Orthopedic surgery block.

Long case
presentation

Rahaf Abdulkarim Aljurayyid

437000061 #22
Components
1. History taking
2. Physical examinations
3. Investigations
4. Problem list
5. Management plan

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History taking
Personal data

Reliability: Mother

Name: Saoud Dhafar Age: 1 M 11 D

Gender: M Nationality: Saudi

Chief complaint: Abnormal movement of limbs

A. HPI

Saoud is 1 month old Saudi male. Previously admitted through the ER after transfer from
Almuzahmiah general hospital as a life saving case after RTA where Saoud was on his mother lap
during the car impact hitting the dashboard on 80 km/h mother was not wearing a seatbelt, there
were no fatalities or rollover. The impact resulted in polytrauma injury. mother admits vomiting
and loss of consciousness at the scene. Abnormal limbs movement with eye rolling happened
once on the 7th day of admission and lasted for about 5 mins. Baby is irritable crying and had
spikes of fever due to MRSA infection.

B. Systemic review

GI: Positive for vomiting and no jaundice. No constipation.

Respiratory: negative for cough or wheezes

Cardiac: negative for cyanosis or SoB.

ENT: positive dry bleeding from right ear.

Neurological: no vision problems no weakness

MSK&Skin: positive for bruises negative for rashes

C. Past medical and surgical

Patient admitted on 7/5/2022 due to RTA. he is followed-up by TBI protocol. Received PRBC and
ABx. No allergies

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> Prenatal: mother is 31 y/o she does not take any medication or have any chronic illnesses. No
hx of abortion not a smoker or alcoholic.

> Peri-natal: C-section at hospital preterm(34wks). Baby weighted 1.4kg. Mother can not
remember apgar score.

>Post-natal: admitted to PiCU due to jaundice for 14 days. Baby developed umbilical hernia.

>Nutritional: Baby was on breastfeeding and formula.

>Immunization: Baby received vaccines up to his age.

D. Family history

Mother is 31 y/o not working has 3 children (7 F- 5 M- 1M M). Father is 36 y/o school teacher. Both
parents does not have any chronic or genetic illnesses.

E. Social history

They live in Almuzahmiyah in their own villa. No hx of recent travel.

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Physical examination
A. Vital signs

> On admission: BP. 80/28 HR. 220 RR. 22 SpO2. 97% on RA Temperature. 36.7

> Today: BP.97/67 HR. 167 RR. 22 SpO2. 97% RA Temperature. 37

B. General inspection

Baby is pale, irritated and crying, right temporal swelling, external dry bleeding cut wound on the
right ear. Right elbow deformity. No rashes or skin abnormalities. Connected to IV line and
cardiac monitor.

C. Abdominal examination

No scars, abdomen is soft. Umbilical herniation since birth. Normal bowel sounds.

D. Pericardial examination

No hives or thrills no murmurs, S1 S2, capillary refill time >2 secs

E. Chest examination

No deformities, minimal bruises on the left side. Normal breathing sounds.

F. Neurological examination

Conscious and alert. lethargic. Palpable distal pulses, baby turning head and moving his limbs.
Bulging of the right eye. Open eyes and responds to light. No battles, raccoon eyes. no CSF
rhinorrhea or otorrhea. GCS is 14/15.

SUMMARY

Saoud is 1M old previously admitted to hospital due to RTA which resulted in severe TBI. Elbow
deformity and swollen brain. Positive LoC and vomiting at the scene. Developed one time seizure
and spikes of fever due to MRSA infection.

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Investigations
Blood group and cross match - CBC - LFT - VBG - Electrolytes - Blood culture - C-reactive protein
- x-ray - CT w/o contrast of the head - CT angiogram

Laboratory Results:

07/05/2022

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12/05/2022

24/05/2022

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Imaging results: 06/05/2022 CT Brain w/o contrast

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07/05/2022

CT- brain angiogram - series Abdo art tap portal

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08/05/2022

CT- Brain w/o contrast

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CT-Brain w/o contrast

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Problem list & Management plan
A. Hypotension > received PRBC, IVF,
B. Right displaced humerus fracture > Back slap applied.
C. 7th posterior right > Conservative.
D. Multiple skull displaced fracture with diffuse edema & extra-axial acute hemorrhage.
E. Seizure > anticonvulsant therapy.
F. TBI > Osmolar therapy, hypertonic sline.
G. MRSA > Abx ( Vancomycin, cefotaxime, Ampicillin)
H. Respiratory alkalosis
I. Metabolic acidosis
J. Pain > regular paracetamol

To be continued with Pediatric neurology, pediatric infectious disease and orthopedic to recast.

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