1. Case Conference Intern 溫千瑩

2. Patient profile 王 X 銘, 39y/o, male Occupation : 自由業 Chart No.: 1266XXXX Admission to ER date: 96-3-25, 04:44 Way of admission: alone Discharge from ER date: 96-3-25, 09:50

3. Injury mechanism He suffered from head injury while he took a taxi on 3/23 4:00 am. Syncope on 3/25 3:00 am was noted. 現場生命現象 : clear (E4V5M6) CC: Dizziness

4. Initial evaluation (KMUH) A (airway) / B (breathing): Collar fixation: (-) Airway: speech: illustrate smoothly respiration: smooth airway obstruction sign: No foreign body in the mouth: No trachea: midline breathing sound: ?

5. C (circulation): Rate: brachial a., carotid a., femoral a., dorsalis pedis a. Cuff BP : 110/79 mmHg Skin condition: appearance: red temp: warm humidity: normal

6. D (disable): GCS: E4V5M6 Pupil response: ?

7. E ( exposure ) : Right face contusion Right forehead laceration wound (3 cm) Right eye blindness

9. Current medication Denied

10. Past history DM: (-), HTN: (-), Hepatitis: (-) Other systemic diseases: denied Smoking(+), Alcohol(+), Betel nut: unknown Op. hx.: Left frontal fracture, EDH post OP in 民 83 Right orbital floor fracture post OP in 民 83 Right eye prosthesis Allergy hx.: (-) Travel hx: (-), Contact hx.: (-)

11. Family history Not contributory

12. Secondary evaluation (KMUH ER) Skull X-ray Brain CT Lab data 12 leads EKG Chest X-ray

14. CBC

15. Electrolytes & Sugar

18. Impression 1. Head injury with brain contusion 2. Face laceration wound (3 cm) 3. Old left frontal fracture post OP 4. Old right orbital floor fracture post OP 5. Right eye prosthesis

19. Plan Wound CD Panadol 1# Tid Diphenidol 1# Tid Keep observation 頭部外傷衛教單

20. Thanks for your attention