Final Diagnosis: BILATERAL NASAL BONE FRACTURE

procedure done :NASAL BONE FRACTURE REDUCTION UNDER LA

Chief complaints:

c/o nasal bleeding for 4 hrs

c/o nasal obstruction for 4 hrs

History of present illness:

Alleged history of accidental injury in nose

C/o nasal bleeding from left nostril

C/o nasal obstruction

C/o pain and swelling over nose

No h/o LOC

Past medical history:

Not a known case of diabetes mellitus, systemic hypertension, epilepsy, bronchial asthma ,
tuberculosis

Past surgical history:

Nil

Personal History:

mixed diet

normal bowel and bladder habits

Examination:

General condition:

Gc fair

conscious ,oriented and afebrile

No pallor, no pedal edema, no cyanosis, no clubbing, no generalized lymphadenopathy

Vitals stable

Systemic examination:

CVS: S1 and S2 heard

RS: Normal vesicular breath sounds heard

Local examination of external nose:

Diffuse swelling present over root and dorsum of nose

 RIGHT LEFT

Anterior Active bleeding present

Normal
rhinoscopy
No septal haematoma

Ear:

RIGHT LEFT

PINNA Normal Normal

EAC Normal Normal

Tympanic membrane Intact Intact

PTA - -

Impedance - -

Facial nerve clinically intact clinically intact

Throat:

Tonsil grade and condition normal

Oral cavity normal

Oropharynx normal

Larynx normal

Hypopharynx normal

Neck: normal

Investigations: enclosed
Course of stay: patient with above mentioned complaints admitted in ENT department, CT PNS - showed
nasal bone fracture with septal dislocation, patient underwent nasal bone fracture reduction under LA pt
improved symptomatically, hence discharged with following advice
Treatment given

INJ. CEFOTAXIM 1GM IV BD

INJ. DICLOFENAC 50MG IM BD

INJ. PANTOPRAZOLE 40MG IV OD

TAB. CHYMORAL FORTE TDS

OXYMETAZOLINE NASAL DROPS 3 DROPS TDS

OPERATIVE NOTES:

Under LA, pt In supine position,Septum reduced with Asch forceps , nasal bone reduced with
walsham forceps , nasal packing done with vaseline soaked ribbon gauze, POP cast applied over the nose

Medication advised at discharge:

Sl
Formulation Drug Dose Frequency 5 Days Before/After food
No

1 Tab. CEFIXIME 200mg BD 5 days After food

2 Tab. Pantoprazole 40mg OD 5days Before food

3 Drops OXYMETAZOLINE 3 drops TDS 5 days

5. Tab. Zerodol p BD 5 days After food

6 Tab. Montex lc Hs 5 days After food

review after 5 days in ent opd with

Precautions and danger signs

Nose
Avoid blowing of nose, sneezing.
Avoid trauma to nose.
Review in Emergency/ OPD in case of bleeding from nose/ mouth or any watery nasal discharge.

Signature & Seal of Treating Consultant

NOTE: In case of Emergency; Please Contact: 044 27528528, Toll Free No: 1800 599 0999.
அவசர உதவிக்கு தொடர்புகொள்ள வேண்டிய எண் : 044 2752 8528,
கட்டணமில்லா தொலைபேசி எண் : 1800 599 0999