Chief complain: air riffle shot wound on the forehead
It has been suffered since 2 hours before admitted to hospital. He was carrying an air riffle when he fell down and accidentally shot his forehead. History of decrease consciousness (-), decrease vision (+).
Primary SurveyA: clearB: spontaneous, RR: 20 times/minuteC: warm acral, HR: 88 times/minute, BP: 110/70 mmHgD: GCS 15E: undress, log roll bruise (-)
Secondary Survey• Head: air riffle shot wound on the forehead,
Ø 2 mm, regular edge, active bleeding (-), pain (-)
• Neck: no abnormalities
• Chest: L: symmetrical L: vesicular on both hemithorax F: pain (-)
• Abdomen: L: symmetrical, distension (-)L: peristaltic (+)
normalF: supple
• Extremities: no abnormalities
Laboratory findingsHb/Hct/Leu/Plt : 14.3/39.5/11.18/248Na/K/Cl : 130/4.3/100Ur/Cr : 17.65/0.57KGD : 119.53
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