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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
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Case Conference
Intern 溫千瑩
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
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
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: ?
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
D (disable): GCS: E4V5M6 Pupil response: ?
E ( exposure ) : Right face contusion Right forehead laceration wound (3 cm) Right eye blindness
Current medication
Denied
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.: (-)
Family history
Not contributory
Secondary evaluation (KMUH ER) Skull X-ray Brain CT Lab data 12 leads EKG Chest X-ray
CBC
Electrolytes & Sugar
Impression
1. Head injury with brain contusion2. Face laceration wound (3 cm)3. Old left frontal fracture post OP4. Old right orbital floor fracture post OP5. Right eye prosthesis
Plan Wound CD Panadol 1# Tid Diphenidol 1# Tid Keep observation 頭部外傷衛教單
Thanks for your attention