Scribd Logo
Upload

Welcome to Scribd!

  • 15 views

    Name: Mrs. S Age: 63 ID: 01422313 ADM: National Health Insurance

    Uploaded by

    syaiful_sn
    Mrs. S, a 63-year-old woman, presented to the emergency department with persistent headache after falling off her bicycle 10 hours prior. On examination, she was conscious with a Glasgow Coma Scale of E4V5M6 and an equal-sized pupil reaction. A CT scan showed edema in her brain. She was diagnosed with a mild brain injury and cerebral edema. Her treatment plan included oxygen, intravenous fluids, pain medication, observation of her vital signs and Glasgow Coma Scale, and admission for further monitoring.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Name: Mrs. S Age: 63 ID: 01422313 ADM: National Health Insurance

    Uploaded by

    syaiful_sn
    15 views9 pages
    Mrs. S, a 63-year-old woman, presented to the emergency department with persistent headache after falling off her bicycle 10 hours prior. On examination, she was conscious with a Glasgow Coma Scale of E4V5M6 and an equal-sized pupil reaction. A CT scan showed edema in her brain. She was diagnosed with a mild brain injury and cerebral edema. Her treatment plan included oxygen, intravenous fluids, pain medication, observation of her vital signs and Glasgow Coma Scale, and admission for further monitoring.

    Original Description:

    Semoga nermanffat

    Original Title

    Mild Brain

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Mrs. S, a 63-year-old woman, presented to the emergency department with persistent headache after falling off her bicycle 10 hours prior. On examination, she was conscious with a Glasgow Coma Scale of E4V5M6 and an equal-sized pupil reaction. A CT scan showed edema in her brain. She was diagnosed with a mild brain injury and cerebral edema. Her treatment plan included oxygen, intravenous fluids, pain medication, observation of her vital signs and Glasgow Coma Scale, and admission for further monitoring.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    15 views9 pages

    Name: Mrs. S Age: 63 ID: 01422313 ADM: National Health Insurance

    Uploaded by

    syaiful_sn
    Mrs. S, a 63-year-old woman, presented to the emergency department with persistent headache after falling off her bicycle 10 hours prior. On examination, she was conscious with a Glasgow Coma Scale of E4V5M6 and an equal-sized pupil reaction. A CT scan showed edema in her brain. She was diagnosed with a mild brain injury and cerebral edema. Her treatment plan included oxygen, intravenous fluids, pain medication, observation of her vital signs and Glasgow Coma Scale, and admission for further monitoring.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 9

    Name : Mrs.

    S
    Age : 63
    ID : 01422313
    ADM : National Health Insurance
    Chief complaint:
    Persistent headache after falling

    Present illness:

    Ten hours prior to admission, while the patient was riding


    bicycle, the bicycle was slipped and he fell down in unknown
    position. Unconsciousness (+), vomit (-), seizure (-). After the
    accident, patient complained persistent headache. By the
    helper, he was brought to Panti Waluyo Hospital. Because of
    limited facility, he was brought to Moewardi Hospital.
    Primary survey

    A : Clear

    B : I : Equal chest expansion, RR : 20 x/mnt

    P : crepitation (-/-)

    P : Sonor/sonor

    A : Vesicular breathing sound (+/+), additional sound (-/-)

    C : HR : 94 x/mnt, BP : 130/80 mmHg

    D : GCS E4V5M6, equal pupil width (3 mm/3 mm), light reflexes (+/+)

    E : T : 36,6o C
    Secondary Survey

    Head : Hematom R. Parietal (D) (+)

    Eyes : no abnormality

    Nose : no abnormality

    Mouth : no abnormality

    Face : no abnormality

    Ear : no abnormality

    Neck : no abnormality

    Chest : no abnormality

    Abdomen : no abnormality

    Extremity : no abnormalilty
    1st Assessment :
    Mild Brain Injury GCS E4V5M6 with persistent headache

    1st Plan :
    O2 3 lpm
    Head Up 30°
    IVFD NaCl 0.9% 1500 cc/24 hours
    Metamizole inj. 300 g/8 hours
    Laboratory
    Head Ct scan
    Head ct scan from Moewardi
    2nd Assesment:
    Mild Brain Injury GCS E4V5M6 (ICD X S06.2)
    Oedema Cerebri (ICD X G93.4)

    2nd Plan:
    Inward
    Observation VS, GCS and lateralization.
    Arrival Time 16.10

    Triage Time 16.15

    Surgery Dept. Time 16.20

    Radiology Time 16.35-17.30

    Diagnose Time 17.35

    Inward Time 17.40

    You might also like