Answer
1) Further question to ask
a) The exact mechanism of fall.
b) What causing him to fall, is it because of slippery or loss of consciousness prior to fall
c) Did he regain consciousness after the fall?,
d) Any disability or neurological deficit after the fall
e) Any sign and symptom of increase intracranial pressure; blurring of vision, vomiting, headache.
f) Pain score.
+ any allergic, medication, past medical history, last meal.
2) X ray finding
Fracture of the right lateral and inferior orbital wall.
3) Further management to the patient
a) Stabilize the patient and ensure ABC is intact
b) Re evaluate the patient.
- Look for any other injury and neurological deficit
- Elicit cervical spine tenderness
- Sign and symptoms of increase intracranial pressure.
c) Pain management depending on the level of the pain
- IM voltaren 75 mg stat or,
- IV Tramadol 50 mg + IV maxalon 10 mg stat, or
- IM pethidine 50 mg
- Repeat the injection or put patient on continuous IV analgesic infusion if severe pain.
d) CT brain if brain injury or basal skull fracture is suspected.
e) Referred the patient to be evaluate by ophthalmologist & maxilla-facial surgeon team for futher management of orbital wall fracture.
f) Referral to neurosurgeon (if required)
g) Observe the patient for at least 6H with trauma chart.