Case Conference Intern 張倍豪

基本資料 姓名：郭崇成 年齡： 66 years old 性別： Male 病歷號碼： 求診日期： 96/4/30

Chief Complaint Chest pain due to motorcycle traffic accident on 1 ： 40PM of 4/30

Vital sign BT ： 36.7C HR ： 88 bpm RR ： 20 cpm BP ： 161/108 mmHg

Primary survey-Airway Phonation ： intact Neck motion ： intact Neck stiffness ： nil

Primary survey-Breath Hyperventilation ： RR=20cpm Dyspnea （ + ） Shortness of breath （ + ） SpO2=89%->98%

Primary survey-Circulation 皮膚：溫暖 膚色：紅潤 脈搏強弱：正常 HR ： 88bpm BP ： 161/108mmHg Bleeding wound ： mild bleeding at right elbow

Primary survey-Disability GCS ： E4V5M6 AVPU ： alert, irritable Pupil ： 3mm/3mm Pupil light reflex ： intact/intact

Primary survey-Exposure Skin abrasion over right elbow and forearm, left elbow Contusion over right chest wall

Present Illness Motorcycle traffic accident with 安全帽 on 1 ： 40PM of 4/30 Tranferred to our ER by 119

Past History Chronic kidney disease Congestive heart failure, NYHA II Hypertension(+) DM(-) Cushing syndrome Peptic ulcer Smoking ： 1PPD Alcohol ： quit

Allergy Denied

Current medication Norvasc 1# QD Concor 0.5# QD Co-Diovan 1# QD Cortisone 3# QD Prophyllin 2# bid Mubroxol 1# bid Spiriva inhl QD Combivent inhl prn

Current medication Diphenidol 1# tid Kascoal 1# tid Strocain 1# tid Harnalidge 1# QD Quicran 1# bid

Physical Examination Conjunctiva ： not pale Sclera ： not icteric Neck ： supple, jugular venous engorement （＋） Chest ： symmetric expansion –Breath sound ： wheezing –Heart sound ： regular

Physical Examination Abdomen ： soft, no tenderness –Bowel sound ： normactive Extremities ： no pitting edema

Lab data WBC ： RBC ： 3.63 Hgb ： 11.6 PLT ： 32.1 Glu ： 136 BUN/Cr ： 29.5/1.6 Na/K ： 139/4.2 GOT/GPT ： 24/22

Image

Impression Right elbow and forearm skin abrasion Asthma attack

Plan Cataflam Rinderon Mgo Acetin

Chief Complaint Right chest pain since 4/30

Present Illness Motorcycle traffic accident on 4/30 After condition stable, discharged from our 急外 Chest pain flare up gradually Visited our 急內 on 5/2

Physical Examination Conjunctiva ： not pale Sclera ： not icteric Neck ： supple, jugular venous engorement （＋） Chest ： symmetric expansion –Breath sound ： Bilateral crackle （ right>>left ） –Heart sound ： regular, systolic murmur Gr II, S3(+)

Physical Examination Abdomen ： soft, no tenderness –Bowel sound ： normactive Extremities ： no pitting edema

Image 4/30

Image Finding 1) Fracture of the right 2nd to 9th ribs. 2) Severe subcutaneous emphysema in the right chest wall and lower neck. 3) Arteriosclerosis of tortuous aorta. 4) Suspect pulmonary contusion or infectious process in both lower lungs.

Impression Subcutaneous emphysema Fracture of the right 2nd to 9th ribs

Plan Tranferred to 急外 Arrange chest CT Consult chest surgeron

Chest CT

Chest CT Finding 1) Pneumomediastinum and subcutaneous emphysema in the bilateral chest wall and right aspect of the abdominal wall. 2) Fractures of the right 2nd-6th ribs. 3) Subsegmental atelectasis in the left lingular lobe. 4) Cardiomegaly, arteriosclerosis of the aorta, bilateral common carotid and coronary artery(LAD) 5) Calcification of mitral valves. 6) Spondylosis deformans of thoracolumbar spine. 7) Tiny right renal calculus. 8) Consider bilateral renal cysts. Bosniak classification Category I.

EKG

Image on 5/3

Esophagogram on 5/3

Esophagogram Finding No imaging evidence of the esophageal perforation in this study

Brochoscopy on 5/3 No evidence of the trachea perforation in this study

Progress Admission chest surgery on 5/3 Discharge from CS on 5/8 Follow up at OPD

Chest X-ray on 5/7

Chest X-ray on 5/10