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TRAUMA. PATIENT DATA N.H 53/M Married Filipino Roman Catholic Pasig city.

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Presentation on theme: "TRAUMA. PATIENT DATA N.H 53/M Married Filipino Roman Catholic Pasig city."— Presentation transcript:

1 TRAUMA

2 PATIENT DATA N.H 53/M Married Filipino Roman Catholic Pasig city

3 CHIEF COMPLAINT "nabangga ng motor" (motor accident)

4 HISTORY OF PRESENT ILLNESS NOI: motorcycle accident (motorcycle versus motorcycle) TOI: 6:50 PM POI: Julia Vargas ave cor. Meralco ave DOI: Feb

5 10 mins prior to consult Patient was riding his motorcycle, with a helmet, along Julia Vargas ave. when another motorcycle hit his motorcycle from the back throwing him off forward causing multiple injuries.

6 There was no loss of consciousness No vomiting No dizziness (+) pain, generalized, most at right leg and left hand

7 Patient was then brought to TMC-ER for evaluation Hence consult and subsequent admission

8 PAST MEDICAL HISTORY (+) Diabetes Mellitus maintained on Metformin 500 mg OD (+) Hypocalcemia, diagnosed 1 year prior during routine company check-up Calcium supplement Previous hospitalization. Acute Gastroenteritis Previous surgery. Inguinal heniorrhaphy No known allergies

9 FAMILY HISTORY (-) DM (-) HTN

10 PERSONAL-SOCIAL UNILAB employee Non-smoker Occasional alcohol beverage drinker

11 PHYSICAL EXAMINATION Stretcher Alert, coherent, cooperative BP 140/90 T 36.9 HR 92 RR 22 VAS 8/10 Weight 71.5 kg Height 178 cm BMI = 22

12 Head and neck: (+) laceration, infero-medial eyelid, R (+) contusion hematoma, periorbital area, R (+) blood clots, per nostril cervical collar Chest: No gross lesions, adynamic precordium, normal rate, regular rhythm Lungs: No gross lesions, clear breath sounds, no rales/wheeze Abdomen: Flat, Soft, non-tender, (-)guarding

13 Extremities: (+) laceration, anterior shoulder, R (+) Gross deformity, 2nd, 3rd, 4th digit with traumatic nail avulsion, 3rd digit

14 (+) swelling with gross deformity, middle third, R thigh (+) multiple abrasions, medial aspect, middle third, R thigh (+) gross deformity 2x2 with 2cm laceration, anterior aspect, middle third, R thigh (+) 1-2cm laceration, posterior aspect, middle third, R thigh


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