Initial ED Vitals: BP 128/64, P 71, R 21, SPO2 99%, T 36.78 C
Initial Labs/radiology in ED:
CBC: WBC 7.47, RBC 4.5, Hgb 13, Hct 39.7, MCV 88.3, MCH 28.9, MCHC 32.7, RDW 13.6, Platelet 189
BMP: Glucose 108, BUN 20, Cr 1.5, Na 140, K+ 4, Cl 103, CO2 28.3, Ca 9.9
Hepatic panel: Albumin 5.1, total protein 6.8, alk phos 190, AST 28, ALT 13, total bilirubin 0.1, direct bilirubin 0.3, lipase 24
***Pt was transferred to Level 1 trauma center***
CBC: WBC 7.3, RBC 3.47, Hgb 10.1, Hct 30.3, MCV 87, MCH 29.2, MCHC 33.4 RDW 13.3, platelet 148
PT- 12.9, INR- 1.19, PTT 26.0,
Xray Left Shoulder 3 view: normal
CT Head/Brain W/O contrast- impression: No evidence of acute intracranial process. No evidence of intracranial hemorrhage.
CT Spine Cervical W/O contrast- impression: Straightening of normal cervical lordosis. No evidence of acute fracture or traumatic malalignment.
CT Abdomen and Pelvis W Contrast- impression: Shattered lower pole spleen with evidence of subcapsular hematoma. Moderate free fluid in the abdomen, bilateral paracolic gutters and a large amount of fluid seen within the pelvis. There is high density fluid seen in the lower pole of the spleen in the area of multiple lacerations or shattered spleen indicative of active bleeding which would indicate vascular involvement.
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