1. Case present FALLING DOWN

2. C.C & P.I  CC : Falling down from 2meters  P.I :  A 39 years old man falled down 2meters to a whole  He complained of trauma to left hemi thorax, pain & dyspnea  He couldn’t give history because of pain & dyspnea  He complained trauma to Rt knee  PH& DH Neg

3. PH EXAM  GCS = 15/15  V/S :  BP = 120/70  RR = 23  PR = 110  SAT O2 = 94%

4. PH EXAM  Air way was intact( responsive)  He spoke hardly because of pain  Breathing  inspection : abrasion in lower left hemi thorax about 6 th to 10 th rib. Without laceration.  Without intercostal & supra sternal retraction. Thoracic movement was symmetric. JVP nor.

5. PH EXAM  Palpatio n : tenderness on lower left hemi thorax,  without cryptation or subcutaneous emphysema or palpable rib fx  Ascultasion :symmetric & Without decrease of lung sound.  Circulation : active bleeding neg  shock signs & symptoms ( Pale / Sweeting/ AMS) neg Abdomen : deliberate garding. Without tenderness. pelvic : fixed

6. PH EXAM  Disability : GCS 15/15  Pupillary normal size & reaction without FND EXPOSURE : Log Roll : without mid line tenderness Rt knee tenderness. Distal pulses were normal & symmetric

7. PARACLINIC  E.FAST heterogeneity in spleen  LAB DATA : WBC: 14400 Hb : 13.1 Hct : 37.9 U/A RBC : 20-25 WBC : 4-6

8. PARA…  CBC after 6 hours : Hb : 12.9 Hct : 39.4 CBC after 12 hours : Hb : 13.1 Hct : 39.7 CBC after 24 hours : Hb : 12.4 Hct : 36.1

9. ECG

10. MANAGEMENT RIB FRACTURE  Rib fx discharge with adequate oral analgesic for young & healthy patients. forbidden use restrictive devices  Rib fx >= 3 => hospitalization to receive aggressive pulmonary therapy and appropriate effective analgesia  Rib fx >= 6 => ICU addmitoion

11. The spleen is the organ most often injured, and in nearly two thirds of these cases it is the only damaged intraperitoneal structure Liver is second & intestine is the most h.v to be damaged

12. Grade Description of spleen injury I Capsular tear, < 1 cm parenchymal  II Capsular tear, 1-3 cm depth which does not involve a trebecular vessel  III Laceration > 3 cm parenchymal depth involving trebecular vessels Ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma > 5 cm or expanding  IV Laceration involving segmental or 4hilar vessels producing major devascularization (> 25% of spleen) V Shattered spleen or hilar vascular 5injury which devascularizes spleen

13. GradeInjury DescriptionAIS-90  I Haematoma Subcapsular <10% surface area Laceration Capsular tear, <1cm parenchymal depth  II Haematoma Subcapsular 10-50% surface area Intraparenchymal, <5cm diameter Laceration1-3cm parenchymal depth not involving a parenchymal vessel  III HaematomaSubcapsular, >50% surface area or expanding. Ruptured subcapsular or parenchymal haematoma. Intraparencymal haematoma >5cm Laceration>3cm parenchymal depth or involving trabecular vessels3

14. Grade…  IV Laceration of segmental or hilar vessels producing major devascularization (>25% of spleen)  V LacerationCompletely shattered spleen5 VascularHilar vascular injury which devascularized spleen