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Case Report

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. Chief Problems. Falling down from 4th floor at 11:25 in 6/25. Present Illness + Physical Exam. Consciousness ： alert E3V4M6, GCS 13

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Case Report

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  1. Case Report 95/06/11 Intern 張偉德

  2. Patient’ s Profile • Name：郭○玲 • Age：40 y/o • Sex：female • Chart no. ：14026717 • 95/6/25, 12:04 入ER

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

  4. 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℃ • Head：ILOC (?), Dizzy (-), Headache (-), Nausea/Vomiting (-), Amnesia (-), • Neck：Stiff, pain, soreness (-) • Chest：Pain, dyspnea (-) • Abdomen：Pain (-)

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

  6. Airway + 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

  7. Breathing / Ventilation • RR：10-24/min • O2 saturation

  8. Circulation + 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

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

  10. Exposure + Environment control • Exposure： • Left lower leg laceration wound • Protect spine

  11. Treatment • 12：10

  12. Left lower leg

  13. Pelvic

  14. Brain CT • Dull response • No significant findings

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

  16. Abdominal CT

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

  18. 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

  19. Impression • Pelvic fracture • Left lower leg open fracture • Abdominal internal bleeding • L1 burst fracture

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