1. Case Conference Intern 張倍豪

2. 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

3. Chief Complaint Chest pain due to motorcycle traffic accident on 1 ： 40PM of 4/30

4. Vital sign BT ： 36.7C HR ： 88 bpm RR ： 20 cpm BP ： 161/108 mmHg

5. Primary survey-Airway Phonation ： intact Neck motion ： intact Neck stiffness ： nil

6. Primary survey-Breath Hyperventilation ： RR=20cpm Dyspnea （ + ） Shortness of breath （ + ） SpO2=89%->98%

7. 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

8. Primary survey-Disability GCS ： E4V5M6 AVPU ： alert, irritable Pupil ： 3mm/3mm Pupil light reflex ： intact/intact

9. Primary survey-Exposure Skin abrasion over right elbow and forearm, left elbow Contusion over right chest wall

10. Present Illness Motorcycle traffic accident with 安全帽 on 1 ： 40PM of 4/30 Tranferred to our ER by 119

12. Past History Chronic kidney disease Congestive heart failure, NYHA II Hypertension(+) DM(-) Cushing syndrome Peptic ulcer Smoking ： 1PPD Alcohol ： quit

13. Allergy Denied

14. 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

15. Current medication Diphenidol 1# tid Kascoal 1# tid Strocain 1# tid Harnalidge 1# QD Quicran 1# bid

16. Physical Examination Conjunctiva ： not pale Sclera ： not icteric Neck ： supple, jugular venous engorement （＋） Chest ： symmetric expansion –Breath sound ： wheezing –Heart sound ： regular

17. Physical Examination Abdomen ： soft, no tenderness –Bowel sound ： normactive Extremities ： no pitting edema

18. 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

19. Image

21. Impression Right elbow and forearm skin abrasion Asthma attack

22. Plan Cataflam Rinderon Mgo Acetin

24. Chief Complaint Right chest pain since 4/30

25. 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

26. 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(+)

27. Physical Examination Abdomen ： soft, no tenderness –Bowel sound ： normactive Extremities ： no pitting edema

28. Image 4/30

29. 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.

30. Impression Subcutaneous emphysema Fracture of the right 2nd to 9th ribs

31. Plan Tranferred to 急外 Arrange chest CT Consult chest surgeron

33. Chest CT

37. 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 common 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 Category I.

38. EKG

39. Image on 5/3

40. Esophagogram on 5/3

42. Esophagogram Finding No imaging evidence of the esophageal perforation in this study

43. Brochoscopy on 5/3 No evidence of the trachea perforation in this study

44. Progress Admission chest surgery on 5/3 Discharge from CS on 5/8 Follow up at OPD

45. Chest X-ray on 5/7

46. Chest X-ray on 5/10