2. A Thai man, 20 years old
Motorcycle accident 30 minutes PTA
3.
4. Primary survey
Airway and C-spine protection
can speak , no stridor
able to achieve neck movements all directions without pain , not tender
along posterior cervical midline , absence of focal neurological deficit , no
evidence of alcohol intoxication , absence of distracting painful injury
Breathing
no open chest wound , RR 22/min , trachea in midline , equal chest
movements and equal breath sound both lungs , chest compression test
negative , absence of paradoxical movement of chest wall , neck vein not
engorged
5. Primary survey
Circulation
vital signs : BP 119/60 mmHg , Pulse rate 130 bpm , no
active bleeding , pelvic compression test negative , not
tender at both thighs
Disability
E4V5M6 pupil 2.5 mm RTLBE
6. Primary survey
Exposure
multiple abrasion wounds at right knee and both arms
marked swelling at left forearm , tender at mid forearm ,
no obvious deformity
deformity of right leg as shown in the picture
no wound at back , not tender along spine
8. Secondary survey
Allergies : deny history of food and drug allergy
Medication : no current medication
Past illness : no known underlying disease
Last meal : 8.00
Event : motorcycle crash with a car
9. Physical examination
General appearance : A Thai adolescent man, alert,
oriented to time place person
HEENT : no wound on scalp and face, no periorbital
ecchymosis, no abnormal discharge from ears or nose
Cardiovascular : pulse full regular all extremities , no
distant heart sound , normal S1 S2 , no murmur
Respiratory : clear , equal breath sound both lungs , no
adventitious sound
10. Physical examination
Abdomen : no ecchymosis , soft , not tender , no
guarding , no rebound tenderness
Neurologic : alert , active , oriented to time place
person , E4V5M6 , pupils 2mm RTLBE
motor V/V (could not evaluate left arm and right leg
due to pain) , sensory intact , DTR 2+
11. Physical examination
Extremities :
Right arm and Left leg : no deformity , presence of small
abrasion wounds , not tender , full active ROM , intact
sensation , pulse 2+
Left arm : marked swelling at left forearm , no obvious
deformity , tender at mid forearm , limit elbow and wrist
ROM due to pain , full ROM of fingers , intact sensation ,
radial pulse and ulnar pulse 2+
12. Physical examination
Right leg : deformity as shown in the picture , tender at buttock
area , not tender and groin thigh knee ankle and foot , no stepping
limit active hip and knee ROM due to pain , passive ROM was not
evaluated
able to perform ankle dorsiflexion plantarflexion inversion and
eversion , able to perform toes dorsiflexion plantarflexion
abduction and adduction
intact pinprick sensation
dorsalis pedis pulse and posterior tibial pulse 2+
18. Problem lists
Mild head injury ( Moderate risk)
R/O blunt abdominal injury
Posterior dislocation of right hip
Closed fracture mid shaft of left radius
