NIK FAIZOL, 16 yrs 2 days, Male HRPZ899778



16 years old, malay, boy 
previously nkmi 
active smokers 
denied substances induced 

alleged mva around 11 pm 
MB vs MB 
unsure mechanism of injury 
LOC 
- unsure duration 
- regain consciousness at site 
retrograde amnesia 
- unable to give clear history 
had bleeding on right nose 
pain and swollen ove right face 
able to ambulate 
no nausea, no vomiting 
no ear bleed 
no chest pain, no palpitation
no abdominal pain 

Airway : patent,  on cervical collar , no cervical deformity, no cervical tenderness
Breathing : symetrical chest rise, no abnormal breathing, ascultation : clear, equal air entry, SPO2 :100%
Circulation : clinically pink, good pulse volume, CRT < 2 seconds, warmth peripheries, BP : 149/90   HR : 105 bpm, 
Disabilty : GCS 15/15 / AVPU, pupils  3 mm reactive bilaterally/ no abnormal movement
Exposure : swollen over right face, right eye



o/e:  gcs 15/15, pupil 3mm reactive bilaterally, not tachypnic, hydration good, pink
bp: 119/90 
pr: 105
rr: 21
t: 37 
spo2 99% under ra 
pa 5 
lungs : clear , equal air entry 
cvs: drnm 
pa: soft , non tender 

l/e over face : swollen at right face, bluish, bony tenderness, no external bleed 

l/e over right eye : swollen below right orbital, no external bleed 

FAST scan x 1 : negative 

ct brain : hydrochephalus , hyperdense lesion over left basal ganglia , HU 200++
bilateral lateral orbital wall bone fracture, nasaal bone fracture, bilateral maxillary bone fracture 



imp: 1. Mild TBI with bilateral thalamic hyperdensity (L>R)
- DDx: left thalamic contusion/bleed
- thalamic calcification
2. Multiple facial bone fractures
3. Ventriculomegaly incidental finding

Plan
1. For observation in HRPZ
2. Strict gcs and pupilary charting
3. Trace formal reporting
4. Kiv rpt Ct scan if neurological deterioration
5. Analgesics
6. Refer OMF