Long Case 3 Trauma

Long Case 3

                                                Trauma

C/C – Pain on back and pelvic region – 2/ 52

HOPI –

Fall injury , landed on buttock from 5 mtrs tall height

No Loss of Consciousness (LOC) , ENT bleeding , vomiting ,

Wound/bleeding

Movement – Walking / standing

Distal neurology – color / ability to move toes or fingers

Transport following fall

                                                            Stretcher ?

                                                            Carried on arm and dragged ?

                                                            Carried on extremities ?

                                                            Ambulance

Primary Treatment –

                                                            Pain management

                                                            X-ray ? – Diagnosis

                                                            Splinting

                                                            Antibiotics , TT

                                                            Catherterization

           

                                                             outcome of the treatment 

Definite Treatment – First on OPD or Emergency  ?

                                                            Blood Transfusion ?

                                                            Traction

                                                            Debridement

                                                            Bone grafting

                                                            OT procedure – chronologically

                                                            Extenal Fixator

           

                        Days admitted – ICU ?

                                       outcome of the treatment 

                                          Complications  ?                       

                                              Systemic –      Fever

                                                                        Local   -           Wound Infection

                                                                        Bed Sore

                                         Improved?

Present Status

            Pain –                         Site (S)- on lower back

                                                Onset(O)-

                                                Character(C)- Aching

                                                Radiation (R) -

                                                Accentuation (A)-

                                                Time (T)- Night pain

                                                Exacerbating Factors(E)-

            Swelling

            Discharge

            Loss of movement – Sitting

                                                Standing

                                                Walking

            Function                    

ADLs –Dressing  

                                    Stands/Walks / sit and squats / runs

                                    Climbing stairs                                                          for lower extremity

                                    Using Indian/ British toilets

           

             

                                    ADLs – Brushing /washing face /dressing

                                    Elevates hand above shoulder ,reaches back , opposite shoulder  UE    

                                    Lifts objects

           

                                               

                                                           

           

                                               

           

                       

           

Past

Family

Personal

Menstrual History

Birth and Developmental

Vaccination History

Socioeconomic History