April 16, 2018

GENERAL DATA:
• A.V.
• 9y/o
• Female
• Child
• Filipino
• RC
• July 4, 2008
• Minglanilla, Cebu
HISTORY OF PRESENT ILLNESS:
NOI – MVA
TOI – 11:30AM
DOI – April 15, 2018
POI – Argao
• 4hours PTA
Patient is a passenger in a mini van, back seat, when a collision happened
against a 10-wheeler truck.
Brought to South Gen. Hospital
Referred for further management
PAST MEDICAL HISTORY:
• No previous hospitalizations or operations
• No diagnosed medical problems
• No allergy
FAMILY HISTORY:
• No HFD
PERSONAL/SOCIAL HISTORY:
• Grade 4 pupil
• Lives in Minglanilla, Cebu
PHYSICAL EXAMINATION:
GENERAL:
Asleep & not in respiratory distress with the ff. V/S:
BP – 120/10mmHg Wt – 26.7kg
T – 36.5C Ht – 135cm
HR – 162bpm BMI – 14.7kg/m2
RR – 24cpm O2 sat – 97%

• SKIN: warm, dry, good turgor & mobility

• HEENT: (+) hematoma, OU, (+) 2-3cm laceration, right maxillary area,
intubated on continuous ambubagging, multiple abrasions on face,
firm to soft cranium
PHYSICAL EXAMINATION:
• CVS: adynamic precordium, distinct S1 & S2, no murmur

• C/L: equal chest expansion, no retractions, clear breath sounds

• ABD: flat, normoactive bowel sounds, soft, non-tender

• EXT: faint pulses, no edema, CRT 2-3secs

CT-Scan, Brain
Preliminary Report:
1. Small right epidural hematoma overlying the right frontal convexity.
2. Contusion hemorrhages In the right inferior frontal lobe.
3. Linear fractures in the right frontal bone and posterior orbital wall. A
calcified body is seen protruding inferiorly into the orbital cavity,
abutting the superior rectus muscle. A smaller punctate foreign body
is also embedded in the right sclerae. There is hemorrhage into the
adjacent sinuses. There is right periorbital edema.
4. soft tissue hematoma and emphysema overlying the right frontal
area.
CT-Scan, Abdomen
1. Wedge shape opacity in the basal segment of the right lower lobe.
2. There is an area of hypoenhancement in the spleen which is
compatible with splenic laceration, grade 2.
3. Enlarged and prominent mesenteric lymph nodes in the right lower
quadrant.
4. Minimal pelvic ascites.
X-ray, APL, Forearm

Torus fracture of the distal third of right ulna.

IMPRESSION:
1. Non-Displaced linear skull fracture, right
frontal area
2. Fracture, distal 3rd, ulna
3. Splenic laceration, grade 3 secondary to blunt
trauma secondary to MVA
4. Multiple abrasions secondary to MVA
DISCUSSION