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  • Chief Complaint: History Taking: No. Name: Ms. K Sex: Female Age: 21 Years No. Reg: 664949

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    Mohamad Zulfikar
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    Ms. K, a 21-year-old female, presented with a headache after a traffic accident where her motorcycle was hit from behind and she was thrown into an oncoming car. On examination, she had a 4x2 cm excoriation wound on her forehead and a 1 cm wound on her neck, both tender. Her vital signs were stable. The working diagnosis was mild head injury and tracheal fracture. She was given oxygen and medications, and her prognosis was good.

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    Ms. K, a 21-year-old female, presented with a headache after a traffic accident where her motorcycle was hit from behind and she was thrown into an oncoming car. On examination, she had a 4x2 cm excoriation wound on her forehead and a 1 cm wound on her neck, both tender. Her vital signs were stable. The working diagnosis was mild head injury and tracheal fracture. She was given oxygen and medications, and her prognosis was good.

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    1 views4 pages

    Chief Complaint: History Taking: No. Name: Ms. K Sex: Female Age: 21 Years No. Reg: 664949

    Uploaded by

    Mohamad Zulfikar
    Ms. K, a 21-year-old female, presented with a headache after a traffic accident where her motorcycle was hit from behind and she was thrown into an oncoming car. On examination, she had a 4x2 cm excoriation wound on her forehead and a 1 cm wound on her neck, both tender. Her vital signs were stable. The working diagnosis was mild head injury and tracheal fracture. She was given oxygen and medications, and her prognosis was good.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 4

    No.

    Name : Ms. K Sex : Female


    Age : 21 years No. Reg : 664949

    Chief complaint : Headache

    History taking : This condition has been apparent for 1 hours before
    admitted to the hospital due to traffic accident. History
    loss of consciousness (-) nausea (-) vomiting (-).
    Mechanism of : She was riding her motorcycle when suddenly a car hit
    injury her motorcycle from behind, then she was thrown into a
    car came from her opposite direction
    Injury sustain : Head, neck
    Symptom & sign : Headache, dyspneu
    Examination : Physical examination
    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear

    B: RR 16 x/minutes, spontaneous, symmetric, thoraco


    abdominal type

    C: BP :120/ 70 mmHg, HR :78 x/minute, regular, adequate

    D: GCS 15 (E4 M6 V5), pupil equal 2,5 /2,5 mm , LR +/+

    E: T (ax) : 36,7 oC
    Secondary Survey
    Frontal region :
    I : Seen excoriation wound, size 4x2 cm
    P : Tenderness (+), Crepitatation (-)
    Neck region :
    I : Seen vulnus ictum wound diameter 1 cm
    P : Tenderness (+) Crepitation (+) Airflow (+)
    WORKING DIAGNOSIS : Mild head injury GCS 15 (E4M6V5)
    Tracheal fracture
    MANAGEMENT : O2
    Medicaments

    PROGNOSIS : Good

    FOLLOW UP : Vital sign

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