case write-up orthopedic 2

Patient’s Data

Name: Nurul Afiqah

Age:17 year s old

Gender: female

Race: malay

Date of admission: 2/2/2011

Chief complaint:

Patient was referred from Manjung Hospital due to lower back pain after got thrown off from seat and landed on buttock in a bus one day prior to admission.

History of presenting illness:

She said on the way back home from Kem PLKN Selama the bus hit a hole on the road .Then because of the impact she was bouncing on her seat. However the bus was under control and no other passenger had any injury. Post trauma, she experience a severe throbbing pain on her lower back. The intensity was 10/10 and it was persistent. However she still could walk as she move to the front seat because she felt dizziness and vomit one time on the front seat. The pain did not radiate to the lower limb and also no numbness was felt on lower limb. The pain was aggravated by walking but relief a bit by bending forward. However no bowel  or urinary incontinence. After arrive home in Manjung, her mother brought her to the Manjung Hospital . At A&E department X-ray imaging was done. The doctor said that her lower spine become compressed due to the trauma. They sent her to Ipoh Hospital for CT scanning and MRI.

Past medical history:

No past medical history.

Past surgical history:

No past surgical history

Family history:

No history of bone disease run in the family. The parents are healthy and so do her siblings.

Social history:

She is a PLKN trainee. She never smoking and never consume any alcohol. The live in Manjung with her parents.

Physical examination:

General  examination:

She was alert and conscious. GCS was 15/15. Good hydration status. Hand is warm and pink. Capillary refilling time less than 2 second.

Bp-110/70mmHg

Pulse- 80bpm

Temperature- 37.0 degrees celcius

Respiratory rate-20 per minute

Neurological examination:

For all limbs muscle tone are normal, muscle power is 5/5, normal reflex. For the plantar reflex, the toes are flexing downward. All sensation are intact. No muscle wasting. Spinal examination cannot be done because doctor said he must lying down supine to prevent further injury.

Abdominal examination:

Abdomen is soft, no tenderness and no palpable mass.

Respiratory examination:

Lungs are clear. Normal breath sounds are present.

Cardiovascular examination:

First and second heart sound are present and no murmur detectable.

Investigation :

X-ray imaging- there is a compression on the L1 vertebra. And the alignment is run off.

MRI- there are burst fracture of the L1. The spinal cord still intact.

Full blood count to check the hemoglobin level and neutrophil level.

Management:

Surgically repair the spine and put a internal fixator. Immobilize  and  follow up the patient to check any deformity and the healing process of her spine.