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)  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, 5 th 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