Trauma sgd
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Trauma SGD. MB. 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)

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Trauma SGD

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Trauma sgd

Trauma SGD

MB


History

History


General data

General Data

  • MB

  • 14/male

  • From Rosario Cavite

  • Grade 6, unemployed

  • Right-handed


Chief complaint

Chief Complaint

  • Multiple injuries


Trauma sgd

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


Trauma sgd

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)


Trauma sgd

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


Trauma sgd

PMH

  • (+) bronchial asthma

  • (-) PTB

  • (-) allergies

  • (-) goiter

  • (-) hypertension

  • Bronchial asthma (Cavite Hospital, 1998)


Trauma sgd

FMH

  • (+) PTB (father)

  • (+) hypertension (mother)

  • (-) bronchial asthma

  • (-) allergies

  • (-) goiter

  • (-) DM


Personal and social history

Personal and Social History

  • (-) smoking

  • (-) alcohol use


Physical exam

Physical exam


General survey

General Survey

  • Awake

  • Conscious

  • Coherent

  • Not in cardiorespiratory distress


Vital signs

Vital Signs

  • BP 120/70

  • HR 72 beats/min

  • RR 18 breaths/min

  • Temperature afebrile

  • Not in pain


Systemic pe

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

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 extremities1

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

Laboratory Exams


Assessment

Assessment


Working impression

Working Impression

  • Multiple injuries secondary to a MVC

    • Hip: fracture, closed, complete, spiral, displaced, subtrochanteric, femur, right

    • Multiple abrasions


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