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Case Conference

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： 09230830 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.

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Case Conference

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  1. Case Conference Intern 張倍豪

  2. 基本資料 • 姓名：郭崇成 • 年齡：66 years old • 性別：Male • 病歷號碼：09230830 • 求診日期：96/4/30

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

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

  5. Primary survey-Airway • Phonation：intact • Neck motion：intact • Neck stiffness：nil

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

  7. 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

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

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

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

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

  12. Allergy • Denied

  13. 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

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

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

  16. Physical Examination • Abdomen：soft, no tenderness • Bowel sound：normactive • Extremities：no pitting edema

  17. Lab data • WBC：13.26 • 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

  18. Image

  19. Image

  20. Impression • Right elbow and forearm skin abrasion • Asthma attack

  21. Plan • Cataflam • Rinderon • Mgo • Acetin

  22. 故事結束... 等等... 還有...

  23. Chief Complaint • Right chest pain since 4/30

  24. 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

  25. 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(+)

  26. Physical Examination • Abdomen：soft, no tenderness • Bowel sound：normactive • Extremities：no pitting edema

  27. Image 4/30

  28. 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.

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

  30. Plan • Tranferred to 急外 • Arrange chest CT • Consult chest surgeron

  31. Chest CT

  32. Chest CT

  33. Chest CT

  34. Chest CT

  35. 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.

  36. EKG

  37. Image on 5/3

  38. Esophagogram on 5/3

  39. Esophagogram on 5/3

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

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

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

  43. Chest X-ray on 5/7

  44. Chest X-ray on 5/10

  45. 謝 謝 您 的 收 聽

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