TRAUMA CASE HISTORY
C/O:
HOPI :
MOI – A/H/O
DOI
TOI
POI
Influence of alcohol
Helmet
Following the incident pt sustained injury to head, face , ------------- and was taken to ------- hospital
for primary care and then was referred to SDM medical where CT scans, and __________clearances
sought and later referred to SDMCFU for further management.
H/O LOC/vomiting/seizures/headache
H/O ENT Bleed/ oral bleed
H/O blunt trauma to chest/abdomen
Medical history:
Comorbidities and medications
Social history :
Profession-
Habit-
H/O areca nut/tobacco/smoking – no of times/day, since how many years
H/O alcohol consumption – ml/day, since how many years
General examination
If any long bone fracture / organ injury or any neuro condition
Local examination
Extraoral:
On Inspection,
Gross facial asymmetry noted in the
Diffuse swelling noted extending -AP
-SI
-
Measuring
Flattening of face/ lengthening of face , malar flattening/ depression
Skin over the swelling
Abrasions, Cut lacerated wound - extent, measurement
Pus discharge sinus tract opening
EYE –
Periorbital oedema
Periorbital ecchymosis
Subconjunctival haemorrhage – medial / lateral
chemosis
Diplopia
Vision
EOM
Telecanthus
Entropion / ectropion
Hypoglobus / enopthalmus / proptosis/ ptosis / exophthalmos
Mongoloid / Antimongoloid slant
Epiphora
FNOE
CSF Rhinorrhoea / otorrhoea
EAR – hearing , bleed
NOSE – epistaxis , DNS
Palpation,
All inspectory findings confirmed
Tenderness
Consistency of the swelling
Crepitus
Step deformity
Sinus tract – skin indurated, not pinchable , active pus discharge
Paraesthesia – which region :
IO – lower eyelid , lateral wall of nose , upper lip on same side, malar region , sensitivity of
teeth
IAN / Mental nerve – lower lip , chin , sensitivity of teeth
TMJ – clicking , movements , which side deviation on opening mouth , movements reduced, lateral
excursive movements
Lymph nodes – which level , consistency(soft, hard, firm) , fixed/ mobile, restricted mobility , number
Intra oral
Mouth opening – in mm
Occlusion - class I/III/II ,
Open bite/ cross bite
Step deformity , segmental mobility
Intraoral lacerations
hematoma (Coleman/ Guerin’s sign)
Tenderness
DMFT, mobile teeth , Ellis fracture (TVP)
Buccal mucosa - if blanched , fibrous bands (perioral, vertical)
Any ulcers/ proliferative growth
Tongue – if atrophied , movements (in protrusion, lateral, towards the palate)
Uvula – if hockey/bud shaped
Oral hygiene (stains, calculus)
Halitosis
Dentoalveolar fracture
Provisional Diagnosis:
Final diagnosis – with classification
1. Mandibular fractures -Digman and Natwig
2. Condylar fractures – Lindahl / AO -2010
3. ZMC – North and Knight and how many points fracture – 5/4/3/2
4. Arch – Yamamoto
5. Orbital fracture – Hammer classification , Nolasco -1995
6. Lefort – I/II/III – Marciani 1993
7. NFOT – Stanleys / Gouty classification of frontal sinus fracture
8. Nasal bone – Row and Killeys , Rorich 2000
9. Palatal fractures – Hendrickson 1998
