Patient Testimony: Motor Vehicle Accident

Chief complaint: I was involved in a motor vehicle accident

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HPI: the patient was driving through town when he crashed into an electric pole. The patient attributes this to poor vision owing to the rainy weather. He sustained injuries to his chest and upper limbs.

PMH: no previous diseases or hospitalisationsSurgery: none

Allergies: none

Medications: none

Age/ health status: 15-year-old male appears to be in good state of health

Family history: the father has hypertension

Social history: he is the only child in their family. He lives with his father and mother. No smokers in the house and no pets.

Review of systems

General: denies irritability, weight gain or loss or any fever

HEENT: denies any ear pain or nasal congestion

Respiratory: the patient admits to having difficulty in breathing, denies coughing, hemoptysis, wheezing or history of asthma, bronchitis and pneumonia

Integumentary: skin appears normal

Allergies: none

OBJECTIVE:

Height: 128cm Weight: 21Kg BMI: 24.8

Vital signs: T98F, P 84, RR 25 BP 122/76

General: alert, appears oriented to time and place, no acute distress

HEENT: normocephalic, no sinus tenderness, no exudates observed, no palpable nodes

Cardiovascular: S1 and S2 detected, no rubs, murmurs or clicks. Pulses for brachial, radial, femoral, popliteal and dorsalis pedis are 2+ and symmetrical

Respiratory: asymmetrical respiratory movements, dyspnea, lungs are not clear to auscultation, dullness detected on the left chest on percussion, no rales, rhonchi or wheezes

Integumentary; bruises on the upper limbs, no dryness, lesions, discolourations or rashes

TESTS:

Carry out a chest x-ray scan to determine the presence of fluid within the chest cavity and its location. This will also point out the location of possible fractures.

ASSESSMENT:

Paralysis of the respiratory muscles- this may be due to injury to the phrenic nerve or damage to the intercostal muscles. This leads to uncoordinated movements during respiration (Trentz, 2014).

Hemothorax- accumulation of blood in the pleural cavity (Mahoozi, Volmerig & Hecker, 2016). This space usually contains a small amount of pleural fluid. Accumulation of blood interferes with the normal respiratory movements resulting in dyspnea and poor oxygenation of blood (Aboalsaud & Deckelbaum, 2015).

PLAN:

Fix a chest tube to drain fluid that may be within the pleural space

Administer assisted ventilation

Administer morphine bolus to manage the pain

Dress bruises on the hands and arms

References

Mahoozi, H.R., Volmerig, J., & Hecker, E. (2016). Modern Management of Traumatic Hemothorax. J Trauma Treat, 5(326), 2167-1222.

Aboalsaud, A., & Deckelbaum, D.L. (2015). Chest Trauma. In Pocket Manual of General Thoracic Surgery (pp.153-174).

Springer, Cham.Trentz, O. (2014). Polytrauma: pathophysiology, priorities and management. In General Trauma Care and Related Aspects (pp. 69-76). Springer, Berlin, Heidelberg.