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 

No pallor

No icterus 

No pedal edema 

Edema present of the back of left palm 

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:- 

TREATMENT:-

Inj Metrogyl 500mg

Inj Tramadol

Inj Zofer

Inj PAN 40mg

Tab Chymoral forte

Tab Vit C