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SURGERY CASE PRESENTATION

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.

HISTORY OF PRESENT ILLNES


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 tricycle Patient had an immediate episode of epistaxis with unrecalled amount, with blurring of speech due to lower lip injury no dyspnea, no blurring of vision, no loss of consciousness He was brought to local hospital near by pulis. Further referred here..

PAST MEDICAL HISTORY

No history of hypertension, asthma, DM, Allergies

PERSONAL SOCAIL HISTORY


Smoking (+ve) one pack per day for past 20 yrs
Drinking (+ve)- once a week Soft drinks (+ve)- every day

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

warm to touch, good tugor,

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

CVS PMI 5th ICS Regular rhythm No thrills No heaves No murmurs

RESPIRATORY Symetrical expansion, Tactile fermintus equal on both lung field, No wheezing

ABDOMEN Non- Tender to touch No palpable mass

No scars

MUSCULOSKETAL No edema No tenderness GENITAL/RECTAL

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

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