August 22, 2014

Ateneo School of Medicine and Public Health

Clerkship Year: Orthopedics Rotation (Medical City)
Case Write-up
Date of Consult: August 18, 2014
Time/Place of Consult: TMC

Informant: Patient
Reliability: Good
HISTORY

I.

CHIEF COMPLAINT
Multiple injuries secondary to vehicular accident

II.

HISTORY OF PRESENT ILLNESS

A.P. is a 38 year old Filipino male, right-handed, messenger who came in for multiple injuries secondary to vehicular accident.

One day PTC (8/17/14 4 AM), patient was riding a taxi on a passenger seat when a head on collision with a truck occurred.
Patient claimed to have lost consciousness and have no recollection of the said event. He woke up in a hospital in Pasig City
complaining of 6/10 left sided hip pain and 7/10 left sided chest pain on deep inspiration; both of which are characterized as
crushing, worsened by movement and relieved with rest. No headache, nausea, or vomiting were noted. AP view xrays were
ordered and showed no noticeable fractures. Patient was then cleared from initial assessment and was allowed to go home after
given mefenamic acid, amoxicillin, and muciprocin ointment as home medication.
Few hours PTC (8/18/14 6 PM), patient noted that he could not move his left leg due to 7/10 left hip pain; persistence of
which prompted ER consult in our institution and subsequent referral to Orthopedic service.

1st
2nd
trimester
trimester
Inability to move left leg

3rd
1
trimester
hour
left sided hip pain and chest pain

III. REVIEW OF SYSTEMS

GENERAL: (-) headache, dizziness; (-) weight loss, fever, weakness

HEENT: (-) blurring of vision, tinnitus, nosebleeds, hoarseness, dry mouth, gum bleeding, enlarged lymph nodes
RESPIRATORY: (-) cough and colds, (-) dyspnea, hemoptysis, wheezing
CARDIOVASCULAR: (-) palpitations; chest pains, syncope, orthopnea
GASTROINTESTINAL: (-) dysphagia, (-) heartburn, rectal bleeding, jaundice
GENITOURINARY: (-) increased frequency; nocturia, dysuria, hematuria
ENDOCRINE: (-) excess sweat, heat intolerance, polyuria, excessive thirst, cold intolerance
MUSCULOSKELETAL/DERMATOLOGIC: (-) lumps, sores, itching, changes in skin color, changes in hair/nails

IV. PAST MEDICAL HISTORY

No allergies and other comorbidities

PRIOR HOSPITALIZATION: Right forearm laceration on a volar surface secondary to mauling accident (1994)

PRIOR SURGERY: none

VI.

FAMILY AND IMMUNIZATION HISTORY

Patient claimed that his father has a history of long standing chronic hypertension

August 22, 2014

Ateneo School of Medicine and Public Health
Clerkship Year: Orthopedics Rotation (Medical City)
Case Write-up

VII. PERSONAL/SOCIAL HISTORY

Patient is a highschool graduate who currently works as a messenger. Patient denies substance use and smoking but admits to
have occasionally drunk various alcoholic substances in social events. He also claimed to regularly walk for about 30-40 minutes
everyday and to eat regular diet 3x a day.

Stakeholders Analysis

STAKEHOLDERS

INTEREST

ROLE

LEVEL OF INFLUENCE

INSIGHT

Patient

High/ ally

Receiver of care

High

Supportive care

Mother

High

Decision maker and

gatekeeper

High

Attending
Physician

High/ ally

Patient advocate

High

Inform Hx and PE finding

Inform Hx and PE finding

PHYSICAL EXAMINATION

I.

GENERAL INSPECTION
Patient was alert and coherent, and does not appear to be in cardiorespiratory distress.
GCS 15/15 (E4 V5 M6) and oriented to 3 spheres

II.

VITALS
Respiratory Rate: 18 breaths per minute
Heart Rate: 87 beats per minute
Temperature: 36.5C

Blood pressure: 125/81

2
BMI: 22 kg/m

III. PHYSICAL EXAM

Head and Neck: normocephalic and symmetric, (-) enlarged lymph node, (-) septal deviation, (+) multiple
abrasions, right forehead and face
Eyes: pale conjunctivae, (-) icteric sclerae, (-) hemorrhage
th
Cardiovascular: adynamic precordium, apex beat is felt and 5 left ICS (-) thrills, (-) murmur, (-) heaves, normal
S1 and S2, (-) bruits
Chest and Lungs: clear breath sounds, symmetric chest expansion, (-) ronchi, (-) rales, (-) wheezes, (-) crackles,
(+) pain on deep inspiration, left chest
Back: symmetric, non-tender, (-) abnormal curvature
Abdomen: scaphoid, (-) abnormal pulsation/ scar, (-) striae, tympanitic, normoactive bowel sound, (+)
tenderness on right anterior hip (inguinal area and right gluteal area)
Upper & Lower Extremities: equal and full pulses, (-) bipedal edema, (+) scar on right forearm, (+) contracture
Integumentary: good skin turgor, (-) cyanosis (-) clubbing (-) jaundice
Special Test:
- SLR
o negative

August 22, 2014

Ateneo School of Medicine and Public Health
Clerkship Year: Orthopedics Rotation (Medical City)
Case Write-up

MMT
Upper Extremity
Shoulder shrug
Elbow flexion
Elbow Extension
Wrist flexion
Wrist extension
Finger abduction/
adduction
Lower Extremity
Hip flexion
Knee flexion
Knee extension
Ankle dorsiflexion
Great toe extension
Ankle plantar
flexion

Left
5/5
5/5
5/5
5/5
5/5
5/5

Unable to move
due pain
5/5
5/5
5/5
5/5
5/5

5/5

Right
100%
100%
100%
50%
20%

Left
100%
100%
100%
100%
100%

5/5
5/5
5/5
5/5
5/5

Sensory Testing
Sensory
C5
C6
C7
C8
T1

Right
5/5
5/5
5/5
5/5
5/5
3/5

Sensory Testing
o Was not done
DIAGNOSTIC FINDINGS/ COURSE IN THE WARDS

08/18/2014
IMAGING (initial reading/ xray)
C7 vertebral body, posterior process, and the cervicothoracic junction are not visualized in the lateral view
There is a cortical irregularity seen along the interoinferior endplate of the C2 vertebral body seen in the
lateral view. Minimally developed spur is seen along C4 and C5 vertebral bodies. The rest of the visualized
vertebral bodies, disc spaces, and posterior elements are intact. There is no evidence of spondylolisthesis/
dislocation. The cervical lordosis is straightened, which may be positional in nature
nd
The complete, displaced, fracture, of the left 2 rib is partly seen in this study. Cortical irregularities along
the anteroinferior C2 vertebral body endplate for which the fracture cannot be excluded. Further evaluation
with CT is suggested if clinically indicated
Mild degenerative osseous changes
nd
Fracture of the LEFT 2 rib, as described
08/18/2014
MEDICATION
Current medication: Celecoxib, Dolcet, Amoxicillin, Mefenamic acid, Mupirocin
IMAGING
Cranial CT: no bleed, linear frature maxillary alveolar ridge; Pelvic/ chest/ skull Xrays: unremarkable

August 22, 2014

Ateneo School of Medicine and Public Health
Clerkship Year: Orthopedics Rotation (Medical City)
Case Write-up

Chest CT: multiple rib fracture; possible pulmonary contusion/ hematoma/ pneumonia, minimal bilateral
pleural effusion with atelectasis and consolidation, pleural thickening in the right upper hemithorax
Spinal Xray: anteroinferior C2 vertebral body endplate fracture on Philadelphia collar

OTHER
Referral to ENT service for facial CT evaluation

ASSESSMENT/ DISCUSSION/ PROGNOSIS

Fracture, closed, complete, displaced, oblique inferior endplate, vertebral body and cervical vertebrae, multiple rib
nd th
fractures (2 -5 ribs, left); s/p repair of laceration, right forearm (2004)
The mechanism of injury that involves fracture of C2 usually is caused by the forcible hyperextension of the head,
usually with distraction of the neck- occurs mainly with deceleration injuries in which the victims face or chin strike
an unyielding object.
Survival from this type of fracture is relatively common, as the fracture itself tends to expand the spinal canal at the
C2 level.
MANAGEMENT, PROGNOSIS AND PREVENTION
A. MANAGEMENT
1. Appropriate goal setting
* Attempt to alleviate pain through close monitoring and administration of pain medication (i.e. Dolcet, Mefenamic
acid, and Celecoxib)
* Order appropriate imaging study (i.e. initial X-ray study followed by CT scan to observe the extent of trauma)
* Order baseline laboratory study (i.e. CBC for hemodynamic stability and r/o infection)
* Administration of empirical antibiotic regimen when appropriate (i.e. Amoxicillin)
* Referral to other medical services (i.e. ENT)
* management of patient expectation: inform possibility of permanent neurodeficits and explain possibility of surgical
repair and duration of hospital stay
2. Lifestyle modifications
* Advice sufficient intake of fluid and regular diet as tolerated
* Advise bedrest and discourage ambulation until patient is cleared
* Advise short interval and low intensity exercise while in bed rest
* Advise patient to stop drinking. Enroll the patient in a professional service if warranted.
* Refer to PT or OT service
* Educate patient
3. Regular monitoring for complication (i.e. serial lab study, etc)
4. Reassurance
B. PREVENTION
Most commonly, this vertebral spine fracture can occur during a car accident. Person involved in a car crash, such as
what happened in this case, can slam their chin against an unyielding object causing hyperextension and multiple
crash injuries to occur. Wearing seatbelts and following standard traffic rules and regulations might help preventing
the occurrence of this incident.
References
Medscape
Medline