1. CASE REPORT Intern 呂佾欣

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

3. Chief complaint Fall down from riding motorcycle at 4:00am,9/9. 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. 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. 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. 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 motorcycle versus car and falling down from motocycle dizziness, headache, nausea, chest pain dizziness, headache, nausea, chest pain Abdominal pain (-). Abdominal pain (-).

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

7. Current medicine nil nil

8. Physic examination Conscious: clear, E4V5M6 Conscious: clear, E4V5M6 Vital signs: BP:149/89 mmHg, RR:20/min, HR: 100/min, BT: 36.3 ℃ 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 Pupil : L/R :2.5mm/2.5mm with symmetric light reflex Conjuctiva: no pale, sclera : no icteric 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 Conjuctiva: no pale, sclera : no icteric 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 Neck : supple, no lymphadenopathy Neck : supple, no lymphadenopathy Chest : symmetric expansion, tenderness over anterior chest breathing sound, bilateral corase Chest : symmetric expansion, tenderness over anterior chest breathing sound, bilateral corase

9. Heat sound: regular heart bear, no murmur Heat sound: regular heart bear, no murmur Abdomen : soft, flat, no tenderness, no shifting dullness, tympanic percussion bowel sound: normoactive Abdomen : soft, flat, no tenderness, no shifting dullness, tympanic percussion bowel sound: normoactive Lower legs: no pitting edema Lower legs: no pitting edema Muscle power: DTR: Muscle power: DTR: 55++

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 scan And consult Plasty 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 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

11. The Status on Arrival 04:08 am 09/08 Consciousness : clear, E4V5M6 Consciousness : clear, E4V5M6 Respiratory Rate : 10-24 cpm Respiratory Rate : 10-24 cpm Pulse Rate : 84 bpm Pulse Rate : 84 bpm Blood Pressure : 162/91 mmHg Blood Pressure : 162/91 mmHg Body Temperature : 35.8 o C Body Temperature : 35.8 o C

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

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

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

15. Lab data at 09/08 WBC9.53 x10 3 /ml RBC4.34 x10 6 /ml HGB14.1g/dl HCT41.7% MCV96.1fl MCH32.5Pg MCHC33.8g/dl PLT178 x10 3 /ml RDW-CV12.4% RDW-SD43.6Fl 項目結果單位SGOT89IU/L SGPT42IU/L Ethanol170.5Mg/dl Urea N 9.9ng/dl Creatinin e 0.72ng/dl Na145Mmol/dl K3.67Mmol/dl CPK131U/L Tropo-l0.003Ng/ml CK-MB(S)42.8U/L

16. Lab data at 09/08 項目結果單位 SGOT89IU/L SGPT42IU/L Ethanol170.5Mg/dl Urea N 9.9ng/dl Creatinine0.72ng/dl Na145Mmol/dl K3.67Mmol/dl項目結果單位CPK131U/L Tropo-l0.003Ng/ml CK-MB(S)42.8U/L

61. Impression 1.Head injury with brain concussion 1.Head injury with brain concussion 2.nasal bone fracture 2.nasal bone fracture 3.chest contusion 3.chest contusion

62. 10:30 pm 09/08 2:25 am 09/09 04:10 am 09/09 06:00 am 09/09 09:30 am 09/09 10:00 am 09/09 12:00 am 09/09 BP:139/96 mmHg, HR: 73/bpm, BT:36.8 ℃ Conscious clear,E4V5M6 S: chest pain  Demerol 40mg IM Ice packing S: chest pain  12Lead EKG BP:128/74 mmHg, HR: 85/bpm Conscious clear,E4V5M6 BP:121/68 mmHg, HR: 72/bpm, BT:35 ℃ Conscious clear,E4V5M6 Check CXR Plasty suggest that no instability neiter maligment of nasal bone. No surgical intervention infdication for her. OPD F/U is suggested Admission to NS

65. Thanks for your attention~~!!