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 15 2012

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