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• Nikhil Nath

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Fatima University Medical Center Mc Arthur Highway, Valenzuela City Department of Otolaryngology, Head and Neck Surgery CLINICAL HISTORY ______________________________________________________________ Name: JUERA, Joshua Cupillo Age/sex: 21 years old/male Date of admission: January 14, 2019 Attending physician: Jim Caluag , MD Admitting diagnosis: lacerated wound; r/o cerebral concussion; r/o nasal bone fracture Chief complaint: Industrial Accident History of present Illness: 3 days PTC, the patient had an accident at work while delivering motorcycle in Marinduque. Patient was riding on motorcycle with no helmet then he pulled the break, a part of motorcycle was hinged accidentally on the ramp. Patient fell at a height of approximately 2 meters. His co – workers seen him laid unconscious and immediately call for help. Then the patient was rushed to the hospital. He vomited with watery , non-projectile. Xray was done and the patient vomited again, non-projectile. Then the lacerated wound in his parieto- occipital area measured 5-6cm was sutured. The patient was still in pain when walking with a pain scale of 9/10. Then he was prescribed with Co-Amoxiclav 625mg/tab BID and Celecoxib 250mg BID and was discharged around 10:30AM. 2 days PTC, the patient experienced dizziness with associated vomiting twice, nonprojectile of previously ingested food. The patient still in pain while walking but now with pain scale of 7/10. The patient claimed that he is compliant with his medications. No consult was done. 1 day PTC, still with the above symptoms, patient was compliant with his medications. No consult was done. Few hours PTC, due to persistence, patient sought consult here in our institution, hence admitted. Past Medical History: (-) Surgeries (-)HPN (-) DM (-) Asthma (-) Thyroid dse (-) Surgeries (-) Allergy to food and drugs Family Medical History: (-) Diabetes Mellitus (+) HPN – mother (-) Asthma (-) Kidney disease (-) Allergy to food and drugs (-) Malignancies Personal/ Social History: (-) smoker (-) alcoholic beverage-drinker

PHYSICAL EXAMINATION: GENERAL: Patient is conscious, coherent, ambulatory, not in cardiorespiratory distress BP: 100/80 mmHg HR:86 bpm RR: 20 cpm Temp: 36.4 °C Skin: brown in color, soft, warm to touch Head: Normocephalic, (+) lacerated wound at parieto- occipital measuring 5-6cm, (-) mass

EAR (-) Discharge Patent ear canal Intact tympanic membrane (+) Cone of light NOSE (+) nasal discharge (-) lesion (-) Mass (-) Obstruction

THROAT

(-) Tonsillopharyngeal congestion (+) Grade 3 tonsils bilateral, hyperemic, enlarged tonsils (-) Edematous, erythematous uvula

NECK (-) Cervical lymphadenopathy (-) No lesion

HEART: Adynamic precordium, normal rate, regular rhythm, (-) murmur

CHEST & LUNGS: Symmetrical chest expansion, (-) retractions, (-) lagging, equal vocal and tactile fremitus, with clear breath sounds ABDOMEN: Globular, normoactive bowel sounds, soft, tympanitic, (-) tenderness on deep and light palpation EXTREMITIES: Grossly normal extremities, no cyanosis, no edema, full equal pulses, (+) lacerated wound on left elbow NEUROLOGIC EXAM: (-) Seizure, (-) involuntary movements, GCS 15 _____________________ Clerk- in-charge

Jim Caluag , M.D. Attending Physician