Trauma Case Conference 2007.07.10 Intern 賴柔吟. Patient Profile 彭 ○ 惠， 30y/o ， Female 彭 ○ 惠， 30y/o ， Female Chart No. ： 14693347 Chart No. ： 14693347 Date.

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Presentation transcript:

Trauma Case Conference Intern 賴柔吟

Patient Profile 彭 ○ 惠， 30y/o ， Female 彭 ○ 惠， 30y/o ， Female Chart No. ： Chart No. ： Date of ER visiting ： Date of ER visiting ： Mechanism of Injury ： Motor bike VS Car Mechanism of Injury ： Motor bike VS Car Helmet (+) on 6/29 Sent to our ER at 20:40 by her family after discharged from other hospital on 6/30 Sent to our ER at 20:40 by her family after discharged from other hospital on 6/30

Chief Complaint Dizziness and vomiting Dizziness and vomiting

Present Illness This 30 y/o female patient is a case of major depressive disorder with regular OPD f/u. According to her family, she had a traffic accident on 6/29 around 23:00. The patient lost her conscious, recent memory and she was disoriented. After discharge from that hospital on 6/30 15:00, she continued to feel dizziness, nausea/vomiting(+), hearing loss and tinnitus on the r ’ t side and unsteady gait. Thus, she came to our ER for help. This 30 y/o female patient is a case of major depressive disorder with regular OPD f/u. According to her family, she had a traffic accident on 6/29 around 23:00. The patient lost her conscious, recent memory and she was disoriented. After discharge from that hospital on 6/30 15:00, she continued to feel dizziness, nausea/vomiting(+), hearing loss and tinnitus on the r ’ t side and unsteady gait. Thus, she came to our ER for help.

Past History: Past History: DM(-), H/T(-), Major depressive disorder(+) DM(-), H/T(-), Major depressive disorder(+) Current medicine: Current medicine: Stilnox use 6# qd, not using in recent 3 days Stilnox use 6# qd, not using in recent 3 days

Primary Survey and Management Airway: patent Airway: patent Breathing: regular(18/min), bilateral clear on auscultation Breathing: regular(18/min), bilateral clear on auscultation Circulation: HR 64, BP 138/84mmHg Circulation: HR 64, BP 138/84mmHg Disability E3V4~5M6 Disability E3V4~5M6 Exposure: ecchymosis around right ear on the back side about 1 cm in with, some abrasion wound on extremities and the trunk Exposure: ecchymosis around right ear on the back side about 1 cm in with, some abrasion wound on extremities and the trunk arrange Brain CT and Chest PA for evaluation arrange Brain CT and Chest PA for evaluation

Primary Survey and Management 21: % G/S 500mL, Glycerol 250mL 21: % G/S 500mL, Glycerol 250mL 23:00 – DPH 2 Amp + N/S 50mL IV 23:00 – DPH 2 Amp + N/S 50mL IV Gaster 1 Amp Gaster 1 Amp 01:00 NPO till coming morning 01:00 NPO till coming morning 03:00 2.5% G/S 500mL 03:00 2.5% G/S 500mL 04:10 Laston 1 Amp IM 04:10 Laston 1 Amp IM

Brain CT

Chest X ray

NS consultation DPH ½ Amp IV q8h DPH ½ Amp IV q8h Glycerol 250 mL IVD q8h Glycerol 250 mL IVD q8h Suggest for admission to NSICU Suggest for admission to NSICU Speech : confused and disoriented. Speech : confused and disoriented. No other abnormal finding on neurological examination No other abnormal finding on neurological examination

ENT consultation Hemotympanium on the right side Hemotympanium on the right side No facial palsy noted No facial palsy noted R’tR’tR’tR’t L’tL’tL’tL’t Hearing loss +- Tinnitus+- Otalgia-- Otorrhea-- Fullness--

Impression Skull fracture Skull fracture Multiple contusion hemorrhage Multiple contusion hemorrhage Right hemotympanium with hearing loss Right hemotympanium with hearing loss