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GENERAL DATA
RE 44 y/o male married Roman Catholic Valenzuela City Admitted for the 1st time October 1, 2011
FAMILY HISTORY
(+) Hypertension (+) Diabetes mellitus (-) Asthma (-) Allergy
PHYSICAL EXAMINATION
General Survey: Patient was confused, stretcher bound, cardio-respiratory distress Vital Signs: BP : palpatory 60mmhg - 80/70 90/50mmhg PR : 130 pm RR : 22cpm T : 36.2 C
PHYSICAL EXAMINATION
Skin: Cold, moist, pale skin HEENT: - pale palpebral conjunctiva - anicteric sclerae - no nasoaural discharge - no tonsillopharyngeal congestion - no cervical lymphadenopathy Chest and Lungs: - tachypnic, symmetrical chest expansion - no retractions - vesicular breath sounds Heart: - adynamic precordium - tachycardic but with regular rhythm - no murmur
PHYSICAL EXAMINATION
Abdomen: Abdomen:
Sligthly Globular Air gun shot wound at RLQ approx 3cm above the midinguinal point hypoactive bowel sounds rigid, guarding Direct and rebound tenderness at lower abdomen with involuntary guarding
PHYSICAL EXAMINATION
Perineum: Perineum:
Normal external genitalia
Rectal:
Good sphincteric tone, (-) pararectal tenderness nor masses, ((-) blood on tactating fingers.
Extremities: Extremities
Grossly normal extremities ,no edema, no cyanosis, rapid and weak pulses (very weak pulses at right femoral and right dorsalis pedis pulses)
PERTINENT FINDINGS
44 y/o male Clammy Gunshot Wound RLQ Point of entry: RLQ Point of exit: none Rigid abdomen RLQ
ADMITTING DIAGNOSIS
Severe Hemorrhagic shock 2r to air gun shot wound RLQ Acute abdomen due to perforated hollow viscous
BASIS:
1. Severe hemorrhagic shock:
Air gun shot wound (right iliac region) Palpatory BP of 60 mmhg; pulse rate of 112/min Pale palpebral conjunctiva Tachypnic Adynamic precordium Cold clummy skin on extremities
Pathophysiology
Hypovolemic Shock (Hemorrhagic Shock):
most common Most of the blood is lost from systemic and small veins (50%) ----> decrease cardiac return ----> low cardiac output ----> decrease blood pressure
Hyperventilation:
with spontaneous deep breathing there is a decreased intra-thoracic ----> increase ventricular end diastolic volume ----> increase cardiac output.
Collapse:
Displaced blood from extremity to the heart and the brain
BASIS
2. ACUTE ABDOMEN probably due to perforated hollow viscous:
History of air gun shot wound at right iliac region Development of signs of peritonitis:
Direct and rebound tenderness Board like rigidity of the lower abdomen Hypotension
Admitted the pt. - - - NPO IVF: PNSS 1L Q6hr RA PLR 1L Q8hr in LA Diagnostics: 1. CBC with ABO typing 2. Abdomen X-ray supine and upright X3. FAST (Focus Abdominal Sonography in Trauma) (?) (?) (?) 4. CBG-203 CBG5. Serum electrolyte 6. CXR PA 7. 12 L ECG Therapeutics 1. Tetavax 2.Tetagam 3.Cefuroxime 1.5 Gm STAT ANST(-) now and then 750mg Q8 hours ANST(4. Ketorolac 30 mg (Tramadol) Q 8 ANST(-) ANST(-
PLAN
PLAN
Foley catheterization and connect to Urobag (for measuring urine output) No hematuria NGT Insertion done O2 inhalation 2-3 L/ min Prepare 4 units of FWB properly typed and crossmatched Transfuse 1unit of FWB once available For Exploratory Lap (done within 2 hrs)
CBC
WBC Neutrophil Lymphocyte Monocyte Eosinophil Basophil
Normal values
5.05.0-10.0 x 10 g/L 0.400.40-0.60 0.200.20-0.40 0.020.02-0.08 0.010.01-0.03 00-0.02
10/01/2011
10:03AM
HGb
HCt RBC MCV MCH MCHC RDW Platelet MPV PDW
M: 140-175g/L 140M: 0.42-0.48 0.42M: 5.5-6.5 x 10 12/L 5.58888-96 2727-33pg 300300-360g/L 12.712.7-22.7% 150150-450 x 10g/L 4.54.5-7.5 fL
7.6
0.43 4.42 96.8 33 341 11.0 168 5.7 17.4
Serum electrolytes
RESULT
(10//01/2011)
N.V.
Na K Ca Cl
IMPRESSION:
HISTOPATHOLOGY
Submitted Specimen : Ileum
POSTPOST-OPERATIVE
Placed in ICU VS Monitoring q15min O2 inhalation 3-4LPM 3 Connect ET to T-piece apparatus T Diet: NPO temporarily IVF: 1. D5LR 1L x 8hrs 2. D5NM 1L x 8hrs 3. D5W 1L x 8hrs
POSTPOST-OPERATIVE
Therapeutics: Therapeutics: 1. Cefuroxime 750mg TIV q8h 2. Metronidazole 500mg IV q 8hr 3. Parecoxib 40mg (Dynastat) IV q
12 4. Ketorolac 30mg TIV q8h PRN for severe pain . Transfuse another unit (500ml) FWB, Type . Repeat hgb,hct, determination 6 hours post BT . Specimen to lab for histopath exam
THE END
st 1
(-) Flatus (-) Bowel mov t (-) fever (-) N/V JP drain 220mL Adequate UO
Diet NPO IVF to follow: D5LRS 1L x 8hours D5 NM1L x 8hours D5LRS 1L x 8hours Request for Serum electrolyte tom AM. May transfer to ROC this afternoon Deep breathing exercise Therapeutics: Cont. Present meds May give Paracetamol (Aeknil) 300mg IV ANST ( ) Diphenhydramine IV
Refer for difficulty of breathing Suction secretions
CBC
WBC Neutrophil Monocyte Eosinophil Basophil HGb HCt RBC MCV MCH MCHC RDW Platelet MPV PDW 5.05.0-10.0 x 10 g/L 0.400.40-0.60 0.020.02-0.08 0.010.01-0.03 00-0.02 M: 140-175g/L 140M: 0.42-0.48 0.42M: 5.5-6.5 x 10 12/L 5.58888-96 2727-33pg 300300-360g/L 12.712.7-22.7% 150150-450 x 10g/L 4.54.5-7.5 fL
10/02/2011
07:58AM
3rd
Vital Signs: * transfuse 1 unit of PRBC BP : 130/80 mmHg properly typed and crossmatched PR : 20 bpm Post BT Hgb after 4 hours RR : 80 cpm Diet: maintain on NPO T : 36.7 C IVF: D5 LR 1L D5NM 1L (-) Flatus D5NSS 1L (-) Bowel mov t * cont. meds (-) fever Diphenhydramine IV Adequate UO Paracetamol (Aeknil ) IV for fever JP drain- 205mL
CBC
WBC Neutrophil Monocyte Eosinophil Basophil HGb HCt RBC MCV MCH MCHC RDW Platelet MPV PDW 5.05.0-10.0 x 10 g/L 0.400.40-0.60 0.020.02-0.08 0.010.01-0.03 00-0.02 M: 140-175g/L 140M: 0.42-0.48 0.42M: 5.5-6.5 x 10 12/L 5.58888-96 2727-33pg 300300-360g/L 12.712.7-22.7% 150150-450 x 10g/L 4.54.5-7.5 fL
10/03/2011
7:08 AM
11.4 0.75 0.14 0.08 0.01 0.01 94 0.27 3.21 85 29.3 346 13.8 0.68 5.11
Serum electrolytes
RESULT
(10/03/2011)
N.V.
Na K Ca Cl
4th
Vital Signs: BP : 130/80 mmHg PR : 20 bpm RR : 82 cpm T : 36. 9C (+) Flatus (+) Bowel mov t (-) fever (-) N/V Adequate UO
CBC
WBC Neutrophil Monocyte Eosinophil Basophil HGb HCt RBC MCV MCH MCHC RDW Platelet MPV PDW 5.05.0-10.0 x 10 g/L 0.400.40-0.60 0.020.02-0.08 0.010.01-0.03 00-0.02 M: 140-175g/L 140M: 0.42-0.48 0.42M: 5.5-6.5 x 10 12/L 5.58888-96 2727-33pg 300300-360g/L 12.712.7-22.7% 150150-450 x 10g/L 4.54.5-7.5 fL
10/04/2011
7:38AM
6.3 0.72 0.17 0.07 0.03 0.01` 102 0.30 3.48 85 29.2 343 13.8 86 5.11
CBC
WBC g/L Neutrophil Monocyte Eosinophil Basophil HGb 175g/L HCt RBC 12/L MCV MCH MCHC 5.05.0-10.0 x 10 0.400.40-0.60 0.020.02-0.08 0.010.01-0.03 00-0.02 M: 140140M: 0.42-0.48 0.42M: 5.5-6.5 x 10 5.58888-96 2727-33pg 300300-360g/L
10/01/2011
10:03AM
10/02/2011
07:58AM
10/03/2011
7:08 AM
10/04/2011
7:38AM
9.9 0.38 0.57 0.05 0.02 0.01 146 0.43 4.42 96.8 33 341
N.V.
Na K Ca Cl
th 6
Vital Signs: BP mmHg PR RR T : 120/80
HD (5th POD)
Diet: DAT IVF to consume
(+) Flatus (-) Bowel Movt (+) soft abdomen (-) fever
th 7
Vital Signs: BP mmHg PR RR T : 120/80
HD
th (4
POD)
For discharge Home Medications: 1. Cefuroxime 500mg/tab q8h x 5D : 88 bpm 2. Metronidazole 500mg/tab q8h x 3D : 19 cpm : 36.5 C FollowFollow-up after 1 week at Surgery OPD
(+) Flatus (+) Bowel Movt (+) soft abdomen (-) fever