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Trauma SGD

MB. Trauma SGD. 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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  1. MB Trauma SGD

  2. History

  3. General Data • MB • 14/male • From Rosario Cavite • Grade 6, unemployed • Right-handed

  4. Chief Complaint • Multiple injuries

  5. 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

  6. 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)

  7. 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

  8. PMH • (+) bronchial asthma • (-) PTB • (-) allergies • (-) goiter • (-) hypertension • Bronchial asthma (Cavite Hospital, 1998)

  9. FMH • (+) PTB (father) • (+) hypertension (mother) • (-) bronchial asthma • (-) allergies • (-) goiter • (-) DM

  10. Personal and Social History • (-) smoking • (-) alcohol use

  11. Physical exam

  12. General Survey • Awake • Conscious • Coherent • Not in cardiorespiratory distress

  13. Vital Signs • BP 120/70 • HR 72 beats/min • RR 18 breaths/min • Temperature afebrile • Not in pain

  14. 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

  15. 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…

  16. 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)

  17. Laboratory Exams

  18. Assessment

  19. Working Impression • Multiple injuries secondary to a MVC • Hip: fracture, closed, complete, spiral, displaced, subtrochanteric, femur, right • Multiple abrasions

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