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CASE SHEET PROFORMA

Road Traffic Accident - Scalp Laceration

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SECTION 1: REGISTRATION / ADMISSION DETAILS

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SECTION 2: PATIENT IDENTIFICATION

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SECTION 3: MEDICO-LEGAL DETAILS (Mandatory - RTA)

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SECTION 4: HISTORY

• Date and time of accident: ___________
• Place of accident: ___________
• Mechanism of injury: Collision between two bikes
• Patient's position: Rider / Pillion rider
• Speed of vehicle (if known): ___________
• Helmet worn: Yes / No
• Seat belt (N/A for bike): -
• Loss of consciousness: Yes / No
• If yes, duration: ___________
• Amnesia (pre/post event): Yes / No
• Seizures after injury: Yes / No
• Vomiting: Yes / No (number of episodes: ___)
• Headache: Yes / No (grade: ___)
• Ear/nose bleeding: Yes / No
• Vision disturbance: Yes / No
• Any treatment given prior to arrival: Yes / No
• If yes, details: ___________

• Hypertension: Yes / No
• Diabetes Mellitus: Yes / No
• Epilepsy: Yes / No
• Bleeding disorders / on anticoagulants: Yes / No
• Previous surgeries: Yes / No
• Drug allergy: Yes / No

• LMP: ___________
• Possibility of pregnancy: Yes / No / Unknown
• G ___ P ___ L ___ A ___

• Smoking / Tobacco: Yes / No
• Alcohol: Yes / No (last consumed: ___)
• Medications currently taken: ___________

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SECTION 5: GENERAL EXAMINATION

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SECTION 6: NEUROLOGICAL ASSESSMENT (Critical for head injury)

• Motor: Present / Absent - Details: ___________
• Sensory: Present / Absent
• Cranial nerve deficit: Present / Absent
• Cerebellar signs: Present / Absent

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SECTION 7: LOCAL EXAMINATION OF WOUND (Scalp)

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SECTION 8: SYSTEMIC EXAMINATION

• S1 S2: Heard / Not heard
• Murmurs: Present / Absent

• Air entry: Bilateral equal / Unequal
• Added sounds: Nil / Wheeze / Crepts

• Tenderness: Present / Absent
• Guarding / Rigidity: Present / Absent
• Organomegaly: Present / Absent

• Bony tenderness: Nil / Present (site: ___)
• Deformity: Nil / Present
• Range of motion: Full / Restricted

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SECTION 9: INVESTIGATIONS

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SECTION 10: DIAGNOSIS

1. Closed head injury with intracranial bleed (rule out by CT)
2. Skull fracture
3. Concussion

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SECTION 11: TREATMENT PLAN

• Airway secured / Patent
• IV access established (gauge: ___)
• IV fluids started (type: ___ @ ___ ml/hr)
• Wound cleaned and dressed
• Bleeding controlled by pressure / suturing
• Tetanus prophylaxis given (TT / TIG)
• Anti-epileptics (if seizures): ___________
• Analgesics: ___________
• Antibiotics: ___________
• CT Brain ordered
• Neurosurgery opinion: Sought / Not required

• Discharged with advice
• Admitted - Ward / HDU / ICU
• Referred to: ___________

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SECTION 12: DOCTOR'S CERTIFICATION (For MLC)

"Certified that the above-mentioned patient was examined by me and the injuries described above were noted. This is a case of Road Traffic Accident (RTA). The findings are recorded to the best of my knowledge. Police has been / will be informed as per MLC protocol."

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SECTION 13: CONSENT

• Written informed consent taken for examination and treatment
• Patient / Guardian unable to consent (reason: ___)
• Emergency consent waived (unconscious / critical)

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Key Reminders for RTA MLC Cases:

• Always intimate police (MLC registration is mandatory).
• Document wound measurements precisely with medico-legal language.
• Order CT Brain for any RTA with scalp laceration - do not rely on clinical exam alone to rule out intracranial injury.
• Note helmet use status - relevant for severity assessment.
• Pregnancy test mandatory before any radiation in females of reproductive age.
• Tetanus prophylaxis must be documented.

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CASE SHEET

Road Traffic Accident - Medico-Legal Case

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SECTION 1: REGISTRATION / ADMISSION DETAILS

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SECTION 2: PATIENT IDENTIFICATION

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SECTION 3: MEDICO-LEGAL DETAILS (MLC - Mandatory)

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SECTION 4: HISTORY

• Date & time of accident: 25 - 07 - 2026, _______ hrs
• Place of accident: Charlapally, Hyderabad
• Mechanism of injury: Collision between two bikes - patient was pillion rider
• Speed of vehicle: Not known
• Helmet worn: No (assumed - to be confirmed)
• Loss of consciousness: Not present / Present (duration ___ mins) - (confirm)
• Amnesia: Absent
• Vomiting: 1 episode after injury
• Headache: Present, mild to moderate
• Seizures: Absent
• Ear / Nose bleeding: Absent
• Vision disturbance: Absent
• Pre-hospital treatment: Pressure dressing applied at scene / Nil

• Hypertension: No
• Diabetes Mellitus: No
• Epilepsy: No
• Bleeding disorder / Anticoagulants: No
• Previous surgeries: No
• Drug allergy: No

• LMP: _________________ (to be recorded)
• Possibility of pregnancy: To be confirmed
• G ___ P ___ L ___ A ___

• Smoking / Tobacco: No
• Alcohol: No

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SECTION 5: GENERAL EXAMINATION

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SECTION 6: NEUROLOGICAL ASSESSMENT

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SECTION 7: LOCAL EXAMINATION OF WOUND (Scalp - MLC Description)

MLC Wound Certificate Language: "A lacerated wound measuring approximately 4 cm × 1 cm is present over the right parietal region of the scalp, with irregular and contused margins, involving skin, subcutaneous tissue and galea aponeurotica. Underlying skull appears intact on palpation. Active bleeding present, controlled with pressure dressing. A contusion of approximately 3 cm × 3 cm is also noted over the same region. No other external injuries noted over the body."

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SECTION 8: SYSTEMIC EXAMINATION

• Heart sounds S1 S2 heard, no murmurs
• Peripheral pulses - present and equal bilaterally

• Air entry - bilateral, equal
• No wheeze, no crepitations

• Soft, non-tender
• No guarding or rigidity
• No organomegaly

• No bony tenderness
• No deformity
• Full range of motion in all limbs
• No neurovascular deficit in limbs

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SECTION 9: INVESTIGATIONS

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SECTION 10: DIAGNOSIS

RTA (Bike vs Bike collision) - Scalp laceration, right parietal region (4 cm × 1 cm) with subgaleal extension - Minor head injury - GCS 15/15

1. Closed head injury with intracranial hemorrhage - to be ruled out by NCCT Brain
2. Linear skull fracture - to be ruled out
3. Concussion

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SECTION 11: TREATMENT

• IV access - 18G cannula, right forearm
• IV fluids - Ringer's Lactate 500 ml @ 60 ml/hr
• Wound cleaning - Normal saline irrigation, betadine dressing
• Wound sutured - 4 interrupted non-absorbable sutures (3-0 Prolene) under local anesthesia (2% Lignocaine)
• Tetanus Toxoid (TT) 0.5 ml IM given
• Inj. Cefazolin 1g IV (antibiotic prophylaxis)
• Tab. Paracetamol 500 mg PO for pain
• NCCT Brain ordered
• Neurosurgery opinion - Not required at present (GCS 15, no focal deficit)
• Police intimated - MLC registered

• Admitted for 24-hour observation (standard for head injury with scalp laceration)
• Advice on return to ED: worsening headache, vomiting, altered sensorium, seizures

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SECTION 12: DOCTOR'S CERTIFICATION (MLC)

"Certified that Ms. Dommati Sindhu, 24 years, Female, was examined by me on 25/07/2026 at _____ hrs. The injuries described above are noted and recorded. This is a case of Road Traffic Accident (Bike vs Bike collision) at Charlapally. Charlapally Police Station has been informed. Findings are recorded to the best of my knowledge and belief."

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SECTION 13: CONSENT

• Written informed consent taken from patient (conscious and oriented)
• Consent for suturing and investigation taken

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Follow-up Instructions:

• Suture removal after 7 days
• Review if CT Brain report is abnormal
• Watch for: worsening headache, repeated vomiting, drowsiness, seizures - report immediately
• Wound care: keep dry, betadine dressing daily

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