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

• 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 ： 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

Image

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

Chest CT

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 c

ommon 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 C

ategory I.

EKG

Image on 5/3

Esophagogram 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