Revista de Ciencias de la Salud

Physical exam

Glasgow 15, blood pressure: 120/70 mmHg, heart Rate: 95 per minute, respiratory rate: 18 per
minute, oxygen saturation: 98 %, multiple lacerations are seen on the face, arms and legs and
abolition of the vesicular murmur in the left pulmonary base.

An exposed fracture of the left tibia is observed at the middle third level, with soft tissue
exposure and active bleeding. Enough reason for consultation with traumatology and we
decide to perform surgical cleaning, reduction and osteosynthesis with the placement of
external tutors.

Complementary test
Hematological biometrics: Red blood cells 3.630.000, Hemoglobin 11.9 g/dL, Hematocrit 35.8
%, Platelets 170.000, Leukocytes 10.230, PMN 73.6 %, Lymphocytes 18.4 %, Monocytes 7.3
%, Basophils 0.2 %, EKG: Sinus rhythm.

Image studies
Radiographies
AP and left leg side: Multifragmentary fracture the left tibial shaft.
Thorax standard: Basal mass is observed in the left lung, deviation of the cardiac silhouette
and trachea to the right (See Figure 1).

Figure 1. Standard Chest XR.

Qhalikay. Revista de Ciencias de la Salud 3 (2017) 104-113

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