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CASE REPORT

CASE REPORT. Intern 呂佾欣. Profile. Name: 劉ｘ珍 Chart No.:23099946 Gender: female Age: 49 y/o Admission date : 09/08/2006. Chief complaint . Fall down from riding motorcycle at 4:00am,9/9. Present illness.

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CASE REPORT

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  1. CASE REPORT Intern 呂佾欣

  2. Profile • Name:劉ｘ珍 • Chart No.:23099946 • Gender: female • Age: 49 y/o • Admission date : 09/08/2006

  3. Chief complaint • Fall down from riding motorcycle at 4:00am,9/9.

  4. Present illness • This 49 y/o female who denied any systemic disease suffered from falling down when riding motorcycle at 4:00am ,9/8. • The anterior site of chest, frontal area and facial area were crushed first. She also complained dizziness, headache, nausea, chest pain after trauma. • She complained neck pain and upper limbs mild numbness, but denied lower limbs numbness or weakness, initial loss of conscious, dyspnea, palpitation.

  5. The status after the traffic accident • motorcycle versus car and falling down from motocycle • dizziness, headache, nausea, chest pain • Abdominal pain (-).

  6. Past history • Diabetes mellitus (-), hypertension(-), • Smoking(+), alcohol(+) social • Betel nuts(-) • Operation history:C/S • Denied allergy history

  7. Current medicine • nil

  8. Physic examination • Conscious: clear, E4V5M6 • Vital signs: BP:149/89 mmHg, RR:20/min, HR: 100/min, BT: 36.3℃ • Pupil : L/R :2.5mm/2.5mm with symmetric light reflex • Conjuctiva: no pale, sclera : no ictericnasal bleedingfrontal area swelling with eccymosis, mild tenderness, no local heatBilateral periorbital area ecchymosis,mild tenderness, no local heat,Bilateral zygomatic area swelling, mild tenderness, no local heat • Neck : supple, no lymphadenopathy • Chest : symmetric expansion, tenderness over anterior chest breathing sound, bilateral corase

  9. Heat sound: regular heart bear, no murmur • Abdomen : soft, flat, no tenderness, no shifting dullness, tympanic percussionbowel sound: normoactive • Lower legs: no pitting edema • Muscle power: DTR: 5 5 ++ ++

  10. Admission : 4:08 am ,09/08/2006 BP: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-I On ECG, And arrange CXR, C-spine ant,Lateral view, and facial CT scanAnd consult Plasty 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 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

  11. The Status on Arrival04:08 am 09/08 • Consciousness : clear, E4V5M6 • Respiratory Rate : 10-24 cpm • Pulse Rate : 84 bpm • Blood Pressure : 162/91 mmHg • Body Temperature : 35.8oC

  12. Initial assessment • Airway: patent airway. on neck collar • Breathing: spontaneous breathing. • Circulation: radial pulse (+), • Pulse Rate : 84 bpm • Blood Pressure : 162/91 mmHg

  13. Disability: E4V5M6. L/R :2.5mm/2.5mm with symmetric light reflexz • Exposure • nasal bleeding • frontal area swelling with eccymosis, mild tenderness, no local heat • Bilateral periorbital area ecchymosis,mild tenderness, no local heat, • Bilateral zygomatic area swelling, mild tenderness, no local heat

  14. Management • On neck collar • Keep NPO and IVF :N/S 1 BT st • 12Lead EKG • Ice packing and pain control • Check CBC, BUN/CREA, Na/K, GOT/GPT, Ethanol, CK,CK-MB, Troponin-I • Arrange CXR AP view, spine AP and Lateral view • Arrange Facial CT scan • Consult Plasty for nasal bone fracture

  15. Lab data at 09/08

  16. Lab data at 09/08

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