Baguio General Hospital Medical Center Department of Surgery CLINICAL ABSTRACT Name : Age/Sex : Date admitted : Date discharged

: Attending physicians : Diagnosis : Operations Done: PABLO, AGUSTIN 48/MALE October 6, 2011 presently admitted Dr. Cabfit/Dr. Besarino/Dr. Fongayao/Dr. Lomboy Compartment Syndrome Right Leg secondary to Encavement Injury Emergency Lower Leg Fasciotomy, right Wound Debridement

This is the case of Pablo, Agustin 46 years old, single, Filipino, Roman Catholic, born August 10, 1965 in Tublay, Benguet currently and permanently residing at Labey, Ambassador, Tublay, Benguet, admitted on October 6, 2011 due to Blunt thoracoabdominal injury secondary to encavement. The present condition started 20 hours prior to admission, when the patient accidentally had a trauma to his right lower extremity, and abdominal area with associated multiple lacerations and abrasions secondary to encavement. There was associated episodes of nausea and vomiting, difficulty of breathing and chest pain. No associated loss of consciousness, numbness, or dizziness noted. Patient was immediately brought in this institution and was subsequently admitted for further care and management. On admission the patient was conscious, coherent and not in any form of cardiopulmonary distress with stable vital signs. There was no noted pallor, jaundice, or cyanosis and with good skin turgor. The patient has equally distributed hair, anicteric sclera, pink palpebral conjunctiva, no ear and nasal discharges, dry lips and moist buccal mucosa, no neck vein engorgement and no cervical lympadenopathy noted. Symmetrical chest wall expansion, no retractions, no lagging, clear breath sounds. Adynamic precordium, normal rate, regular rhythm, no murmurs noted. The abdomen is flat, with multiple abrasions and lacerations, soft, normoactive bowel sounds, tympanitic, no palpable masses. Patient has lacerations and abrasions on his right leg, with equal and full peripheral pulses and good capillary refill. Motor System: 5/5 3/5 5/5 5/5 Sensory System: 100 100 100 100 Reflexes: ++ ++ ++ ++

Course in the Ward: Upon admission, diagnostics were done such as CBC, blood typing, CBG, chest x-ray APL and cervical APL. Venoclysis and medications were started and underwent an emergency fasciotomy of his right lower extremity. Patient was transferred to the recovery room after the procedure, where vital signs were closely monitored. He was then transferred to the ward with stable vital signs. Medications were given; vital signs, bleeding and swelling of the right leg were continuously monitored. One day to ten days post operatively, patient had stable vital signs, with noted mild swelling of the right leg and no hematoma and bleeding episodes. The patient had also mild tolerable pain on the affected area with elastic bandage in place. Wound care and elevation of right leg with 2 pillows were continuously monitored. Medications were continuously given. Eleven days post op, patient had improved but with noted febrile episodes and a yellowish discharge on the right foot with mildly soaked dressing and elastic bandage in place. Patient has stable vital signs except for fever, no complains of pain, decreased swelling, no bleeding and hematoma noted on the affected leg. Also, a sample of the discharge was sent to the laboratory for gram stain revealed a smear shows plenty of gram negative rods and pus cell of two.

Twelve days post op, there was no febrile episodes noted, but with complains of pain on the right lower extremity. Medications were continuously given, monitored vital signs. Wound care was done and maintained on elevation of the affected leg. Thirteen days post op, patient experienced epigastric pain rated as 7/10, burning and gnawing in character with no associated loose bowel movement, constipation, or nausea/vomiting noted. Patient was given with appropriate medications. Twenty two days post op, a repeat CBC revealed anemia, and 2 units of packed RBC were secured. Twenty three days post op, patient underwent wound debridement for drainage of pus in the affected area. He was then transferred to the ward with stable vital signs. Medications were given; vital signs, bleeding and swelling of the right leg were continuously monitored. Twenty four days post op, he again underwent serial debridement for proper dissolution of pus in the affected area. Monitored vital signs and medications were continued. Twenty seven days post op, blood transfusion were facilitated and were given. A repeat hemoglobin and rd hematocrit count was done 6 hours after the 3 unit of blood transfusion was given. Daily wound care was done with dry and intact dressing and elastic bandage in place. The patient is currently admitted in this institution where vital signs were continuously monitored, daily wound care, medications were properly given, with noted mild swelling of the right leg and no hematoma and bleeding episodes. *****Please see attached photocopied laboratory results and OR technique. Medications in the Ward: 1. 2. 3. 4. 5. 6. 7. 8. Calcium carbonate 1 tab TID Vitamin ACES + Zinc soft gel 1 cap OD Vitamin C 1tab BID Tramadol 500mg 1 tab TID prn for pain Sertraline 50mg 1 tab at bedtime Metoclopramide 10mg IV q8 prn for n/v Omeprazole 40mg 1 tab OD pre-breakfast NaCl 1 tab TID 9. 10. 11. 12. 13. 14. Ferrous sulfate 1 tab TID Ketorolac 30mg IV q6 x 4 doses Tramadol 50mg IV q8 x 3 doses Ciprofloxacin 500mg 1 tab BID Alprazolam 500mg 1 tab at bedtime Nalbuphine 10mg IV now then q4 prn for severe pain

Prepared by: Garrote, Euler Kern V. Surgical Junior Intern

Noted by: Dr. Besarino/Dr. Fongayao/Dr. Lomboy Surgical Residents

Attending Physicians: Dr. Cabfit Attending Consultant