This document summarizes the medical notes from an examination of a 48-year-old male patient who was in a motorcycle accident 5 hours prior. The primary survey found the patient had an intact airway, equal breath sounds, stable vital signs, and swelling and deformity in the left wrist. Adjunct exams like FAST, CXR, and pelvis X-ray were normal. The secondary survey revealed abrasions and lacerations on the body and no past medical history. Physical exam was normal except for the deformed left wrist. CT brain was also normal. The patient was diagnosed with a left wrist fracture which was closed reduced and placed in a long arm slab and sling. He was admitted for possible surgery.
Dr.MD.Monsur Rahman,PT
MPT-Musculoskeletal Disorders
Maharishi Markandeshwar Institute Of Physiotherapy And Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana - Ambala,133-207 (Haryana)
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http://sandymillin.wordpress.com/iateflwebinar2024
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2. ผู้ป่วยชาย อายุ 48 ปี ขับมอเตอร์ไซค์ชนกับรถเก๋ง 5 ชั่วโมง ก่อนมาโรงพยาบาล
Primary survey
• A airway patent ,can speak ,no c-spine tenderness
• B equal breath sound ,CCT-negative
• C vital sign stable ,abdomen soft,not tender,no guarding
• D E4V5M6 pupil 3 mm RTLBE
• E swelling ,deformity at left wrist with limit ROM due to pain
6. Secondary survey
• A no food and drug allergy
• M no usual medication
• P no underlying disease
• L last meal at 6.00 pm yesterday
• E 5 ชม. ก่อนมาโรงพยาบาล ขับมอเตอร์ไซค์ชนกับรถเก๋ง สลบ ณ ที่เกิดเหตุ รู้ตัวตอนรถโรงพยาบาลมา
รับ มีแผลถลอกตามตัว ข้อมือซ้ายผิดรูป
7. Physical examination
• HEENT not pale ,no jaundice
• HEART normal s1 s2 ,no murmur ,pulse full ,regular
• LUNG equal breath sound ,clear both lungs ,no subcutaneous
emphysematous
• ABDOMEN soft ,not tender ,no guarding
• EXTREMITIES
• NEUROLOGICAL good consciousness ,E4V5M6 ,pupil3mm RTLBE
,median nerve left hand intact
39. • closed reduction and cast immobilization
• extra-articular
• <5mm radial shortening
• dorsal angulation <5° or within 20° of contralateral distal radius
Short arm cast or short arm slab 4 wk
correct
1.dorsal / radial displacement
2.shortening of radius
3.loss of normal 10 degree volar tilt in lat view
