CEREBRAL LACERATION

CHIEF COMPLAINT Cerebral laceration HPI SYMPTOM LIST •Unconsciousness •Drowsy •Confused •Restless •Agitated •Vomiting •Seizures •Impaired balance •Impaired coordination •Coma SEVERITY •Mild •Moderate •Severe •Normal •Increased •Decreased •Stable •No significant change from prior visit ONSET •Sudden •Gradual DURATION •Recent •Few days •Many days

•Few weeks •Many weeks •Few months •Many months •Few years •Many years NOTES

HISTORY (PMFSH) PAST HISTORY •Injury to head •Road traffic accident Allergy-Drugs -Environment FAMILY HISTORY SOCIAL HISTORY •Habits o Tobacco o Alcohol o Drugs •Occupation

ROS

PHYSICAL EXAMINATION

SPECIFIC DATA LIKE GRADING ETC

Glasgow Coma Scale 1 Does E not yes open eyes 2 Opens eyes in response to painful stimuli 3 Opens eyes in response to voice 4 5 6 N/A Opens eyes N/A spontaneo usly

Oriente Utters d, V Makes Incomprehe Confused, inappropr conver erba no nsible disoriente N/A iate ses l sounds sounds d words normal ly Flexion / Makes Abnormal Localiz Extension to Withdraw Obeys M no flexion to es painful al to Comma otor moveme painful painful stimuli painful nds nts stimuli stimuli stimuli

TESTS TO BE ORDERED •Blood tests •Chest X-ray •Skull X-ray •CT brain •MRI ASSESSMENT/PLAN & INSTRUCTIONS/EDUCATION
•Supplemental oxygen was given •Patient was on mechanical ventilation •Pain relievers and sedation was given to the patient

•Fever and seizures are treated. MEDICATION •Carbamazepine

•Lamotrigine •Sodium Valproate •Olanzapine •Risperidone •Citalopram •Fluoxetine •Vecuronium •Thiopental) •Pentobarbital •Phenobarbital •Midazolam •Lorazepam •Phenytoin •Furosemide •Mannitol •Lidocaine

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