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
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