Ospital ng Maynila Medical Center DEPARTMENT OF OTORHINOLARYNGOLOGY-HEAD AND NECK SURGERY
Name: Tobias, Alliah Amor Age/Sex: 6/F Address: 67 Inang Wika St. Look 1st Camiogan Malolos City Bulacan Date Admitted: August 7, 2008 Admitting Diagnosis: Nasal Bone Fracture Physicians-in-charge: Drs. Quimlat/SO/Del Valle/Ricardo/Catignas/Regino CIC: Fabian/Ilarde/Ingles/Item/Junsay/Nohay
Hospital No. 1502924 Room No: 319
PATIENT DISCHARGE SUMMARY This is a case of a 6 year old female who was came in due to nasal trauma. NOI: TOI: POI: DOI: Ground Level Fall 10:00 AM School, Malolos Bulacan Aug 1, 2008
History of Present Illness
1 week PTA, patient fell to the ground hitting face first while playing and acquiring injury to the nasal area and epistaxis was noted. 3 days PTA, there was due to the presence of nasal injury, patient opted to seek consult at a local physician wherein Xray was done revealing nasal bone fracture. Operation and repair was advised. Patient opted for second opinion and due to financial constraints patient sought consult at OMMC ENT department.
Past Medical History: (-)DM,HD, asthma, allergies (-)previous hospitalizations and operation (+) vaccination complete Family History: unremarkable Personal/ Social History unremarkable Review of Systems General: no fever, no weight loss Skin: no skin lesion, no pruritus Respiratory: no cough, no DOB, no colds, no hemoptysis Cardiac: no chest pain, no orthopnea, no palpitations Gastrointestinal: no nausea, no vomiting, no abdominal pain, no change in bowel habit Genitourinary: no dysuria, no oliguria, no hematuria, no polyuria Hematology: no easy bruisability or bleeding, no pallor Endocrinology: no polyuria, no polyphagia, no polydipsia; no heat/cold intolerance Musculoskeletal: no joint pains Neuro: no LOC, no convulsion, no seizures Physical Examination General: conscious, coherent, not in cardio-respiratory distress Vital Signs: HR: 82 bpm RR: 20 cpm Temp: 36.7°C EYES: pink palpebral conjunctivae, anicteric sclera, pupil equally reactive to light
(+) retained cerumen Intact Tympanic membrane
(-) tragal tenderness
(-) septal deviation (-) congestion (-) mass
(+) gross deformity (+) CLAD
Uvula midline (-) TPC (-) deviation of tongue (-) exudates
CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds HEART: adynamic precordium, normal rate, regular rhythm, no murmur ABDOMEN: flat, normoactive bowel sounds, soft, non-tender EXTREMITIES: grossly normal, full and equal pulses, no cyanosis, no edema Assessment: Nasal Bone Fracture
Plan: for admission COURSE IN THE WARDS: Patient was admitted to room 319 under the service of Drs. Chiong/So/Del Valle/Tolentino/Catignas/Regino. Patient was venoclysed to D5NR and was placed on NPO. Diagnostics requested were: CBC with PC, Townes view xray, and Urinalysis. Patient is for elective closed reduction of nasal bone. Patient was fully awake after operation and was transferred to PACU were oxygen inhalation at 5 lpm via face mask was placed. Present IVF was regulated. Patient was placed on NPO. Medications were: 1. Keterolac 20mg IV q6 2. Paracetamol 300mg q4 3. Ranitidine 30mg q8 Vitals were monitored every 15 minutes for 2 hours then every 30 minutes then every hour thereafter. Patient was then transferred to the wards were patient vital signs were monitored. On the 1st hospital day, condition improved and was ready for discharge. Home meds given were Co-Amoxiclav 8ml 312.5mg/5ml TID for 1 week, Ibuprofen 100mg/5ml TID and Dimetapp syrup 5ml TID for 5 days. Follow up was scheduled on 8/12/08.