Thursday, September 17, 2009

Left FP ASDH

Referred case from ED yellow zone

16yo malay boy
No known medical illness

Alleged MVA this morning
MB vs MB, at 7.15am near Sek Men Teknik Paya Jaras today Had LOC ? duration, regained consciousness on the way to hospital. No vomiting
No limb weakness- able to move all limbs, but noted by ED MO pt a bit restless- given sedation prior to CT brain done
No ENT bleeding
No SOB/ chest pain/ abdominal pain

o/e:
GCS E3V3-4M5 (11-12/15)
Pupils 3/3 ++
Noted multiple abrasions wound (small) over the face

Chest/ pelvic spring -ve

No spine tenderness
No obvious long bone deformity

BP 135/87
HR 90
Spo2 100% on air

Lungs: clear
P/a: soft, nontender

Moving all 4 limbs power bilateral UL/LL >4/5
Reflexes normal










CT brainLt frontal contusion with Lt frontoparietal SDH with maximum thickness 0.5cm over 10cuts MLS 0.5cm Brain edematous BS partially efface
Impression: Lt frontoparietal SDH with Lt frontal contusion

He unerwent craniectomy and evacuation of clots with EVD placement for ICP monitoring. Post-op CT scan was performed POD 1





3 comments:

asma' afifi said...

boss, i think got typing error mybe....
the description of bleed : rt ftp asdh...suppose to be lt ftp asdh...
please correct me if im wrong...tq

A Member of Ex-USMCK Group said...

Thanks for correcting me. Hope to see more comments from u.

mkariff said...

Hi doc...how can i contact you?