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重症医学科
Physical Examination
• Vital sign:T 37.0℃，P 85bpm，R 25bpm，BP 152/102mmHg.
• No tracheal deviation.
• Tenderness of the chest(+).The respiratory sounds on both sides of the lungs were rough and the respiratory sounds on the right of the lung were low.The thoracic drainage tube is closed. After opening, we could see the red blood flowing into the catheter and the quantity was about 400ml.Tenderness and percussion pain of the 1st-3rd lumbar spine (+).
• Cardiac,abdomen,head,pelvis,limb,artery,nerve: Negative finding.
• FAST: the perihepatic space, perisplenic space, pericardium and the pelvis:
重症医பைடு நூலகம்科
Negative finding.
One day ago, the patient was hit by a tree trunk falling from about 4 meters high on his right back. He felt severe pain in his right chest and back, limited respiratory movement on his right side, no dizziness, no headache, no nausea and vomiting, no chest tightness and shortness of breath, no bloody urine and bloody stool, no fecal incontinence and urinary incontinence.
General Information
Name: Age:60-year-old Gender: Male Occupation: Worker Chart NO.: ICU-09
重症医学科
Marital Status:Married
Date of Admission:2018-08-29
Date of Discharge:2018-09-04
He was referred to our hospital for emergency treatment. Chest CT showed contusion on the right lower lobe lung tissue. Right pneumothorax. The 9th-12th posterior ribs were broken on the right side. The 1st-3rd lumbar transverse process were broken on the right side. At the same day, we countercheck the chest CT, which showed that the pleural effusion on the right side increased. So the closed chest drainage was performed in emergency department, and a small amount of bloody fluid was drained. Considering multiple injuries, we took the patient into our department.
Case Report
Sep.5th
Contents
• Part 1 • Part 2 • Part 3 • Part 4 • Part 5 • Part 6 • part 7 • Part 8 • Part 9 重 症• P医a学rt科10
General information Chief complaint History of present illness Physical examination Past history Imaging examination Laboratory Data Diagnosis Diagnostic basis Treatment
2018-08-28 15:51
重症医学科
Pleural effusion
Imaging Examination
RR pneumothorax
Pulmonary contusion
重症医学科
2018-08-28
Imaging Examination
R
R
Rib fracture
重症医学科
Past History •The patient is healthy before. •No history of infective diseases. •No allergy of food or drugs.
重症医学科
Imaging Examination
R
R
2018-08-28 11:11
Complainer of History:Patient's kinsfolk and himself Reliability:Reliable
Chief Complaint Trauma caused his right chest and back pain for 1 day.
重症医学科
History of Present Illness
Physical Examination
• Vital sign:T 37.0℃，P 85bpm，R 25bpm，BP 152/102mmHg.
• No tracheal deviation.
• Tenderness of the chest(+).The respiratory sounds on both sides of the lungs were rough and the respiratory sounds on the right of the lung were low.The thoracic drainage tube is closed. After opening, we could see the red blood flowing into the catheter and the quantity was about 400ml.Tenderness and percussion pain of the 1st-3rd lumbar spine (+).
• Cardiac,abdomen,head,pelvis,limb,artery,nerve: Negative finding.
• FAST: the perihepatic space, perisplenic space, pericardium and the pelvis:
重症医பைடு நூலகம்科
Negative finding.
One day ago, the patient was hit by a tree trunk falling from about 4 meters high on his right back. He felt severe pain in his right chest and back, limited respiratory movement on his right side, no dizziness, no headache, no nausea and vomiting, no chest tightness and shortness of breath, no bloody urine and bloody stool, no fecal incontinence and urinary incontinence.
General Information
Name: Age:60-year-old Gender: Male Occupation: Worker Chart NO.: ICU-09
重症医学科
Marital Status:Married
Date of Admission:2018-08-29
Date of Discharge:2018-09-04
He was referred to our hospital for emergency treatment. Chest CT showed contusion on the right lower lobe lung tissue. Right pneumothorax. The 9th-12th posterior ribs were broken on the right side. The 1st-3rd lumbar transverse process were broken on the right side. At the same day, we countercheck the chest CT, which showed that the pleural effusion on the right side increased. So the closed chest drainage was performed in emergency department, and a small amount of bloody fluid was drained. Considering multiple injuries, we took the patient into our department.
Case Report
Sep.5th
Contents
• Part 1 • Part 2 • Part 3 • Part 4 • Part 5 • Part 6 • part 7 • Part 8 • Part 9 重 症• P医a学rt科10
General information Chief complaint History of present illness Physical examination Past history Imaging examination Laboratory Data Diagnosis Diagnostic basis Treatment
2018-08-28 15:51
重症医学科
Pleural effusion
Imaging Examination
RR pneumothorax
Pulmonary contusion
重症医学科
2018-08-28
Imaging Examination
R
R
Rib fracture
重症医学科
Past History •The patient is healthy before. •No history of infective diseases. •No allergy of food or drugs.
重症医学科
Imaging Examination
R
R
2018-08-28 11:11
Complainer of History:Patient's kinsfolk and himself Reliability:Reliable
Chief Complaint Trauma caused his right chest and back pain for 1 day.
重症医学科
History of Present Illness