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Eman ibrahim wassef

Medical report
Name: Eman Ibrahim Wassef date of admission: 1/1/2011 Age : 48 years discharge: still in ICU treating doctors: prof. Hatem Amin Attala Concultant of anaethesiology prof. Magdy akel prof. Amin malty Consultant of ophthalmology prof. Hossam Elkafrawy Consultant of plastic surgery dr. Ehab naeem Consultant of ENT The patient was admitted to our hospital after the explosion accident on 1-1-2011.Alexandria, Egypt The patient was admitted to the ICU she was shocked and look pale so fluid resuscitation started and blood transfusion started On admission patient was suffering from: DLOC, RT shoulder open fracture, RT breast contused wound, LT eye trauma, multiple areas of burn and abrasions in the skin of face and legs, perforating wound in the abdomen, inhalational burn injury .
After admission the following interventions were done to her:
ETT was inserted and she was attached to MV for fear of edema of upper airways then
she was weaned when conscious level improved
Orthopedic
Debridement and removal of necrotic tissue for open fracture of the RT shoulder
General surgery
Repair of the contused wound of the RT breast
Exploration of the abdomen was done and a tear in transverse colon was found and
repaired
Shrapnel was removed from the colon
Another one was found in the liver the CT scan showed that she it was in segment 5 of liver near the IVC, it couldn’t be removed. Ophthalmology
A CT of LT orbit and US of the LT eye were done showed the following
• Suspected rupture of globe • Traumatic sublaxation of lens • Subconjunctival he • Fracture of the floor of orbit with herniation of inferior rectus muscle • Corneal edema and abrasions • Contused wound in the LT eye lid which was sutured. • Intraocular foreign body Maxilofascial surgeon reviewed the patient and said she needs surgery 1 gm of solumedrol was given for 3 days and then oral prednisolone was given and many eye drops Plastic surgey
Examined the face and said the small foreign bodies in face can be removed during
operation
Last investigations
Hb : 11.9 WBCS: 6400 platelet :225.000
SGOT: 21 SGPT : 44 urea:27
Creatinine: 0.98 s.albumin :3.3
P.T: 80% INR:1.13
Last medications
Rocephin 2gm iv daily
Levoxin 0.5 gm iv daily
Flagyl 0.5 gm iv q 8hr
Acc e times daily
Solupred 20 mg 2 tab mourning 1 evening
Controloc 40 mg iv daily
Corneo eye gel 3 times daily
Cyclo plegico E.D 3 times daily
Mydracil E.D 3 times daily
Vigamax drops q 8 hr
Predforte E.D q 1hr
Vita c

Vita zinc
Last condition
The patient is fully conscious, well oriented , haemodynamically stable,
On partial parental nutrition
She is still in ICU
Arranging for repairing the floor of LT orbit
She may need :.
1- Repairing of the floor of LT. orbit. 2- Myringoplasty bilaterally.
Medical Director Critical care medicine
Prof. Dr. Hatem Amin Attala Dr. HanySafwat Thabet


Source: http://coptic-news.net/files/Eman%20Ibrahim%20Wassef.pdf

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