Tocao Case Poliquit

8/13/2019 Tocao Case Poliquit

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Name of Student: TOCAO, XYLIA SAHARA E. Date of ER duty :December 3-4, 2013

Patient Data

Hospital:SPMC Case number:2569827Date of Admission: December 4, 2013 Room number: surgery eastTime of Admission :3:30 AM

Admission under the service/s of:Dr. WongType of Admission (Stat/ Elective):ElectiveType of core competency: VII ( trauma & burns )Source of History data & Reliability: father, 89%

HISTORY:

General Patient Data

This is a case of Jomar Poliquit, a 17 year old male, single from Boulevard ,Davao city, who came indue to stab wound

Chief complaint: stab woundHistory of Present illness:

2 hours prior to admission ,patient was drinking alcoholic drinks with his neighbors when suddenly oneof them stab him in the chest area. He didnt have loss of consciousness and no vomiting reported. Hewas rushed in this institution for further evaluation and management.

Past Medical History:

The patient is not hypertensive,non diabetic, non asthmatic with no previous hospitalizations andsurgical operations.

Family History:

There are no other heredofamilial diseases like hypertension, diabetes mellitus , bronchial asthma andcancer reported.

Personal/Social History:

He is not a smoker but an occasional alcoholic beverage drinker . He has no allergies to food anddrugs .

Review of Systems:

General: no recent weight loss,body weaknessEyes:no redness, no unusual dischargeEar: no pain, tinnitusNose: no history of sinusitis , obstructionMouth: no gum bleeding, tonsillitisPulmonary: no difficulty of breathing, cough, hemoptysis and hematemesisCardiovascular: non hypertensive, (-)palpitationGastrointestinal: no change in bowel habits like constipation and diarrhea, no history of peptic ulcer ,pain and food intolerance


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Genitourinary:no history of stones, dysuria, hematuriaMusculoskeletal: no history of body weaknessNeurologic: no history of seizures, head trauma

Physical Examination:

GENERAL:

awake, not in respiratory distress.

VITAL SIGNS:

temperature:36.3 oC blood pressure: 110/80 mmHgpulse rate: 98bpm respiratory rate: 24 cpm

SKIN:Inspection : no rash, (-) abrasions left armPalpation: good skin turgor, dry skin

HEAD:Inspection: normocephalic, no lice & nits notedPalpation: (-) mass

EYES:Inspection: anicteric sclerae, pinkish palpebral conjunctivae

EARS:

Inspection: non erythematous, no cerumen notedPalpation: mobile,firm, non tender

NOSE:Inspection: nasal septum in midline positionPalpation: no sinus tenderness

THROAT:Inspection: no tonsillar enlargement, non erythematous

NECK:Inspection: no thyromegaly

Palpation: (-) cervical lymphadenopathy

CHEST/LUNGS:Inspection: (+) use of accessory muscles for breathingPalpation: (+) tendernessPercussion: dullness lower lung fieldAuscultation: harsh breath sounds

HEART:Inspection:adynamic precordiumPalpation: no thrills /heavesAuscultation: good S1 and S2, no murmurs noted


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ABDOMEN:Inspection:flatAuscultation: normoactive bowel sounds at 10 per minutePercussion: tympaniticPalpation: (+) direct tenderness at RUQ, (+) psoa's sign ,(+) rovsing's sign, (+)rebound tenderness

EXTREMITIESINSPECTION:full range of motionPalpation: full pulses, CRT


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SENSORY:

100% 100%100% 100%

IMPRESSION:

Stab wound left subcostal area level T8

DIFFERENTIAL DIAGNOSES:

Costochrondritis

I have ruled in this condition due to presence of chest pain but cannot be ruled out properly we needimaging studies like chest x ray to confirm our diagnosis

Pneumothorax

I have ruled in this condition due to presence of chest pain . Physical examination must revealdecreased or absent breath sounds over the affected lung but we cannot rule it out properly we needimaging studies like chest x ray to confirm our diagnosis

CASE DISCUSSION:

This is a case of a JP, a 17 year old male from Boulevard, Davao city who came in due to stabwound

For the history of present illness, 2 hours prior to admission ,patient was drinking alcoholic drinks withhis neighbors when suddenly one of them stab him in the chest area. He didnt have loss ofconsciousness and no vomiting reported. He was rushed in this institution for further evaluation andmanagement.

Thoracic injuries account for 20-25% of deaths due to trauma and contribute to 25-50% of the remainingdeaths. Approximately 16,000 deaths per year in the United States alone are attributable to chesttrauma.[1] Therefore, thoracic injuries are a contributing factor in up to 75% of all trauma-related deaths.The increased prevalence of penetrating chest injury (associated with the "drug war" in the UnitedStates) and improved prehospital and perioperative care have resulted in an increasing number ofcritically injured but potentially salvageable patients presenting to trauma centers.

Simple rib fractures are the most common injury sustained following blunt chest trauma, accounting formore than half of thoracic injuries from nonpenetrating trauma. Approximately 10% of all patientsadmitted after blunt chest trauma have one or more rib fractures. These fractures are rarely life-threatening in themselves but can be an external marker of more severe visceral injury inside theabdomen and the chest.

Any organ within the chest is potentially susceptible to penetrating trauma, and each should beconsidered when evaluating a patient with thoracic injury. These organs include the chest wall; the lungand pleura; the tracheobronchial system, including the esophagus, diaphragm, thoracic blood vessels,and thoracic duct; and the heart and mediastinal structures.


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Chest wall injury

The chest serves the important functions of respiration and of protection of the vital intrathoracic andupper abdominal organs from externally applied force and is composed of the rigid structure of the ribcage, clavicles, sternum, scapulae, and heavy overlying musculature. Most wounds to these structurescan be managed nonoperatively or by simple techniques such as tube thoracostomy. The treatment of a

stable patient with a normal initial chest radiograph remains controversial.

Ammons and coworkers further defined the role of outpatient observation of selected patients withnonpenetrating thoracic GSWs and stab wounds. In their study, observation for 6 hours withsubsequent repeat chest radiography revealed a 7% rate of delayed pneumothorax, and hospitalizationwas avoided in 86% of patients treated according to this protocol.

Large, open, chest wall defect closure can be a formidable task. When techniques involving closure withautogenous tissue of myocutaneous flaps based on the trapezius, rectus abdominus, pectoral, orlatissimus dorsi muscles fail, prosthetic material (eg, polypropylene mesh, expandedpolytetrafluoroethylene, cyanoacrylate) may be used.

Rarely, chest wall hemorrhage from the muscular, intercostal, and internal mammary arteries can resultin exsanguination and may require operative control.

First and second rib fractures are often accompanied by serious associated injuries, particularly ifmultiple rib fractures are evident. Treatment of any associated injuries must be expeditious.

Severe thoracic injury that causes paradoxical motion of segments of the chest wall has been termedflail chest, which may be categorized by size or location. In adults, pulmonary contusion accompaniesflail chest injuries in approximately half the patients.

The primary treatment of chest wall injuries is a combination of pain control, aggressive pulmonary andphysical therapy, selective use of intubation and ventilation, and close observation for respiratorydecompensation. Sufficient evidence now supports the notion that the pathophysiologic findings

associated with severe chest wall trauma are related to the underlying injuries, chiefly pulmonarycontusion and parenchymal injuries, and have little to do with the movement of the chest wall.

Indications for operative fixation of the chest wall or sternum include the following:

Need for thoracotomy for other reasons Large flail segments in patients with borderline premorbid pulmonary status Severe instability and pain and failure to wean from the ventilator after an adequate trial Secondary infections

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Tocao Case Poliquit