Chief report

A middle-aged man without personal details was admitted to our ICU at 0:20AM of 15th, 2006.

The patient fell from a building and got wounded on the head. He had been unconscious after that .On admission his face was bleeding.Cranial CT showed maxillary bone and inner orbital wall were broken, antrocele existed.The man was admitted in emergency after ophthalmic debridement and suture without dyspnea,twitch ,encopresis or aconuresis.

Previous disease and other histories are all unknown.

Physical exam: T P76bpm R17bpm BP140/90mmHg , unconscious, GCS 13. Both pupils equal and roud, in diameter. Sereral skin lacerations on the face. Breath

Sounds on the right side weaker than those on the left by auscultation. Right thigh swelled and malformed. Babinsky sign (-).

Cranial CT showed maxillary bone and inner orbital wall were broken, antrocele existed; X-ray showed right thighbone was fractured.

Initial diagnosis: 1、anterior cranial fossa , maxillary bone and inner orbital wall fracture 2、right thighbone fracture 3、chest injury 4、skin lacerations on face 5、soft tissue injury.

Initial plan for treatment: the patient was given intramuscular injection of 1500u TAT on admission. He is in intensive care, forbidden diet and drink. His vital signs are being closely monitored. Thoracal surgeon’s consultation has been made. Mannitol, antibiotics, tagamet and hemostatics will be given to him every day.
Other minor errors:

Nev. 15th, 2006. = Nov. 15th 2006

Both pupils equal and round
Several skin

Thoracal surgeon’s = Thoracic surgeon's
What do you mean by "defaults"?
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Grammatical errors have been corrected by a master. I'm not sure if the medical iterms are accurate.
I have never heard of a "forbidden diet" - would that be "NPO" - nothing by mouth, or a "restricted diet" which should list the restrictrion (s). For example, "clear liquids" , " no dairy" , "low sodium", "low calorie", etc. etc. etc.

Thanks !!!
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