Case Report

Intern 謝旻翰

Status on Arrival

• Consciousness– Alert

• Vital sign– RR: 10-24– 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, cholecystecto

my, 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

Blood,Toxoid,N/S

05:07

C-spine,Other x-ray

05:22

CT

05:44

Chest PA

06:15

Facial w’d suture

07:30

BT: 35.8BP:153/106PR:91

08:25

E3V4M6Pupil: R:3.0 L:腫BP:175/125PR:107

08:42

Sign permit(CT)

08:45

躁動Citosol 1 amp

09:02

BP: 157/125PR: 81SaO2:99%

09:15

E2V4M6BP:178/85PR:73SaO2:100%

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

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Lab Data

WBC (103/uL)

6.46

RBC (106/uL)

3.41

Hgb (g/dL) 10.9

Hct (%) 34.4

MCV (fL) 100.9

MCHC (Hgb/cell) 31.7

PLT (103/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

INR 1.13

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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 clin

ical correlation.– (b) hematoma in left nasal cavity– (c) pneumocephalus in right temporal and frontal regions.– (d) soft tissue swelling with subcutaneus hematoma in both mal

ar 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.

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