This man came off his motorbike three days ago. He says he was unconscious for an hour and he was taken to hospital. He isn’t thai so was not entitled to treatment without payment. He didn’t have any money, so he eventually came to MKT clinic to ask for help.
Luckily he had been wearing a helmet, but ones on sale here are very flimsy, and only cost £3. Notice the bruise under his eye (both sides) and the lump on his left shoulder. He said that his nose was bleeding. I asked him if he had noticed anything about his sense of smell. He said that now he couldn’t smell anything. I examined the back of his eyes with my ophthalmoscope and there was no papilloedema (evidence of increased pressure inside the skull). I thought he could have suffered a fracture of the base of the skull, behind the bridge of his nose. This is where the olefactory nerve fibres pass through the cribriform plate at the top of the nostrils, allowing us to smell. The bloody watery discharge from his nose was also evidence of this, with fluid leaking from around the brain.
I was feeling rather pleased with my diagnostic acumen when the medic pointed out that perhaps he couldn’t smell because he had pushed wedges of cotton wool up his nose to stop the flow! To salvage some pride as a clinician, I suggested that we removed the cotton wool and test the discharge for glucose with urine testing sticks. If positive, the fluid is likely to be coming from around the brain. Another test would be to catch a drop of bloody fluid on some filter paper. If it is cerebrospinal fluid, it produces a bloody spot with a of clear fluid around it – the halo sign. The patient didn’t want to take the cotton wool out, for fear of restarting his nosebleeds, so we will wait for when he changes the plugs.
His left collar bone is clearly fractured, but we couldn’t find a triangular bandage to make a sling. We had to improvise with some cloth. I explained about keeping the fingers, wrist and elbow moving actively, but to do gentle pendulum exercises for his shoulder every day for six weeks. Perhaps something was lost in translation, because he looked at me very strangely. The medic also suggested some B vitamin therapy, too as he might not have been completely sober when he crashed.