ER case conference

報告者：溫聖辰

Patient profile

Chart No.: 14722060Name: 巫 X緯Gender: maleAge: 18Date of visiting: 19:04,May 3, 2007

Status on arrival

Conscious : clear, E4V5M6 vital signs :

Temperature: 37.0 ℃ Pulse: 68 bpmRespiratory rate: 24 cpm Blood pressure: 130 / 79 mmHg

Chief complaint

Chest pain started since around 12 o’clock

Present illnessThis 18-year-old male denied any systemic disease.Chest pain was attacked to him at 00:00 , May 3, 2007Description of the pain

Location: left chestDuration: persist Frequency: ?Onset: Sudden onsetCharacter: compressive painAggravating factor: breathingRelieving factor: changing positionRadiatoin: shoulder

Other associated symptoms and sign:cold sweating (-), mild dyspnea.Due to above reasons, he was brought to ER for medical aid at 19 o’clock on May 3, 2007.

Past historyAsthma(-)Drug allergy (-)Admission history:

Acute pharyngotonsilitis [87/08/22~25]cc: intermittent fever with leukocytosis on 8/10Admitted to pediatric ward.

Physical examinationBody weight:60KgConsciousness: E4M6V5 Vital sign:

BP: 130/79, PR: 68bpm, T: 37℃, RR: 24 times/minHead

Conjunctiva: Sclera:Oral mucosa:

Neck: Supple, LAP ( ) JVE ( ) Chest:

Crepitus was found around both clavicular area.Breathing sound: decreased over left upper lung fieldChest sono: no occult pneumothoraxHeart sound:

Abdomen: Bowel soundPalpationPercussion

Extremities:

19:04 Arrival on KMUH ER - conscious clear, vital signs stable - Chest PA. - on O2 2l/m

5/3 00:00 Chest pain occurred

19:45

Blood examChest CT non-enhancedNPON/S 1BTStin 1vial + Aqdest 1 amp

20:35 R/O spontaneous pneumomediastinum Chest CT.

21:40 BP: 111/65 ; P:54 ; SpO2:100%

23:45 BP: 108/63, consciousness : clear

22:20 BP: 130/70 ; P:63 ; BT:36.8; SpO2:100%

5/3 23:55 Sign permit BronchoscopyKeep NPOTransferred to Thoracic surgery ward

5/4 00:30 Admitted to Pediatric surgery ward

5/4 01:30 BT: 36.2 ; BP:110/64 ; P:62bpm ; SpO2:99%Consciousness : clear

DiagnosisSpontaneous pneumomediastinum, Pericardial and extensive subcutaneous emphysema.

Management an follow up

Admitted to thoracic surgeryEsophagogram was done and revealved no extravasion of contrast Empiric antibiotics were given

Cefazolin + GentamycinChest PA was followed and condition improvedMBD and OPD follow up.

Esophagogram

Esophagogram

No contrast extravasation from the esophagus in this study.

Thanks for your attentionThanks for your attention