Case Report Intern 謝旻翰

Status on Arrival Consciousness –Alert Vital sign –RR: –PR ： 70 –BT: 36.5 –BP: 162/102

Brief History Chief Complain –Fall down from 1.5m stair at 3:00am Present Illness –ILOC(-), headache(-), dizziness(-), nausea(-), vomiting(-), amnesia(-) Past History –DM(-), H/T (+), Drug allergy (-) –HCC post s4 segmentectomy, cholecystectomy, TACE

Physical Examination (I) Cons.: E4V5M6 conj: not pale sclera: not icteric neck: supple, LAP(-), JVE(-) chest: symmetric expansion –HS: Regular heart beat, no murmur –BS: bil. clear Abdomen: soft, and flat –no tenderness; BS: normoactive –Liver/Spleen: impalpable Extremety: no pitting edema

Physical Examination (II) Face Extremity

Initial Impression Head injury –r/o bone fracture Facial laceration L ’ t shoulder contusion R ’ t knee & L ’ t lower leg abrasion

Plan CBC GOT, GPT, BUN, Crea, Na, K PT, PTT C-spine Brain & Facial bone CT R ’ t hand, L ’ t shoulder, R ’ t knee X-ray Tetanus toxoid im N/S 500 c.c.

04:33 Admission 05:00 BloodBlood, Toxoid, N/S 05:07 C-spineC-spine, Other x-ray 05:22 CT 05:44 Chest Chest PA 06:15 Facial w ’ d suture

07:30 BT: 35.8 BP:153/106 PR:91 08:25 E3V4M6 Pupil: R:3.0 L: 腫 BP:175/125 PR:107 08:42 Sign permit (CT) 08:45 躁動 Citosol 1 amp 09:02 BP: 157/125 PR: 81 SaO2:99% 09:15 E2V4M6 BP:178/85 PR:73 SaO2:100% 09:30 轉入 7ENI 09:00 Enhanced CT

Final Diagnosis Head injury –L ’ t zygomatic fx with hemosinus –L ’ t frontal bone fx with pneumocephalus –L ’ t frontal traumatic SDH Facial laceration L ’ t shoulder contusion R ’ t knee & L ’ t lower leg abrasion

After transfer to ICU Prophylactic antiboitics –Cefazolin + Gentamicin Prevent seizure –Depakine Close monitor

~THE END~

C-spine BACK

Chest PA BACK

Lab Data WBC (10 3 /uL) 6.46 RBC (10 6 /uL) 3.41 Hgb (g/dL) 10.9 Hct (%) 34.4 MCV (fL) MCHC (Hgb/cell) 31.7 PLT (10 3 /uL) 85 Glucose (mg/dL) 121 BUN (mg/dL) 14.9 Crea (mg/dL) 1.2 Na (mEq/L) 141 K (mEq/L) 3.97 GOT (U/L) 128 GPT (U/L) 100 PT (sec) 12.1 PTT (sec) 28.6 INR1.13 BACK

CT finding 1) Intraparenchymal hemorrhage in left frontal lobe. 2) Fracture of left zygoma, left maxillary sinus walls(anterior and medial), left frontal bone, ethmoid sinus and sphenoid sinus wall and bilateral lamina papyracea with –(a) R/O thrombosis of left internal jugular vein. Recommend clinical correlation. –(b) hematoma in left nasal cavity –(c) pneumocephalus in right temporal and frontal regions. –(d) soft tissue swelling with subcutaneus hematoma in both malar region, frontal scalp, left cheek region and bilateral infratemopral regions. –(e) subcutaneus emphysema in left neural foramina of C1-C3 and resolved on postenhanced images. –(f) hemosinus of ethmoid and sphenoid sinuses, –(g) bilateral chronic subdural hematomas. BACK