Trauma SGDMB

History

General Data

MB 14/male From Rosario Cavite Grade 6, unemployed Right-handed

Chief Complaint

Multiple injuries

HPI

DOI: June 8, 2009 TOI: 4PM POI: Cavite Highway MOI: MVC (motorcycle vs. pedestrian)

Patient was hit by a motorcycle on the right side of his body while he was crossing the highway.

(-) LOC, (-) headache, (-) vomiting, (-) DOB, (+) pain on right leg, (+) multiple abrasions

Patient was ambulatory but had difficulty due to pain

HPI

Motorcycle driver brought the patient to a local hospital X-ray done showed a femoral fracture Anti-tetanus shot given Wooden splint was placed Referred to PGH for admission

PGH ER: 10 hours post-injury (12MN of June 9, 2009)

ROS

(+) headache (VAS 8/10) (-) dizziness (-) blurring of vision (-) difficulty breathing (-) cough/colds (-) hematemesis/vomiting (+) change in bowel movement

(once since the day of injury) (-) pain on the extremities

PMH

(+) bronchial asthma (-) PTB (-) allergies (-) goiter (-) hypertension Bronchial asthma (Cavite Hospital,

1998)

FMH

(+) PTB (father) (+) hypertension (mother) (-) bronchial asthma (-) allergies (-) goiter (-) DM

Personal and Social History

(-) smoking (-) alcohol use

Physical exam

General Survey

Awake Conscious Coherent Not in cardiorespiratory distress

Vital Signs

BP 120/70 HR 72 beats/min RR 18 breaths/min Temperature afebrile Not in pain

Systemic PE

HEENT AS, PPC, (-) CLAD, (-) TPC, (-) ANM, supple neck

Chest/Lungs No gross deformities, SCE, CBS, (-) rales/wheezes

CVS AP, AB = PMI, 5th ICS LMCL, DHS, NRRR, (-)

heaves, (+) palpable thrill LPSB Abdomen

Flat, NABS, soft, non-tender, (-) masses GU

(-) CVA tenderness, deferred

Skin/Extremities

(+) skeletal traction on right leg Varus deformity of right hip Multiple abrasions

Right groin Left knee Bilateral ankles

(-) foul odor on abrasions (+) edematous right leg FEP, PNB, (-) cyanosis, (-) discoloration

continued at the next slide…

Skin/Extremities

(-) tenderness, (+) warmth on right leg, (+) swelling right hip

Girth above the patella: 39 cm (right), 30 cm (left)

ROM of hip: deferred Symmetrical ROM of ankles and upper

extremities No sensorimotor deficits True leg length: 75cm (right), 77cm

(left)

Laboratory Exams

Assessment

Working Impression

Multiple injuries secondary to a MVC Hip: fracture, closed, complete, spiral,

displaced, subtrochanteric, femur, right Multiple abrasions