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Aruchamy, sudharshan Alamuri khadhar, basha Augustus, Joel Ganeshan, Kishore Austin, Nissy
GENERAL DATA
A.R 38 yr old, Male, married Roman catholic Farmer, panabo city DOA - March 17, 2014 at 2:15pm DOI- march 24, 2014, 3:15pm
CHIEF COMPLAINT
Facial injury and nose bleed secondary to vehicular accident.
FAMILY HISTORY
HPN -ve DM -ve
ASTHMA -ve
Malignancy ve
Review of system
PHYSICAL EXAMINATION
GENERAL Awake, concious, well oriented, acutly ill. VITAL SIGNS Temp- 37 Degree celcus RR 18 Breaths /Min HR 98 beats/Min BP 130/80
SKIN -
Fair
no cynosis,
no clubbing, CRT <2 sec
HEENT
HEAD Hair of average texture, scalp without lesion, normocephalic EYES - Periorbital edema, bilateral red eye Normal vision, pupils radiating to light, intact EOM, no exudates EARS good hearing, no nfections Mouth- pink oral mucosa, lower lip edema and swelling. Tongue in midline, NECK midline trachea
CHEST I-Symetirical Good expansion P-No masses Pe-no dullness A- no crackles heard
14
RESPIRATORY Symetrical expansion, Tactile fermintus equal on both lung field, No wheezing
No scars
Deffered
EXTRIMITIES CPR - <2 min Strong pulses No edema No 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