;
MEDICAL
REPORT
S.S/50YRS/ MALE
Diagnosis: Head Trauma secondary to fall from height
History and Presentation :
The above named patient is a 50yr old artisan who was referred from
HMB on account of fall from a 2 storey building while working. He sustained
lacerations to the occiput, low back pain and mild difficulty lifting lower
limbs due to pain. There was no loss of consciousness, no seizures, no bleeding
from any orifices. No memory loss, no confusion, no neck pain. No numbness, no
fecal or urinary incontinence.
He is not a known hypertensive, diabetic
O/E: conscious, not pale, in painful distress, anicteric, acyanosed,
nil pedal edema
Neurology: GCS: 15/15
Pupils: 4/5
in both lower limbs. Normal tone, and reflex. SLR +ve
Abdomen: Full, MWR, No area of tenderness
Chest: Clear
Craniocervical CT scan: Essentially normal brain findings. Cervical
spondylosis with associated paravertebral spasm
Abdominopelvic USS: Essentially normal study.
MRI L/S : mild L3/L4 posterior disc protrusion with canal stenosis.
Diagnosis: Head Trauma secondary
to fall from height
Management Plan:
1. Set up IV access
2.
FBC,EUCR,
Serology, Clotting profile
3.
Monitor
neurovital signs 4 hrly
4.
Monitor
input/ output 4hrly
5.
IVF
N/S alt 5% D/S 1L 8hrly
6.
IV
ceftriaxone 2g stat thenb 1g 8hrly
7.
IV
Metronidazole 500mg 8hrly
8.
IV
Omeprazole 40mg stat, then Tab Omeprazole 20mg bd
9.
IM
Diclofenac 75mg stat,
10.
IV
Pentazocine 30mg stat
11.
Tab
Celebrex 200mg bd x 1/52
12.
Tab
Cocodamol ii tds x 5/7
13. Tab Vit C 1g dly
Laboratory
investigations:
FBC: WBC:5.09 PCV:
41.70 PLT: 176
EUCR: Na: 140 K:
3.34 Urea: 10.88 Cr: 0.58
Clotting profile:
PT: 4.1 secs APTT: 38.1 secs INR: 0.3 secs
Serology: All
negative
Update 03/08/2023
Patient seen. He has
remained neurologically stable. Low back pain has significantly reduced
Plan:
·
Discharge
home
·
Continue
Conservative management
·
Apply
lumbar corset
Discharge
medications and instructions
·
Tab
Celebrex 200mg bd x1/52
·
Tab
Omeprazole 20mg bd x 1/52
·
Tab
Cocodamol ii tds x 5/7
·
Tab
Vit c 1g dly
·
Tab
Cefuroxime 500mg bd x 5/7
·
Tab
Metronidazole 400mg tds x 5/7
·
Apply
lumbar corset x 6/52
·
Rest to encourage recovery
·
For
follow up in 4 /52
Kindly revert to us for clarifications
where necessary.
Yours Sincerely,
Dr. Ukandu Chinedu
For Team Wellington Clinics Abuja