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Clinical-Abstract-CIC Case Folder

A 29-year-old male was admitted to the emergency room after being stabbed in the left anterior chest during a brawl. He was unconscious with weak vital signs. A chest tube was placed and drained 800-1000cc of blood from his chest. He underwent emergency surgery including repair of his chest wall, heart, and abdomen. Despite receiving blood transfusions and medications, his heart rate and blood pressure dropped and he went into cardiac arrest. He received 20 doses of epinephrine but expired at 8:30pm.

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Dedith Comia
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99 views3 pages

Clinical-Abstract-CIC Case Folder

A 29-year-old male was admitted to the emergency room after being stabbed in the left anterior chest during a brawl. He was unconscious with weak vital signs. A chest tube was placed and drained 800-1000cc of blood from his chest. He underwent emergency surgery including repair of his chest wall, heart, and abdomen. Despite receiving blood transfusions and medications, his heart rate and blood pressure dropped and he went into cardiac arrest. He received 20 doses of epinephrine but expired at 8:30pm.

Uploaded by

Dedith Comia
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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DATE RECEIVED:

JULY 19, 2023

CLINICAL ABSTRACT
NAME OF HOSPITAL/AMBULATORY CLINIC: CASE NO.
156437
ADMISSION:
SAN PABLO CITY MEMORIAL HOSPITAL DATE: JULY 19, 2023
TIME 7:20 PM

DATE AND TIME OF DEATH:

JULY 19, 2023 / 8:30 PM

ACCREDIATION NO.: PH-123312


ADDRESS OF HOSPITAL/AMBULATORY CLINIC BARANGAY
National Highway San Roque
MUNICIPALITY CITY PROVINCE ZIP CODE
San Pablo City Laguna 4000

PATIENT’S CLINICAL RECORD

1. PATIENT’S NAME 2. AGE 3. SEX


LAST NAME
29 MALE
CALLA

FIRST NAME 4.

CHRISTOF
RENZO F. BANZUELA, M.D.
MIDDLENAME _______________________________________________
PRINTED NAME AND SIGNATURE OF ADMITTING OFFICER
PRADONO

5. ADMITTING DIAGNOSIS

PHYSICAL INJURY SEC TO STAB WOUND; LEFT ANTERIOR CHEST

6. CHIEF COMPLAINT

STAB WOUND

7. BRIEF HISTORY OF PRESENT ILLNESS/OB HISTORY

20 mins prior to consult, while the patient is engaged in a brawl with known assailant, the patient was suddenly
stabbed on the left anterior chest.

8. PHYSICAL EXAMINATION (PERTINENT FINDINGS PER SYSTEM)

General Survey: Patient is unconscious, weak, in cardiorespiratory distress


Vital Signs BP GP 70/40mmHg HR 90/min RR 29/min TEMP: 36.2 C
HEIGHT 163 cm WEIGHT 70 kg

HEENT: Anicteric sclerae, slightly palpebral conjunctivae, no nasoaural discharge, no tonsillopharyngeal


congestion and no cervical lymphadenopathies

CHEST/LUNGS: decrease breath sounds on the left, (+) stab wound approximately 5cm on the left
anterior chest

Heart: Pericardial tamponade and myocardial injury

ABDOMEN: soft, flabby, nondistended abdomen

SKIN/EXTERMITIES: pale, no cyanosis, no jaundice, warm to touch, good skin turgor

NEUROLOGIC: unconscious, difficulty in movements but with generalized weakness


SAN PABLO CITY MEMORIAL HOSPITAL
National Highway, Brgy San Roque, San Pablo City, Laguna
Tel. No.: (049) 562-4432 / 562-6111

CLINICAL ABSTRACT

Pertinent Laboratory Examination:


(Please see attached results)

Course in the Ward:

At ER, patient was stabilized with iv hydration and medication, chest tube placed left and drained
approximately 800 to 1000cc of hemothorax. Diagnostics were CBC with plt, RT-PCR, PT/PTT, blood
typing, chest x-ray upright. For STAT open thoracotomy left, blood transfusion started.

7:45 PM, Status post anterolateral thoracotomy, evacuation of hemothorax, phrenicorrhaphhy,


hepathoraphy, exploratory laparotomy cholecystectomy, evacuation of hemoperitoneum, sigmoid
colorrhaphy, JP drain insertion, CVP insertion. Estimated blood loss of 2.5L – 3L. Patient was hooked to
cardiac monitoring.

8:00 PM, s/p 3 units of packed RBC given. Medications given were norepinephrine 4 ampule in
100 cc PNSS given. Dobutamine 1amp in 100cc PNSS given. Patient was hooked to mechanical ventilator.

8:30 PM, no heart rate, no blood pressure, fixed dilated pupils, asystole. Patientexpired with 20
doses of epinephrine. Relatives updated about the patient’s condition. Post mortem care done.

Disposition: Died

Resident: Clerk-In-Charge: ___HR Advincula___

Date Accomplished: July 19, 2023 Time: 10:00 PM

SAN PABLO CITY MEMORIAL HOSPITAL


National Highway, Brgy San Roque, San Pablo City, Laguna
Tel. No.: (049) 562-4432 / 562-6111

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