LYCEUM-NORTHWESTERN UNIVERSITY

DR. FRANCISCO Q. DUQUE MEDICAL FOUNDATION

COLLEGE OF MEDICINE
Dagupan City
Group F
ARENAS, Joanne M.

GANGAN, Monique

CARANAY, Francis Neil

DIFUNTORUM, May Anne

MEIMBAN, Giuzeppe Edrei

SANEPARA, Jay
TONGOL, Ej

Date of interview: February 10, 2016

Preceptor: Dr. Jude Gonsalves
SURGICAL HISTORY
Case #1
GENERAL DATA
This is the case of M.M, 31 years old, male, Filipino, Roman Catholic, married, tricycle driver,
residing at Alcala, Pangasinan and admitted for the second time at Region 1 Medical Center on February
3, 2016 around 5 AM.
CHIEF COMPLAINT: bleeding in the right ear
HISTORY OF PRESENT ILLNESS
NOI: Mauling
DOI: February 02, 2016
TOI: 10:30 PM
POI: Tarlac City
Five hours prior to admission, the patient was suddenly attacked by 2 drunkards while walking
along the street after buying goods from a store. A plant pot was smashed on the right temporo-parietal
area of his head and was beaten with a bamboo pole at his left thigh and left arm. He experienced blurring
of vision and tinnitus for approximately 10 seconds but managed to stay conscious. He noticed bleeding
from the right temporo-parietal area of his head, which he perceived to be painful. His right ear and nose
also bled. He also experienced numbness in his left hand. No associated loss of hearing, nausea and
vomiting. He still managed to run away and went home. No medications taken and no medical
consultation was done.
Three hours prior to admission, the patient was brought to a hospital in Bayambang, Pangasinan.
The patient was said to be drunk and was observed.
One hour prior to admission, due to unavailability of a CT scan in the said hospital, the patient
was transferred to R1MC where he was then admitted.
PAST MEDICAL HISTORY
His first hospital admission was 17 years ago (1999); patient had a mandibular fracture due to a
bike accident. He was hospitalized in R1MC for 8 days. Medications were unrecalled. He was also given
metal braces.

His second hospital admission was 1 year ago; patient experienced difficulty of breathing after
drinking a coca-cola soft drink. He was hospitalized in a public hospital in Bayambang for 7 days.
Medications were unrecalled.
Patient claimed to have completed his childhood vaccinations but were unrecalled. No noted
chickenpox, mumps and measles during his childhood. No known allergy to any forms of allergens such
as food, drugs, drinks or even environment.
FAMILY HISTORY
Patient is the youngest among 3 siblings. His father, 60 years old, was a known hypertensive
while his mother died due to leukemia at the age of 58. His eldest brother died due to an unrecalled
disease. Other sibling was apparently well. No other heredofamilial diseases like autoimmune disease,
blood dyscrasia, CAD, DM, lung and liver diseases were noted.
PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY
The patient is a high school graduate and works as a tricycle driver. He is a non-smoker. He
drinks gin and/or beer every night after work, consuming a bottle of beer and/or half a bottle of gin.
He usually consumes 1 cup of rice per meal and prefers eating pork or beef. He drinks a cup of
coffee during breakfast. He lives with his wife, son, and in-laws in a bungalow house made of light
materials. Their source of drinking water is from a water pump.
REVIEW OF SYSTEMS
General
SKIN

HEAD and
NECK
EYES

EARS

(-) Body weakness

(-) Sweats
(-) Jaundice
(-) Pallor
(-) Urticaria
(-) Nodules
(-) Pain
(-) Asymmetry
(-) Icteric Sclera
(-) Blurry Vision

(-) Hearing Loss

(-) Infection
NOSE
(-) Dryness
(-) Pain
MOUTH
(-) Soreness
(-) Gum bleeding
(-) Odynophagia
RESPIRATORY (-) Cough
(-) Hemoptysis
(-) Hyperpnea

(-) Weight loss

(-) Chills
(-) Hematoma
(-) Cyanosis
(-) Bleeding
(-) Stiffness
(-) Infection
(-) Itchiness
(-) Redness
(-) Pale
conjunctiva
(-) Tinnitus
(-) Hearing Aid
(-) Bleeding
(-) Sneezing
(-) Hoarseness
(-) Dysphagia
(-) Dyspnea
(-) Wheezing
(-) Stridor

(-) Fatigue
(-) Fever
(-) Sores
(-) Lesions

(-) Decrease
Appetite
(-) Pruritus
(-) Rashes

(-) Swelling
(-) Alopecia
(-) Pain
(-) Correctives
(-)Lacrimation

(-) Dizziness
(-) headache
(-) Diplopia
(-) Glaucoma
(-) Cataract

(-) Pain
(-) Discharges
(-) Itch
(-) Obstruction
(-) Pain
(-) Dentures

(-) Vertigo

(-) Cyanosis
(-) Tachypnea
(-) Exposure to

(-) Pain
(-) Sputum

(-) Discharge
(-) Dryness
(-) Infection

respiratory hazards
CARDIAC
VASCULAR
GIT or
ABDOMEN

RENAL or
URINARY
GENITALIA
MUSCULOSKELETAL
METABOLIC
NERVOUS

EMOTIONAL

(-) Palpitation
(-) Edema
(-) Varicose Veins
(-) Pain
(-) Nausea
(-) Constipation
(-) Rectal Pain

(-) Angina

(-) Chest pain

(-) Orthopnea

(-) Phlebitis
(-) Anorexia
(-) LBM
(-) Hemorrhoids
(-) Dark Stool

(-) Dysuria
(-) Polyuria
(-) Pain
(-) Irritation/itchiness
(-) Atrophy
(-) Cramps
(-) Stiffness
(-) Heat or Cold
Intolerance
(-) Seizures
(-) Tremors

(-) Hematuria
(-) Nocturia
(-) Swelling
(-) Ulcer
(-) Pain
(-) Joint Pain
(-) Numbness

(-) Ulcers
(-) Vomiting
(-) Melena
(-) Hernia
(-) Excessive
Belching
(-) Flank/ Back Pain
(-) Incotinence
(-) Discharge
(-) Itching
(-) Fractures
(-) Back and Flank
Pain

(-) Claudications
(-) Hematochezia
(-) Hematemesis
(-) Heart Burn
(-) Excessive
Flatus
(-) Anuria
(-) Oliguria
(-) Infection

(-) Pain
(-) Paralysis

(-) Syncope
(-) Convulsions

(-) Anxiety
(-) Ideations

(-) Insomnia
(-) Hallucinations

(-) Depression
(-) Stress

(-) Motor, Sensory,

or memory
problems
(-) Suicidal

(-) Weakness
(-) Sprains
(-) Trauma

PHYSICAL EXAMINATION
General Survey: Patient is medium built muscular young adult man seen lying on bed, in hospital
clothes, awake and conscious. He is not in cardiopulmonary distress.
Vital signs
RR 19 cpm
PR 81 bpm
BP 130/90 mmhg

Temp 36.60 C
SaO2 97%

Skin: Skin is brown. With multiple lacerations. Does not present with clubbing or cyanosis.
HEENT:
Head: Normocephalic. Normal hair distribution. Linear laceration 2.5cm right temporal-parietal area about
10cm superior to the ear, unstitched. Linear laceration .5cm forehead.
Eyes: Palpebral conjunctiva is pink. Anicteric sclera. No opacities, exudates nor hemorrhages. Pupils
equally reactive to light and accommodation.
Ears: No skin lesions, deformities, discharges, swelling, foreign bodies nor tenderness, no lateralization.
Nose: symmetrical, septum in midline, no signs of inflammation. No discharge, nor sinus tenderness.
Mouth: Moist buccal mucosa, no ulcerations noted. No asymmetry as rest.
Throat: pink oral mucosa. Pharynx is not erythematous, no exudates.
Neck: Trachea is midline. The neck is supple. Thyroid isthmus is midline. No lymph node enlargement
noted.
Chest and Lungs: No difficulty of breathing. Symmetric rise and fall of chest during respiration. No
adventitious breath sounds.
Cardiovascular: Adynamic precordium, PMI at 5th ICS MCL. Regular cardiac rhythm, normal rate
noted. Normal S1- S2 noted.
Abdomen: Abdomen is flat; Normoactive bowel sounds. Liver span is 6cm at right MCL. No tenderness
or masses on all quadrants.
Extremities: With good muscular bulk. Linear laceration 6cm right deltoid area about 3cm below the
acromion. Linear laceration 1 cm right postero-superior to the acromion. Multiple linear abrasions distal
3rd dorso-medial right forearm. No varicosities noted. Capillary refill time <3 seconds on all extremities.
NEUROLOGIC EXAMINATION
LEVEL OF CONSCIOUSNESS
Patient is conscious and coherent, oriented to time, place and person, with intact recent (short-term)
memory, conversant with no stuttering and dysarthria, but is a little slow to follow instructions.
Glasgow Coma Scale
Eye Opening
Best Verbal Response
Best Motor Response
TOTAL

4
5
6
15

CRANIAL NERVES
CN I
CN II

Not tested
Visual field: able to locate finger in all four quadrants of the visual field, but
failed to identify the number of fingers shown
CN III, IV, VI (-) ptosis
Pupils equal round and reactive to light (PERRLA)- direct and consensual light
reflex
Primary position, alignment and stability of eyes at straight gaze are normal,
(-) nystagmus
All extraocular muscles are intact except lateral rectus (CN VI) left and right
but is more prominent on the right

CN V
CN VII

CN VIII
CN IX and X
CN XI
CN XII

Sensory: (+) light touch and pain sensation in V1, V2 and V3

Smile is asymmetric- deviated to the right only
Blowing muscle (buccinator) is intact left and right
Frontalis muscle is intact: Patient can wrinkle his forehead
Weber test: sound is heard louder on the right
(-) Rinne test: bone conduction > air conduction on the right side
(-) difficulty in speaking or swallowing
(-) hoarseness or husky voice
Sternocleidomastoid and trapezius are intact
Tongue when protruded is in the midline (no deviations)
Able to move to all directions

MOTOR FUNCTION

SENSORY FUNCTION

Light touch using a soft brush was perceived in all parts of the body

Pain using pin prick was perceived in all parts of the body

INITIAL IMPRESSION: TRAUMATIC BRAIN INJURY probably CEREBRAL CONTUSION

(MILD)
Bases:

history of head injury

Injury to the temporo-parietal bone (laceration and bleeding)- right side

Lateral rectus palsy (CN VI)- both eyes

Blurring of vision- both eyes

Impaired visual fields

Asymmetric smile probably facial nerve (CN VII) palsy

Bone conduction better than air conduction- right ear

Tinnitus

GCS=15 (mild head injury)

Mild confusion, slow to follow instructions

DIFFERENTIAL DIAGNOSES
Cerebral concussion

Intracerebral
hemorrhage

Rule In
Trauma to head
Blurring of vision
Impaired visual field
Numbness

Trauma to head
Blurring of vision
Impaired visual field
Numbness

Rule Out
Vacant stare
Confusion
Memory deficit
Disorientation
Delayed motor and verbal
responses
Headache
Nausea or vomiting
Lack of awareness
Dizziness
sudden weakness, tingling, or
paralysis in the face, arm, or leg,
sudden onset of severe headache
loss of balance and coordination,
dizziness
nausea, vomiting
loss of consciousness
confusion, delirium

MANAGEMENT
Laboratory workups:
CT: CT provides rapid, noninvasive imaging of the brain and skull. CT is superior to MRI in visualizing
fine bone detail in (but not the contents of) the posterior fossa, base of the skull, and spinal canal.
MRI: MRI provides better resolution of neural structures than CT. This difference is most significant
clinically for visualizing cranial nerves, brain stem lesions, abnormalities of the posterior fossa, and the
spinal cord.
Skull Xray to see probable fracture
CBC with blood typing to see hemoglobin and hematocrit level to assess the bleeding, and blood typing
for impending cross matching if transfusion is needed when surgical operation is to be done.

PT/aPTT to determine any abnormalities that may cause coagulation problem

Serum electrolytes may exacerbate brain injury and may require correction.
Determine Mean arterial pressure

Order of urgency:

Surgery to control bleeding in and around the brain

Monitoring and controlling intracranial pressure

Insuring adequate blood flow to the brain

Treating the body for other injuries and infection

A. MEDICAL

Awaken patient every 2 hours and assess neurologically for any signs of deterioration

Mannitol (diuretics) to decrease brain volume and cerebral edema

B. SURGICAL

Relief of intracranial pressure via craniotomy

Ventriculostomy may also be done to increase intracranial pressure