CASE REPORTCASE REPORT

Intern Intern 呂佾呂佾欣欣

ProfileProfile

Name:Name: 劉ｘ珍劉ｘ珍 Chart No.:23099946Chart No.:23099946 Gender: femaleGender: female Age: 49 y/oAge: 49 y/o Admission date : 09/08/2006Admission date : 09/08/2006

Chief complaintChief complaint

Fall down from riding motorcycle Fall down from riding motorcycle at at 4:00am,9/9.4:00am,9/9.

Present illnessPresent illness

This 49 y/o female who denied any This 49 y/o female who denied any systemic disease suffered from falling systemic disease suffered from falling down when riding motorcycle at down when riding motorcycle at 4:00am ,9/8. 4:00am ,9/8.

The anterior site of chest, frontal area The anterior site of chest, frontal area and facial area were crushed first. She and facial area were crushed first. She also complained dizziness, headache, also complained dizziness, headache, nausea, chest pain after trauma. nausea, chest pain after trauma.

She complained neck pain and upper She complained neck pain and upper limbs mild numbness, but denied lower limbs mild numbness, but denied lower limbs numbness or weakness, initial limbs numbness or weakness, initial loss of conscious, dyspnea, palpitation. loss of conscious, dyspnea, palpitation.

The status after the traffic The status after the traffic accidentaccident

motorcycle versus car and falling motorcycle versus car and falling down from motocycledown from motocycle

dizziness, headache, nausea, dizziness, headache, nausea, chest painchest pain

Abdominal pain (-).Abdominal pain (-).

Past historyPast history

Diabetes mellitus (-), Diabetes mellitus (-), hypertension(-),hypertension(-),

Smoking(+), alcohol(+) social Smoking(+), alcohol(+) social Betel nuts(-)Betel nuts(-) Operation history:Operation history:

C/SC/S Denied allergy historyDenied allergy history

Current medicineCurrent medicine

nilnil

Physic examinationPhysic examination

Conscious: clear, E4V5M6Conscious: clear, E4V5M6 Vital signs: BP:149/89 mmHg, RR:20/min, HR: 100/min, Vital signs: BP:149/89 mmHg, RR:20/min, HR: 100/min,

BT: 36.3℃BT: 36.3℃ Pupil : L/R :2.5mm/2.5mm with symmetric light reflexPupil : L/R :2.5mm/2.5mm with symmetric light reflex Conjuctiva: no pale, sclera : no ictericConjuctiva: no pale, sclera : no icteric

nasal bleedingnasal bleedingfrontal area swelling with eccymosis, mild tenderness, frontal area swelling with eccymosis, mild tenderness,

no local heatno local heatBilateral periorbital area ecchymosis,mild tenderness, Bilateral periorbital area ecchymosis,mild tenderness, no local heat,no local heat,Bilateral zygomatic area swelling, mild tenderness, no Bilateral zygomatic area swelling, mild tenderness, no local heatlocal heat

Neck : supple, no lymphadenopathyNeck : supple, no lymphadenopathy Chest : symmetric expansion, tenderness over anterior Chest : symmetric expansion, tenderness over anterior

chestchest breathing sound, bilateral corase breathing sound, bilateral corase

Heat sound: regular heart bear, no murmurHeat sound: regular heart bear, no murmur Abdomen : soft, flat, no tenderness, no shifting Abdomen : soft, flat, no tenderness, no shifting

dullness, tympanic percussiondullness, tympanic percussionbowel sound: normoactivebowel sound: normoactive

Lower legs: no pitting edemaLower legs: no pitting edema Muscle power: DTR:Muscle power: DTR:

5 5 ++ ++

Admission : 4:08 am ,09/08/2006BP:162/91 mmHg,

HR: 84/bpm,BT:35.8℃

Conscious clear,E4V5M6, on neck collar

SpO2:98%, IVF: N/S 1 BT,Tetanus Toxoid st IM,Check Ck,CK-MB,Tro-IOn ECG, And arrange CXR, C-spine ant,Lateral view, and facial CT scanAnd consult Plasty

NPO

Oral drug

BP:132/88 mmHg, HR: 89/bpm, BT:37.8℃

Conscious clear,E4V5M6 , on neck collar

Pirocam 1 amp IM

Check CBC, and 12Lead EKG

BP:122/80 mmHg, HR: 80/bpm, BT:36.2℃

Conscious clear,E4V5M6 , on neck collar Subject: chest tightness arrange CXR

4:08 am 09/08

5:05 am 09/08

6:45 am 09/08

10:00 am 09/08

03:00 pm 09/08

05:00 pm 09/08

06:00 pm 09/08

The Status on ArrivalThe Status on Arrival04:08 am 09/0804:08 am 09/08

Consciousness : clear, E4V5M6Consciousness : clear, E4V5M6 Respiratory Rate : 10-24 cpmRespiratory Rate : 10-24 cpm Pulse Rate : 84 bpmPulse Rate : 84 bpm Blood Pressure : 162/91 mmHgBlood Pressure : 162/91 mmHg Body Temperature : 35.8Body Temperature : 35.8ooCC

Initial assessmentInitial assessment

Airway: Airway: patent airway. on neck collarpatent airway. on neck collar

Breathing: Breathing: spontaneous breathing.spontaneous breathing.

Circulation: radial pulse (+), Circulation: radial pulse (+), Pulse Rate : 84 bpmPulse Rate : 84 bpm Blood Pressure : 162/91 mmHgBlood Pressure : 162/91 mmHg

Disability: Disability: E4V5M6. L/R :2.5mm/2.5mm with E4V5M6. L/R :2.5mm/2.5mm with symmetric light reflexzsymmetric light reflexz

ExposureExposure nasal bleedingnasal bleeding frontal area swelling with eccymosis, mild frontal area swelling with eccymosis, mild

tenderness, no local heattenderness, no local heat Bilateral periorbital area ecchymosis,mild Bilateral periorbital area ecchymosis,mild

tenderness, no local heat,tenderness, no local heat, Bilateral zygomatic area swelling, mild Bilateral zygomatic area swelling, mild

tenderness, no local heattenderness, no local heat

ManagementManagement

On neck collarOn neck collar Keep NPO and IVF :N/S 1 BT stKeep NPO and IVF :N/S 1 BT st 12Lead EKG12Lead EKG Ice packing and pain controlIce packing and pain control Check CBC, BUN/CREA, Na/K, GOT/GPT, Check CBC, BUN/CREA, Na/K, GOT/GPT,

Ethanol, CK,CK-MB, Troponin-IEthanol, CK,CK-MB, Troponin-I Arrange CXR AP view, spine AP and Arrange CXR AP view, spine AP and

Lateral viewLateral view Arrange Facial CT scan Arrange Facial CT scan Consult Plasty for nasal bone fractureConsult Plasty for nasal bone fracture

Lab data Lab data at 09/08at 09/08

WBCWBC 9.539.53 x10x1033/ml/ml

RBCRBC 4.344.34 x10x1066/ml/ml

HGBHGB 14.114.1 g/dlg/dl

HCTHCT 41.741.7 %%

MCVMCV 96.196.1 flfl

MCHMCH 32.532.5 PgPg

MCHCMCHC 33.833.8 g/dlg/dl

PLTPLT 178178 x10x1033/ml/ml

RDW-CVRDW-CV 12.412.4 %%

RDW-SDRDW-SD 43.643.6 FlFl

項目項目 結果結果 單位單位SGOTSGOT 8989 IU/LIU/L

SGPTSGPT 4242 IU/LIU/L

EthanolEthanol 170.5170.5 Mg/dlMg/dl

Urea NUrea N 9.99.9 ng/dlng/dl

CreatiniCreatininene

0.720.72 ng/dlng/dl

NaNa 145145 Mmol/dlMmol/dl

KK 3.673.67 Mmol/dlMmol/dl

CPKCPK 131131 U/LU/L

Tropo-lTropo-l 0.0030.003 Ng/mlNg/ml

CK-CK-MB(S)MB(S)

42.842.8 U/LU/L

Lab data Lab data at 09/08at 09/08

項目項目 結果結果 單位單位

SGOTSGOT 8989 IU/LIU/L

SGPTSGPT 4242 IU/LIU/L

EthanolEthanol 170.5170.5 Mg/dlMg/dl

Urea NUrea N 9.99.9 ng/dlng/dl

CreatinineCreatinine 0.720.72 ng/dlng/dl

NaNa 145145 Mmol/dlMmol/dl

KK 3.673.67 Mmol/dlMmol/dl

項目項目 結果結果 單位單位

CPKCPK 131131 U/LU/L

Tropo-lTropo-l 0.0030.003 Ng/mlNg/ml

CK-CK-MB(S)MB(S)

42.842.8 U/LU/L

ImpressionImpression

1.Head injury with brain 1.Head injury with brain concussionconcussion

2.nasal bone fracture2.nasal bone fracture 3.chest contusion3.chest contusion

10:30 pm 09/08

2:25 am 09/09

04:10 am 09/09

06:00 am 09/09

09:30 am 09/09

10:00 am 09/09

12:00 am 09/09

BP:139/96 mmHg, HR: 73/bpm, BT:36.8℃Conscious clear,E4V5M6

S: chest pain Demerol 40mg IMIce packing

S: chest pain 12Lead EKG

BP:128/74 mmHg, HR: 85/bpm

Conscious clear,E4V5M6

BP:121/68 mmHg, HR: 72/bpm, BT:35℃

Conscious clear,E4V5M6

Check CXR

Plasty suggest that no instability neiter maligment of nasal bone. No surgical intervention infdicationfor her. OPD F/U is suggested

Admission to NS

Thanks for your Thanks for your attention~~!!attention~~!!