Case Report 95/06/11 Intern 張偉德. Patient ’ s Profile  Name ：郭 ○ 玲  Age ： 40 y/o  Sex ： female  Chart no. ： 14026717  95/6/25, 12:04 入 ER.

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Presentation transcript:

Case Report 95/06/11 Intern 張偉德

Patient ’ s Profile  Name ：郭 ○ 玲  Age ： 40 y/o  Sex ： female  Chart no. ：  95/6/25, 12:04 入 ER

Chief Problems  Falling down from 4th floor at 11:25 in 6/25.

Present Illness + Physical Exam  Consciousness ： alert  E3V4M6, GCS 13  Pupil ： 3.0/3.0 mm  Vital sign ： BP 103/66mmHg PR 77/min RR 10-24/min BT 36 ℃ RR 10-24/min BT 36 ℃  Head ： ILOC (?), Dizzy (-), Headache (-), Nausea/Vomiting (-), Amnesia (-),  Neck ： Stiff, pain, soreness (-)  Chest ： Pain, dyspnea (-)  Abdomen ： Pain (-)

AMPLE  Allergy ： denied  Medication ： drug for MDP  Past illness ： MDP  Last meal ： 6/25 7:00  Event ： falling down from 4th floor

A irway + C-spine immobilization  Airway ： patent, RR:10-24/min  C-spine immobilization  Clearance of cervical spine ：  GCS 15, no alcohol consumption and toxic material intake  No neurological defect, neck pain and tenderness  下巴抵前胸, 頸部左右轉, no pain and paresthesia

Breathing / Ventilation  RR ： 10-24/min  O 2 saturation

C irculation + Hemorrhage control  BP ： 103/66 mmHg, PR ： 77/min  循環障礙的評估：  Heart rate  Capillary refilling time  Urine output  Consciousness  Shock 的評估：  Heart rate ↑  Cold extremity  Narrow pulse pressure

Disability  GCS ： E3V4M6  Pupil ： 3.0/3.0mm, light reflex  Motor and sensation function evaluation

E xposure + Environment control  Exposure ：  Left lower leg laceration wound  Protect spine

Treatment  12 ： 10 WBC (×10 3 /ul) GOT (u/l) 209 Na (meq/l) 137 RBC (×10 6 /ul) 3.90 GPT (u/l) 120 K (meq/l) 3.74 Hgb (g/dl) 10.4 BUN (mg/dl) 8.7 PTp/c (s) 12.1/10.6 Hct ( ％ ) 34.9 Creatinine (mg/dl) 0.98INR1.13 PLT (×10 3 /ul) 333 Sugar (mg/dl) 144 aPTTp (s) 26.1/29.3

Left lower leg

Pelvic

Brain CT  Dull response  No significant findings

Treatment  13 ： 10  Suspect internal bleeding  Abdominal and pelvic CT  On CVC at right subclavian vein

Abdominal CT

Treatment  13 ： 45  Transfuse PRBC 4 units  15 ： 40  Transfuse Platelet 12 units  16 ： 00  Transfuse FFP 6 units

Treatment  17 ： 00  Angiogram  Injury of right L4, L5 lumbar artery.  Injury of proximal branch of left internal iliac artery.  Proximal branch of left internal iliac artery was embolized.  17 ： 35  Transfer to Trauma ICU

Impression  Pelvic fracture  Left lower leg open fracture  Abdominal internal bleeding  L1 burst fracture