Transcript Title should be: Medical Grand Rounds Clinical Vignette

Literary Grand Rounds
Clinical Vignette
Barry Crittenden, MD
PGY2
March 18, 2009
Chief Complaint
The patient is a 30 year old female admitted
as a trauma victim after being struck by an
automobile.
History of Present Illness
The patient was standing on a street corner
when she was struck by an SUV. She was
pinned against a metal post by the vehicle.
At the scene, she lost consciousness, but
maintained a pulse and spontaneous
respirations.
Once she was able to be removed from the
post, bystanders applied pressure to her right
leg.
EMS arrived within 10 minutes and rushed
the patient to Bellevue Hospital.
Additional History
Past Medical History: none
Past Surgical History: myomectomy
Social History: the patient is a singersongwriter in New York City. She denies
any toxic habits.
Family History: non-contributory
Allergies: penicillin
Medications: none
Physical Exam
General: awake and alert, in severe pain
Vital signs: T 98.0 BP: 70/palp HR: 130 RR:
32 O2 sat: 100% on NRB
Abdomen: large transverse laceration of her
lower abdomen with visible portions of her
bowel and bladder.
Extremities: right leg partially amputated at
the groin with active bleeding.
Skin: pale and cool
Remainder of physical exam was normal
Laboratory Findings
CBC: WBC 3.9, Hgb 7.6, HCT 22.8, platelets
166 after initial resuscitation
Basic metabolic panel: within normal limits
Hepatic panel: within normal limits
Creatine kinase: 1528
Hospital Course
Hospital Day 1:
The patient was intubated immediately and taken
immediately to the operating room.
Massive volume resuscitation was initiated; she
received a total of 10 liters of NS, 2 liters of LR, 30
units of packed-RBCs, 15 units FFP and 5 units of
cryoglobulin.
She underwent complete amputation of her right
lower extremity.
Consults in the operating room included
orthopedics, vascular surgery, urology, and
gynecology.
Hospital Course
Hospital Day 2:
The patient underwent a diverting loop colostomy
and a right hip wound debridement
Hospital Day 4:
The patient underwent completion of her right hip
disarticulation by orthopedics with a partial wound
closure by plastic surgery
Hospital Day 7:
The patient was weaned from the ventilator
Hospital Day 8:
Psychology, physical therapy and rehab medicine
consults became involved in the patient’s care
Follow-up
The pt began a challenging recovery
Music therapy helped with voice recovery
Diverting colostomy was reversed 4
months later
Despite the extent of her lost limb, the
patient is able to walk on a prosthetic limb
She resumed a successful singing career
She does public speaking and community
service, including motivational work with
other amputees