case conference intern 溫千瑩. patient profile 王 x 銘, 39y/o, male occupation : 自由業...

Case Conference

Intern 溫千瑩

Patient profile

王 X 銘 , 39y/o, male Occupation : 自由業 Chart No.: 1266XXXX Admission to ER date: 96-3-25, 04:44 Way of admission: alone Discharge from ER date: 96-3-25, 09:50

Injury mechanism

He suffered from head injury while he took a taxi on 3/23 4:00 am. Syncope on 3/25 3:00 am was noted.

現場生命現象 : clear (E4V5M6) CC: Dizziness

Initial evaluation (KMUH)

A (airway) / B (breathing): Collar fixation: (-) Airway: speech: illustrate smoothly

respiration: smooth airway obstruction sign: No foreign body in the mouth: No trachea: midline breathing sound: ?

C (circulation): Rate: brachial a. , carotid a.,

femoral a. , dorsalis pedis a. Cuff BP : 110/79 mmHg Skin condition:

appearance: red temp: warm humidity: normal

D (disable): GCS: E4V5M6 Pupil response: ?

E ( exposure ) : Right face contusion Right forehead laceration wound (3 cm) Right eye blindness

Current medication

Denied

Past history DM: (-), HTN: (-), Hepatitis: (-) Other systemic diseases: denied Smoking(+), Alcohol(+), Betel nut: unknown Op. hx.: Left frontal fracture, EDH post OP in 民 83 Right orbital floor fracture post OP in 民 83 Right eye prosthesis Allergy hx.: (-) Travel hx: (-), Contact hx.: (-)

Family history

Not contributory

Secondary evaluation (KMUH ER) Skull X-ray Brain CT Lab data 12 leads EKG Chest X-ray

CBC

Electrolytes & Sugar

Impression

1. Head injury with brain contusion2. Face laceration wound (3 cm)3. Old left frontal fracture post OP4. Old right orbital floor fracture post OP5. Right eye prosthesis

Plan Wound CD Panadol 1# Tid Diphenidol 1# Tid Keep observation 頭部外傷衛教單

Thanks for your attention