Case referred from Hospital Kuala Krai.
Case of mild head injury – managed conservatively there.
Zainab binti Yajid
530626035298

Referral from  23/2/2021 on 11.30 am

Patient's name: Zainab binti Yajid
IC: 530626035298

Diagnosis: alleged fall

1) Small EDH Over right frontotemporal with scalp hematoma
3) closed fracture skull over right frontotemporal



67yro,Malay, male
Nkmi, Adl independent
Presentation:

P/w- alleged fall at home around 4am at home, patient fell down the stairs around 5 metre heights. Pt fell on the back of head

Post trauma-
 + pain and swelling over back of head
+Headache
+Dizziness
+ Vomiting 
-5x total since 6am today, non projectile

O/w, no loc,, no amnesia
No sob, chest pain
No abdominal pain
Able to ambulate

O/e: GCS full, pupils reactive bilaterally 3mm/3mm, not tachypneic 

Bp: 161/72
P; 66
Spo2: 98 under room air
T:36.6

Lungs : equal a/e, clear
Cvs: s1, s2
P/a : soft, non tender

Tender over cervical area, no step deformity

Local examination:
-hematoma over right temporal 5 x6 cm

Cns examination

Power, reflex and, tone normal bilateral upper limb and lower limb 
Babinski equivocal , clonus absent

CN intact

Ix

Blood:
Hb: 12.8 twc:16.8 PLT: 291
Pt: 11.9 aptt: 26.3  INR: 1.08
Na: 138 K: 3.6: 2.8  Cr :52
LFT - ALP: 98 ALT: 48.9  AST: 41

Ct brain: small EDH at right frontotemporal with scalp hematoma
Chest x-ray: clear lung field

Repeat CT Brain at HKK as patient not keen for transfer. Continue observation