1. ER case conference 報告者：溫聖辰

2. Patient profile Chart No.: 14722060 Name: 巫 X 緯 Gender: male Age: 18 Date of visiting: 19:04,May 3, 2007

3. Status on arrival Conscious : clear, E4V5M6 vital signs : Temperature: 37.0 ℃ Pulse: 68 bpm Respiratory rate: 24 cpm Blood pressure: 130 / 79 mmHg

4. Chief complaint Chest pain started since around 12 o’clock

5. Present illness This 18-year-old male denied any systemic disease. Chest pain was attacked to him at 00:00, May 3, 2007 Description of the pain Location: left chest Duration: persist Frequency: ? Onset: Sudden onset Character: compressive pain Aggravating factor: breathing Relieving factor: changing position Radiatoin: shoulder Other associated symptoms and sign: cold sweating (-), mild dyspnea. Due to above reasons, he was brought to ER for medical aid at 19 o’clock on May 3, 2007.

6. Past history Asthma(-) Drug allergy (-) Admission history: Acute pharyngotonsilitis [87/08/22~25] cc: intermittent fever with leukocytosis on 8/10 Admitted to pediatric ward.

7. Physical examination Body weight:60Kg Consciousness: E4M6V5 Vital sign: BP: 130/79, PR: 68bpm, T: 37 ℃, RR: 24 times/min Head Conjunctiva: Sclera: Oral mucosa: Neck: Supple, LAP ( ) JVE ( ) Chest: Crepitus was found around both clavicular area. Breathing sound: decreased over left upper lung field Chest sono: no occult pneumothorax Heart sound: Abdomen: Bowel sound Palpation Percussion Extremities:

8. 19:04 Arrival on KMUH ER - conscious clear, vital signs stable - Chest PA.Chest PA - on O2 2l/m 5/3 00:00 Chest pain occurred 19:45 Blood exam Chest CT non-enhanced NPO N/S 1BT Stin 1vial + Aqdest 1 amp 20:35 R/O spontaneous pneumomediastinum  Chest CT.Chest CT. 21:40 BP: 111/65 ; P:54 ; SpO2:100% 23:45 BP: 108/63, consciousness : clear 22:20 BP: 130/70 ; P:63 ; BT:36.8; SpO2:100%

9. 5/3 23:55 Sign permit Bronchoscopy Keep NPO Transferred to Thoracic surgery ward 5/4 00:30 Admitted to Pediatric surgery ward 5/4 01:30 BT: 36.2 ; BP:110/64 ; P:62bpm ; SpO2:99% Consciousness : clear

10. Chest PA

11. Chest CT Non-enhanced

12. Chest CT Enhanced 1. Penumomediastinum with air upper extension to retropharyngeal region amd bilateral posterior cervical spaces. 2.Soft tissue emphysema in right shoulder region, higher level of back and anterior chest wall and air extension to epidural space. 3. Minimal amount of left pneumothorax.

13. Bronchoscopy Clinical diagnosis: Pneumorrhachis associated with spontaneous pneumomediastinum Comment Vocal cord: symmetric, no paralysis Carina: blunt, suspect related to pneumomediastinum Trachea: No evidence of tear or perforation LMB and RMB:OK, no evidence of tear or perforation Right upper lobe bronchus: variation of anatomy

14. Lab data WBC9950 /ul RBC4.76*10 6 /u l Hgb13.8 g/dl Hct42.1 % MCV88.4 fl MCHC32.8 pg PLT171000/ul Neutro72.5 % Lymph22.3 % Sugar85 BUN14.0 Creatinine0.9 GOT39 IU/L GPT18 IU/L PT P/C12.1/10.5 s PTT P/C33.1/29.4 s Na141 mmol/L K4.0mmol/L Cl106 mmol/L CRP0.28 U/L CBCBiochemistry back

15. Diagnosis Spontaneous pneumomediastinum, Pericardial and extensive subcutaneous emphysema.

16. Management an follow up Admitted to thoracic surgery Esophagogram was done and revealved no extravasion of contrast Empiric antibiotics were given Cefazolin + Gentamycin Chest PA was followed and condition improved MBD and OPD follow up.

17. Esophagogram

19. No contrast extravasation from the esophagus in this study.

20. Thanks for your attention