Case Study On Head Injury

Name: Mr . Suhag Sen Verma

Age -32years

Education: B.Tech

Occupation: Govt. Service Holder

Marital Status: Married

Address: Qtr No 2FlAT -8 BHILLAI

Registration Number:1237456

Ward :M2

Under Doctor: Dr. R. Gulati

Diagnosis: Peri Orbital Hematoma with Left Frontal Hemorrhagic Contusion with Right Hemiparesis

Chief Complain: Alleged history of road traffic accident near by road of his resident on
21/08/2021 sustained head injury and found unconscious. A group of passer byers taken to local
hospital.

Present Medical History: Injury on head and left eye and multiple abrasion over face lacerassion

Wound over left tempo- parital region. On admission patient was intubated from outside hospital, and
patient was restless.

Past Medical History: My client has no past history of any major illness. My client is non diabetic, non-
hypertensive.

Family History: My Client lives with his Father Mother and his wife

Socio- economical history: Patient lives in his own house in a city. Both the parents is teacher and
patient himself is an engineer of a government sector. His wife is a school teacher.
Immunization History:

My client has immunization against Tetanus Toxoid along with Tetanus Immunoglobulin

2 Doses of COVID vaccine has been taken on 2/07/2021.

Allergy History: History of allergy is unknown to my Clinet.

Surgical History: There was no surgical history of my client.

General Examination:

Emotional State: Restless

Level of Consciousness: Unconscious

Speech: Unable to communicate

Limb Movement: Passive movement

Chest Movement: Bilateral

Air Entry: Bi lateral

Cough: No History of cough

Peripheral Pulse: Present

Heart Sound: S1and S2

Neck Vien:

Mouth: Clean

Tongue : Clean

Nutritional Route: Oral

Bowel: Constipation

Void: Catheter

Skin: Laceration marks are present

Cyanosis: Absent

Edema: Neck and lower limb

 Eyes: Clean a

Sleep: Not Known

Joint: Painful

Patient is unable to stand or walk

Definition: he term 'spinal cord injury' refers to damage to the spinal cord resulting from trauma
(e.g. a car crash) or from disease or degeneration (e.g. cancer). ... The most severe spinal cord injury
affects the systems that regulate bowel or bladder control, breathing, heart rate and blood pressure

Etiology:

According to Book According to patient

 Falls. ...
 Vehicle-related collisions. ...
 Motor vehicle accidents (Collision with
 Violence. ... motor bike and truck)
 Sports injuries. ...
 Explosive blasts and other combat
injuries

VITAL SIGN

PARAMETER NORMAL IN PATIENT

Temperature 98 98.6®F
Pulse 72-82 122
Respiration 16-20

INVESTIGATION:

PERAMETER NORMAL IN PATIENT

ABG PH-7.35-7.45 PH-7.43
PO2-75mmHg-100mmHg PO2-232
PCO2-35mmHg-45mmHg PCO2-32.3
Hco322mEq/L-26mEq/L Hco3-18.3
O2 Sat->95% O2Sat-99.5%
Hb 13-17 Hb-10.4
RBC-3.39
RBC 4.5-5.5 PCV-31.2
PCV WBC-14.6
WBC PLATELATE-
Platelets- Na-132
Ptime K-3.5
INR Urea-18
 Na Creatinine-1.07
K
Urea
Creatinine

Medical Management

MEDICINE STRENGTH ROUTE DOSE

Infusion Normal Saline 500ml IV 2 such/day

Infusion Dextrose Normal 500ml IV 2such/day

Saline
Inj Pantoprazole 40mg IV OD
Inj. 3gm IV BD
Cefoperazone+Sulbactu
m
Inj. Mannitol 100ml IV TDS

Inj. Fentanyl 5ml IV Per Hour

Inj. Midazolam 3ml IV Per Hour

Surgical History
Past Surgical History:

My client has no past surgical history

Present Surgical History:

De compressive Craniotomy done on 22/08/2021

ASSESSMENT DIAGNOSIS OBJRCTIVE INTERVENTION OUTCOME

Increased confusion and Decreased Intracranial To reduce ICP and 1Monitor the patient’s
restlessness can Adaptive Capacity r/t neurological status,
increase tissue meaning the LOC, pupils,
indicate deterioration in increased intracranial
perfusion and Glasgow coma scale
status. A change in LOC pressure
scores continuously. 
may be a sign of an 2.Monitor vital signs
increased ICP continuously or at least
(intracranial pressure).  every hour.
3.Keep Po2 between 80
and 100 mmHg and Pco2
between 35 and 38
mmHg.
4.Avoid any activities
and symptoms that
increase ICP. 
5.Administer
medication as ordered
 to decrease ICP. 

Risk for Seizures    patient will remain

free from seizure
activity and injury
thereof.