Case study-3

Surgery
Group __1c__
Group Members:
Abhirup panda (Leader)
Krutika panigrahi
Jill vora
Yuvaraja eswaran
Karthikeya senthilnathan
Mathuravani rethinasamy

Facilitator _________Dr. Elmer cabang_________________

History
General data-

Name- Elimer , Age- 30 , Date- may 10, Address- banilad cebu,city

% Reliability: 85%

Chief complain- stabbed in abdomen

History of present illness-

30 mins prior to come – patient was stabbed in the abdomen.

Patient stabbed by sharp object and suddenly starts pain in the right upper abdomen

Before reaching to hospital wound had already clotted. The sharp object has been
removed by his family members before coming to ER.

Blood group of the patient is “o” +ve

Review of Systems (ROS):
The patient has no changes in sensorium, no rashes, no jaundice, no eye redness or
discharges, no naso-aural discharges, no epistaxis, no vomiting, no diarrhea, no
constipation, no brushing on the chest , no heavy bleeding from the wound, wound
is already clotted, patient are still in conscious, skin was pale and cold, ther was no
dullness,
Past Medical History:
Reveals no perinatal illness. No sign of allergy,With no surgical remarks. no
abnormalities or deformities.
Family History:
There is no significant genetic disorders recorded among the patient’s
family.
Personal & Social History:
Patient was occasional drinker. He lives in Banilad, Cebu city.

Physical Examination
Vital signs – BP-80/60 HR- 120 , RR-20, O2Saturation -98%
Inspection- patient wound has been clotted already it was around 2.5in. on the
right upper abdomen.

Auscultation- There was bowel sound around 20 clicks.

Palpation- complain of rectal tenderness. When we remove the hand patient has
rebound tenderness.

Gastro coma scale- neurologic status of patient is eye movement normal. Patient
able to fallow the movement of eye and moving arm and leg.

Some rigidity in the abdomen. Redness of skin and cold, there is no other injury
rather than the wound of the patient.
Skin: Red color and cold
HEENT: head symmetrical, no lesion, no pinkish palpebral conjunctivae, no
jaundice, no nasal discharges, (-) alar flaring, (-) nasopharyngeal
congestion,noshrunken eye
Chest and Lungs: (-) subcostal and interclavicular retraction, equal chest
expansion, (-) rales both lung fields
Cardiovascular System: PMI at 5th intercostal space midclavicular line at left, no
heave, no thrill, no murmur, normal rhythm
Abdomen: rebound tenderness, wound at upper abdomen.
Extremities: strong pulses
Genital/Rectal Examination: grossly males, no abnormalities
Neurologic Examination: alert, Motor 5/5 all extremities, Sensory intact for pain,
Cranial Nerve I etc……..
GCS=15

Impression / Diagnosis:

Differential Diagnosis:
1.
2.
3.

Management / Orders