23 YEAR OLD MALE PATIENT WITH MULTIPLE ABRASIONS ON THE FACE AND UNDISPLACED NASAL BONE FRACTURE SECONDARILY TO RTA
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A 23 year old male patient,resident of choutuppal,working in a pharmaceutical company came to OPD with a history of RTA at 10:30 pm
HISTORY OF PRESENT ILLNESS:-
Normal routine of the patient - He used to wake up around 5 am in the morning and leave for work at 6 am. For breakfast he usually consumed rice.He had shift from 6 am to 2 pm and he retuned home then had lunch(rice).He used to sleep around 9pm.
The patient had RTA at Choutuppal around 10:30 pm.CT scan shows undisplaced nasal bone fracture.Patient had no c/o of nasal bleeding,nasal obstruction,tenderness, no H/o watery nasal discharge no h/o loc,seizures,giddiness,nausea and vomitings,no h/o bleeding from oral cavity or ears. Multiple lacerations are present over the face.
Chief complaints- sustained injuries to face,headache and blurring of vision
HISTORY OF PAST ILLNESS:-
The patient is not a known case of diabetes, epilepsy,tuberculosis,asthma
PERSONAL HISTORY
- the patient has no loss of appetite
- bladder movements are normal
-no sleep disturbances
-addiction: none
FAMILY HISTORY:
No significant family history.
TREATMENT HISTORY:
The patient is not a known case of drug allergy
GENERAL EXAMINATION:-
Patient is cooperative coherent and conscious
No clubbing
No cyanosis
LOCAL EXAMINATION :-
O/E of nose : external framework - 0.5 x 0.5 x 0.5 cm
Lacerations over roof of the nose,abrasion over mucosa.
No active nasal blends, no crepitus,no step deformity.
O/E of PNS: No tenderness
O/E of oral cavity: Impaction of upper teeth over the upper lip mucosa grade 1
O/E of ear: on the left ear there is tissue loss over the medial surface of the pinna (3x2x1 cm)
No active ENT intervention
VITALS:-
Temp- 98.2 F
BP - 110/70
Pulse rate- 117/min
RR - 20
SpO2 - 98
SYSTEMIC EXAMINATION:
RS: BAE +
CVS: 5, 52+
PA:soft
CNS: No IND
INVESTIGATIONS:-
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