SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO:
SUBMITTED BY:

Cristobal, Phylicia
Duran, Honey Rose

June 16, 2015

de los Santos, Rosheil Mae
Ejera, Alyssa Thea

REPRESENTATIVE CASE
IDENTIFYING DATA: 25 year old male, single from Dumaguete City, admitted for the first time
CHIEF COMPLAINT: Motor Vehicular Accidents
CHIEF COMPLAINT: Blunt abdominal Injury and Burns
NATURE OF INJURY: Motor Vehicular Accident
TIME OF INJURY: About 3:00 am
DATE OF INJURY: May 23, 2015
PLACE OF INJURY: Dumaguete City, Negros Oriental
HISTORY OF PRESENT ILLNESS:
Accident happened 5-23-2015 at 3am at Daro, Dumaguete City. Patient hit a stray dog on the street,
hitting his side including his torso to the ground first. Half-Burned by hot-water on both of his lower
extremities. Condition sustained for 30mins before admission. Vomitting and loss of consciousness not
noted.
PAST MEDICAL HISTORY: No previous hospitalization. Not hypertensive and diabetic.
FAMILY HISTORY: (-)DM, (+) HPN, (-)Cancer, (-)Asthma
PERSONAL AND SOCIAL HISTORY: Alcoholic; Non-smoker
REVIEW OF SYSTEMS
PHYSICAL EXAMINATION
General Survey: Normal
General Survey: Conscious, coherent, lying in bed, not in respiratory
Skin: Normal. (-) Jaundice,
distress
(-) Rashes
Vital Signs: BP: 110/70 mmHg
HR: 64/min
RR: 18cpm
HEENT: Normal.(-) Visual
O2 Sat: 98%
changes, (-) Discharges
Skin: First Degree Burns on both lower extremities
Chest and Lungs: Normal. HEENT: (-) beeding on the head, (-) sunken eyeballs, (-) dry lips, dry oral
(-) Cough,chest tightness,
mucosae
hemoptysis
(-) nose discharges, (-)tracheal displacement
Cardiovascular: Normal.
Chest and Lungs: (-) retractions, (-) adventitious breath sounds
No cardiac anomalies
Cardiovascular: Apical impulse at 5th ICS, (-) tachycardia, murmurs
Abdomen: Normal. No
Abdomen: Abdomen is soft with linear abrasions on the left flank area,
tenderness
limited/voluntary gurading noted. (-) Direct rebound tenderness, (-)
Gastrointestinal: Normal
hyperactive bowel sounds, no organomegaly
bowel movement.
DRE: No mass palpated
Musculoskeletal: (-)
GUT: (-) KPS
Arthritis
Extremities: No bipedal edema, Both lower extremities burned
Genitourinary: (-)
(scalding), good pulse noted
polyuria (-)pain upon
urination
CNS: Normal.
II. PRIMARY IMPRESSION
DIAGNOSIS
RULE IN
RULE OUT
Blunt
CHIEF COMPLAINT: Motor Vehicular Accidents
CANNOT BE
Thoracoabdomin HISTORY OF PRESENT ILLNESS:
RULED OUT
al Trauma and
Hits his side including his torso to the ground first. Half36% Scalding
Burned by hot-water on both of his lower extremities. Vomiting
Inury on both
and loss of consciousness not noted.
Lower
Skin: First Degree Burns on both lower extremities
Extremties
Abdomen: Abdomen is soft with linear abrasions on the left
secondary to
flank area, limited/voluntary guarding noted. (-) Direct rebound
MVA
tenderness, (-) hyperactive bowel sounds, no organomegaly
Extremities: Both lower extremities burned (scalding), good
pulse noted
Labs: No significant findings
Thoracoabdominal inuries secondary to blunt force are
attributed to collisions between inured person and the external
environment and to the acceleration or deceleration forces
acting on the persons internal organs.
III. DIFFERENTIAL DIAGNOSIS
DIAGNOSES
RULE IN
Penetrating
CHIEF COMPLAINT: Motor Vehicular Accidents
Abdominal
HISTORY OF PRESENT ILLNESS:
Trauma
Hits his side including his torso to the ground first. HalfBurned by hot-water on both of his lower extremities

RULE OUT
(-) Hypotension
(-) Tachycardia
(-) Peritoneal
signs

ADVICE AND INFORMATION

Educate the patient and his family about his condition: possible etiology, risk factors,
course of disease, signs and symptoms, complications if left untreated, prognosis, and
medical options for treatment including its benefits, side effects, risks and alternatives.
Increasing patients knowledge about his condition improves medical compliance and
assists in the management of symptoms.

Emphasize the importance of medication compliance in the optimum management of his

condition.
NON-PHARMACOLOGIC TREATMENT
1. Admit Patient.
2. Primary Survey (ABC):
a. Airway. Ensure patent airway. Airway management in blunt trauma require cervical spine
immobilization.
b. Breathing. Supplement O2 therapy and monitor it using the pulse oximeter.
c. Circulation. Monitor Vital signs such as BP and Pulse rate at least every 15 mins.
3. Secondary Survey:
a. GCS monitoring at least every 15 mins.
b. Monitor intake and output.
4. Blood crossmatching for possible surgical procedures.

FOLLOW-UP AND MONITORING

1. Before discharge, provide patients with detailed instructions that describe signs of undiagnosed
injury. Increased abdominal pain or distention, nausea or vomiting, weakness, lightheadedness or
fainting, or new bleeding in urine or feces mandates immediate return and further evaluation.