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    Main Complaint: Case

    Uploaded by

    Mohamad Zulfikar
    Mrs. T, a 22-year-old female, presented to the emergency department with a headache lasting 2 hours. She reported being hit on the head with a bottle thrown by her sister during an altercation. On examination, she had a 1x0.3 cm laceration on her left parietal region with tenderness but no crepitus or neurological deficits. She was treated for the laceration and discharged.

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    Main Complaint: Case

    Uploaded by

    Mohamad Zulfikar
    1 views4 pages
    Mrs. T, a 22-year-old female, presented to the emergency department with a headache lasting 2 hours. She reported being hit on the head with a bottle thrown by her sister during an altercation. On examination, she had a 1x0.3 cm laceration on her left parietal region with tenderness but no crepitus or neurological deficits. She was treated for the laceration and discharged.

    Original Description:

    simple wound

    Original Title

    Tt Simple Wound

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    Mrs. T, a 22-year-old female, presented to the emergency department with a headache lasting 2 hours. She reported being hit on the head with a bottle thrown by her sister during an altercation. On examination, she had a 1x0.3 cm laceration on her left parietal region with tenderness but no crepitus or neurological deficits. She was treated for the laceration and discharged.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    1 views4 pages

    Main Complaint: Case

    Uploaded by

    Mohamad Zulfikar
    Mrs. T, a 22-year-old female, presented to the emergency department with a headache lasting 2 hours. She reported being hit on the head with a bottle thrown by her sister during an altercation. On examination, she had a 1x0.3 cm laceration on her left parietal region with tenderness but no crepitus or neurological deficits. She was treated for the laceration and discharged.

    Copyright:

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

    No.

    Name : Mrs.T Sex : Male


    Age : 22 years ago No. Reg : 672382

    Main complaint : Headache


    Case : The condition had been apparent for 2 hours before the
    patient admitted to the hospital.There were no history of
    nausea, vomiting and lost of conciousness

    Mechanism of : She was hit by a bottle that was thrown by her sister due
    injury to a brawl.
    Sustained injury : Head
    Symptom & sign : Wound
    Examination : Physical examination
    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear

    B: RR : 14x/minutes, spontaneous, symmetric, thoraco


    abdominal type

    C: BP : 110/70 mmHg, PR : 84x/minute, regular, adequate

    D: GCS 15 (E4M6V5), pupil equal 2,5 /2,5 mm, Light Reflex


    +/+, all motoric muscle function are normal
    E: T (ax) : 36,5 oC
    Secondary Survey
    Left parietal region:
    I : Seen lacerated wound size 1x0,3 cm. Active
    bleeding (-)
    P : Tenderness (+), Crepitation (-)
    WORKING DIAGNOSIS : - Lacerated wound on left parietal region

    MANAGEMENT : Medicament
    Proceed Wound Care
    Patient discharged

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