This is the case of R.R., a 28-year old male, born 3/16/1983, single, Catholic, works as an assistant chef, accompanied by his older sister L.R. who served as the primary informant with 60% reliability, who came due to vehicular accident injuries.
HISTORY OF PRESENT ILLNESS
The patient was apparently well until 5 hours prior to admission (11:00 AM), wherein he was involved in a vehicular accident on his way to work. He was allegedly driving a motorcycle in C5 (Libis area) when he tried to overtake a van, resulting in a collision which caused his motorcycle to skid to the road and him being thrown off it in the process. He was wearing a helmet at that time. According to the informant, he did not lose consciousness at this time.
He was then rushed to Quirino Memorial Medical Center, wherein appropriate workup was initiated. Preliminary clinical and laboratory workup revealed a Glasgow Coma Scale score of 8 (E3, V1, M4) and an O2 saturation reading of 90%. He was subsequently intubated via an endotracheal tube, and was recommended to undergo CT Scan. Unfortunately, the CT Scan at that time was unavailable, hence he was transferred to TMC with a discharge summary of "traumatic brain injury, rib fracture 3-5 (R), t/c cervical spine fracture 6-7", and was subsequently admitted to the ACSU/NICU.
PAST MEDICAL HISTORY
The patient had a previous surgical history of Tympanoplasty with Canalplasty, AD, done at TMC in 2010, as definitive treatment for his chronic otitis media diagnosed in 2009 at TMC. No other pertinent past illnesses, and no known allergies to both food and drugs.
FAMILY HISTORY
The patient is the 6th among 9 children. According the informant, their father died due to "sakit sa baga, na nagka-komplikasyon sa puso at atay". No known family illnesses.
PERSONAL AND SOCIAL HISTORY
The patient's highest educational attainment was high school, in Oriental Mindoro. According to the informant, he first worked in a number of unrecalled jobs before moving to Manila in 2003 along with his eldest sister to work in a catering business. He then worked as an assistant chef at Cibo in 2005, and has been working there up to the present.
He is allegedy a non-smoker, an occasional drinker (only du ring social events), and has never tried illegal drugs.
REVIEW OF SYSTEMS
Review of systems was generally unremarkable. No changes in weight, no fever, no fatigue. No rashes, no changes in skin color, no hair or nail changes. No blurring of vision, no problems hearing, no dry mouth, no neck masses. No cough, no wheezing episodes. No heart palpitations. No nausea or vomiting, no heartburn, no changes in bowel habits, no jaundice. No nocturia, no dysuria. No excess sweating, no heat or cold intolerance, no polyuria.
PHYSICAL EXAMINATION
On admission, the patient was seen lying supine, awake, responsive but with occasional lapses (described as "nakatunganga lang"), intubated, and was restless and easily agitated.
HEENT
Head: contusion in R fronto-temporal area, no active bleeding
Eyes: Anicteric sclerae, pink palpebral conjuntiva, both pupils 3-4 mm, briskly reactive to light, no RAPD
Ears: no tragal tenderness, with bloody discharge in R ear partially obstructing the tympanic membrane, no lesions or discharges in L ear with visible cone of light
Nose: with blood clots in both nasal cavities, no active discharges
Throat: with endotracheal tube, no TPC, no palpable LNs, non-palpable thyroid
CARDIOPULMONARY
With contusion, R mid-clavicular region
Apex beat at 5th ICS, LMCL
Decreased breath sounds in lung bases, with rales on all lung fields, no wheezes, tachpneic
Distinct heart sounds, tachycardic, no murmurs
GASTROINTESTINAL
Flat, no lesions
Normoactive bowel sounds
Tympanitic on all quadrants
No tenderness on light and deep palpation
EXTREMITIES
With abrasions in medial aspect of the L thigh and anterior aspect of the R shin
No visible gross deformities
5/5 muscle strength grading on all extremities except for right arm (0/5)
With sensory perception on all extremities except right arm
DIGITAL RECTAL EXAMINATION
Not done.
NEUROLOGIC EXAMINATION
GCS 11 (E4, V1, M6)
Formal neurologic exam not done due to lack of vocal output and patient irritability
SALIENT FEATURES
This is the case of a 28 y/o M, who was involved in a motorcycle accident (wearing a helmet, allegedly no loss of consciousness) 5 hours PTA. He was initially seen at QMMC where he was intubated due to a low O2 saturation of 90%. CT scan was indicated, but due to unavailability at QMMC he was transferred to TMC for further workup and management.
On physical examination, patient had GCS score of 11 (E4, V1, M6). He responds to commands but with lapses (nakatunganga). He was restless, and easily agitated. Both pupils were 3-4 mm, BRTL, with no RAPD. Muscle strength grading of right arm was 0/5, with alleged loss of sensory perception. He had decreased breath sounds on both lung bases, with rales on all lung fiBelds. He was tachypneic, and tachycardic. No gross deformities in all extremities. He had contusions in R fronto-temporal region and R clavicular area.
