived at 8:05pm with head wounds after being beaten with wood. Examination found a laceration on his head but no other injuries. Both patients received IV fluids and pain medications.

Uploaded by

Rothen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd

Saturday, January 9 2016

Name : Mr. VL
Age : 26 years old
Sex : Male
Arrived time : 17.50 p.m.

Chief Complaint :
Wounds at heads up

History
The patient came to ER because he had wounds
at heads up after crashed by motorcycle since 30
minutes ago. The history of unconciousness (+),
nausea (+), vomit (+) 4 times with balackish,
dizzines (+). The history of hemoptoe (+).

A: clear
B : RR: 20 times in a minute
C : Blood pressure : 110/80 mmHg ,
Pulse: 88 times/minute, regular.
D : GCS: E4 V5 M6
E : - Vulnus laceration et regio occipital.
- vulnus excoriation et regio umbilical
sinistra to lumbar sinistra

Eye : anemis (-/-), pupils refleks +/+, icteric


(-/-)
Ear : othoroe (-/-)
Nose : Epistaxis (+/+)

Inpection : chest movement simetrics,


regular, abdominothoracal
Palpation : vocal fremitus R=D, crepitation
(-)
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchie (-/-),
wheezing (-/-)

Inspection : distended (-), bruise (+)


Auscultation : intestinal sounds + normal
Palpation : tenderness pain (-), mass (-)
Percusion : timpany sound (+)

Look
Vulnus excoriation et regio antebrachi sinistra,
edema (-) et regio patela sinistra,
Feel
pain (+)
- Move
ROM : no Limit

Mild head injury


Vulnus laceratum et regio occipitalis

IVFD RL 1500 drops per minute


Ketorolac 3x30 mg
Ranitidin 2x50 mg
Omeprazole 2x40 mg
ATS

Name : Mr. BF
Age : 42 years old
Sex : Male
Arrived time : 20.05 p.m.

Chief Complaint :
Wounds at heads up

History
The patient came to ER because he had
wounds at his heads up after he beaten by
spike wood in peak since 20 minutes ago. The
history of unconciousness (-) , nausea (-),
vomit (-), dizzines (-).

A: clear
B : RR: 20 times in a minute
C : Blood pressure : 110/80 mmHg ,
Pulse: 84 times/minute, regular.
D : GCS: E4 V5 M6
E : - Vulnus laceration et regio parietalis.

Eye : anemis (-/-), pupils refleks +/+, icteric


(-/-)
Ear : othoroe (-/-)
Nose : Epistaxis (-/-)

Inpection : chest movement simetrics,


regular, abdominothoracal, bruise (-)
Palpation : vocal fremitus R=D, crepitation
(-)
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchie (-/-),
wheezing (-/-)

Inspection : distended (-), bruise (-)


Auscultation : intestinal sounds + normal
Palpation : tenderness pain (-), mass (-)
Percusion : timpany sound (+)

Look
normal
Feel
pain (-)
- Move
ROM : no Limit

Mild head injury


Vulnus laceratum et regio pariealis

IVFD RL 1500 drops per minute


Ketorolac 3x30 mg
ATS

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