2018年病例报告ppt(英文)-文档资料.ppt
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1、Personal profile,Name : 吳O民 Gender : male Age : 46 years old Chart number : 16762291 Arrival date at ED : 96/08/20 Time : 04:15 am,Injury mechanism,Suffered from a traffic accident with drunken state this morning (04:00am) Suspect drunken driving 現場生命現象: drowsy and irritable (E3V3M4) CC: Alcoholism
2、with Traffic accident,Pre-hospital evaluation and management,Sent to KMUH ER by 119 Head :ILOC(?), dizziness(?), headache(?), nausea/vomiting(?), amnesia(?), vertigo(?) laceration wound over rt upper eyelid and earlobe Neck: pain, stiff, soreness(?) Chest: pain, dyspnea(?) Abdomen: pain, discomfort(
3、?) Limbs and skin : abrasion wound over bil. knee,AMPLE history,Allergies: unknown Medication: unknown Past illness: DM:(?) HTN:(?) Other systemic diseases(?) Operation history(?) Last Meal : (?),Initial evaluation (KMUH),A (airway) / B (breathing): Collar fixation: (+) Airway: speech: (?) respirati
4、on: smooth airway obstruction sign (-) foreign body in the mouth (-) Trachea Breathing sound: clear,C (circulation): Rate: brachial a. , carotid a., femoral a. , dorsalis pedis a. Cuff BP : 105/45 mmHg Skin condition: appearance, temperature, humidity,D (disable): GCS: E2V2M5 Pupil response: od: 2 m
5、m os: 2 mm E ( exposure ) : abrasion wound over nose and bil. maxillary area, laceration wound over rt. upper eyelid(2 cm) and earlobe(1 cm) abrasion wound over bil. knee,Secondary evaluation (KMUH ER),Chest X-ray AP & lateral view Cervical spine X-ray AP & lateral view Pelvis X-ray AP Brain CT with
6、out contrast (due to drowsy consciousness and irritable state, brain CT was hold for safety concern),Lab data (96/08/20),Lab data (96/08/20),Chest x-ray,Cervical spine X-ray,Pelvis X-ray,Plan,Close observation with plaining brain CT study,At 16:05,Consciousness: coma GCS: E1V1M1 Pupil size: R/L:3.5/
7、2.0 with negative light reflex BP: 150/78 mmHg PR:95/bpm. He was sent for emeregnt brain CT Emergent endotracheal intubation after Citosol sedation with paralytics (Genso),Tentative diagnosis,Traumatic ICH and SDH with mass effect and midline shift Alcoholism addition r/o C- spine injury Left ear lo
8、be laceration (1cm) Facial laceration (2 cm) Abrasion wound over bilateral knees,Under the impression of traumatic ICH and SDH with mass effect and midline shift, N/S was consult and he was sent to OR for emergent right craniectomy, SDH & ICH removal and ICH monitor insertion. Then, he was admitted
9、to 7ENI-31 for further therapy.,Post Operation,08/21, GCS:E1 VE M2 ICP was controled during 1217mmHg, and glycerol was used. Fever up to 39, Sputum (+) were noted. Antibiotics: Cefazolin 1g iv q8h day 2 Gentamicin,During 08/2208/24, spiking fever up to 40 was noted. 08/25: The sputum culture collect
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