Aruchamy, sudharshanAlamuri khadhar, basha

Augustus, JoelGaneshan, Kishore

Austin, Nissy

SURGERY CASE

PRESENTATION

A.R38 yr old, Male, marriedRoman catholicFarmer, panabo cityDOA - March 17, 2014 at 2:15pmDOI- march 24, 2014, 3:15pm

GENERAL DATA

Facial injury and nose bleed secondary to vehicular

accident.

CHIEF COMPLAINT

One day PTA, while patient was riding motor cycle, he crashed himself to a another tricycle ahead of him. He lost his balance and fall off and hit his face to the tricyclePatient had an immediate episode of epistaxis with unrecalled amount, with blurring of speech due to lower lip injuryno dyspnea, no blurring of vision, no loss of consciousnessHe was brought to local hospital near by pulis.Further referred here..

HISTORY OF PRESENT ILLNES

No history of hypertension, asthma, DM, Allergies

PAST MEDICAL HISTORY

Smoking (+ve) – one pack per day for past 20 yrsDrinking (+ve)- once a weekSoft drinks (+ve)- every day

PERSONAL SOCAIL HISTORY

HPN -veDM -veASTHMA -veMalignancy –ve

FAMILY HISTORY

Review of system

GENERAL - no wt loss for past one monthSKIN - No Itching or Dryness, No color change,no rashesHEENT

• HEAD – injury (-), Normocephalic• Eyes - Reading Glass • NOSE – No epistaxis, No discharges, No obstruction or

sinusitis• EAR - no infection, discharge, pain or deafness

•THROAT - no toochache, dry mouth, sore throat, dysphagia, gum bleeding

NECK – no pain or stiffness. No lumps or swollen glandsRespiratory- no wheezing, no hemoptysis or dyspneaCVS - (+), no heart diseaseGIT- Anorexia(-), Vomiting(-), RUQ pain(-), no diahrea, no hemorrhoids, no hematochezia, no previous surgeriesUrinary – No frequency or heamturai or flank pain.GENITAL – Not performed

MUSCULOSKELETAL- no joint painNEUROLOGIC – np lower exrimities numbness , no motor or sensory loss, good memoryHEMATOLOGIC – no bleeding, no amemiaENDOCRINE –no Diabetes, no thyroid problem(-heat/cold intolarance)PSYCHIATRIC - No history of depression or its treatment

GENERAL – Awake, concious, well oriented, acutly ill. VITAL SIGNS-

• Temp- 37 Degree celcus• RR – 18 Breaths /Min• HR – 98 beats/Min• BP – 130/80

PHYSICAL EXAMINATION

SKIN - Fair warm to touch, good tugor, no cynosis, no clubbing, CRT <2 sec

HEAD – Hair of average texture, scalp without lesion, normocephalicEYES - Periorbital edema, bilateral red eyeNormal vision, pupils radiating to light, intact EOM, no exudatesEARS – good hearing, no nfectionsMouth- pink oral mucosa, lower lip edema and swelling. Tongue in midline, NECK – midline trachea

HEENT

14

CHESTI-SymetiricalGood expansionP-No massesPe-no dullnessA- no crackles heard

CVSPMI – 5th ICSRegular rhythmNo thrillsNo heavesNo murmurs

RESPIRATORYSymetrical expansion,Tactile fermintus equal on both lung field,No wheezing

ABDOMENNon- Tender to touchNo palpable massNo scars

MUSCULOSKETALNo edema

No tenderness

GENITAL/RECTALDeffered

EXTRIMITIESCPR - <2 minStrong pulses

No edemaNo cynosis

NEUROLOGIC

• Oriented to time, place and person.• Awake, conscious and coherent•1: able to smell food•2: able to see objects•2 and 3: pupils round, reactive to light and accomodation•3,4 and 6: EOM intact•5: able to feel light touch in all divisions of the face, mastication is good•7:able to smile, close eyes, wrinkle forehead , and show teeth•8: able to hear sounds•9 and 10: gag reflex was good•11:able to shrug shoulders •12: able to protrude tongue, midline