病例报告ppt（英文）.ppt

Case presentation96.09.04 Intern 胡學錦 Personal profile Name : 吳O民 Gender : male Age : 46 years old Chart number : 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 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 r’t upper eyelid and earlobe Neck: pain, stiff, soreness…(?) Chest: pain, dyspnea…(?) Abdomen: pain, discomfort…(?) 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: (?) respiration: 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 mm os: 2 mm E ( exposure ) : abrasion wound over nose and bil. maxillary area, laceration wound over r’t. 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 without 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:3.5/2.0 with negative light reflex BP: 150/78 mmHg PR:95/bpm. He was sent for emeregn