1. Valencia Health Service
‘La Fe’ University Hospital, Valencia Avda. Campanar 21
Resuscitation Unit Tel: (96)3862700
Main Campus 46009 Valencia
Translated by Alana S D Rhoden, Dip Trans IoLET
Patient details
Surnames: XXXX XXXX Name: XXXX XXXX Case Nº: XXXXXX
Age: 31 Bed: R-24 Date of admission: 15/XXXX Discharge date: 19/XXXX
Attending Physician: Dr Cuchillo
Reason for admittance:
31 year old patient admitted to the unit from the Hospital Clinic after being hit by a motor vehicle. The
patient was picked up by the SAMU with a GCS of 13. An abdominal ultrasound was performed at the
Hospital Clinic showing some perihepatic and perisplenic fluid but no other evident injury to internal
organs. The patient also presented with a fracture of the left clavicle, instability in both knees, a
fracture of the right wrist and cuts to the hand. CAT showed negative craneoencephalic trauma and
no focal neurologic deficits. As no beds were available at the Hospital Clinic, the patient was moved to
this hospital to monitor progress.
Personal history and additional examinations
Not relevant.
Progress and discharge status
The patient was admitted to the resuscitation unit in continuous spontaneous ventilation with good
mechanical ventilation. Haemodynamically stable, with a tender abdomen painful when pressed;
however the surgeon on call recommended observation only following assessment. A&P: clear and
regular with normal sounds. Sinus Tach. Neurologically conscious, aware of surroundings and no
focal neurologic deficits; PERRLA. Peripheral pulses present and equal. Hct. 30%. Progress has
been good and the patient has maintained haemodynamic stability since being admitted, despite
initial slight drops in Hct. levels which required a transfusion of 2 units of prbc. Since then the patient’s
Hct. levels have remained similar to the initial 30%. The patient also presented with a well-tolerated
mild fever of 37.5º. Abundant and clear diuresis.
Abdomen NAD which permitted oral tolerance with no negative effects.
Assessment by the Trauma Unit does not seem to suggest the need for urgent surgical intervention.
Given the clinical stability of the patient, urgent action is not necessary at this time and it is
recommended that she be transferred to a hospital ward for further monitoring and treatment.
Diagnosis:
Multiple trauma
Fractured left clavicle
Posterior instability in both knees
Fractured right cubital
Lacerated contused wound, right hand
Treatment:
Spontaneous ventilation with Ventimask at 40% continuous nebulization
30º head elevation
Slight postural adjustments
Regular monitoring of vitals and diuresis
Cervical collar
Monitor pupils, consciousness and responsiveness
Begin bland oral diet
Periplasmal 1.000 cc./24 hrs
Augmentine 1 gr./6 hrs i.v.
Nolotil 1 vial/6 hrs i.v. by perfusion
Omeprazol 1 vial /24 hrs i.v.
BH balanced with: SF 500 cc + 10 mEq de CI K
Signed by the Attending Physician: Dr Cuchillo