ER case conference

1
ER case conference

• ??????

2
Patient profile

• Chart No. 14722060
• Name ?X?
• Gender male
• Age 18
• Date of visiting 1904,May 3, 2007

3
Status on arrival

• Conscious clear, E4V5M6
• vital signs
• Temperature 37.0 ?
• Pulse 68 bpm
• Respiratory rate 24 cpm
• Blood pressure 130 / 79 mmHg

4
Chief complaint

• Chest pain started since around 12 oclock

5
Present illness

• This 18-year-old male denied any systemic
  disease.
• Chest pain was attacked to him at 0000 , May 3,
  2007
• Description of the pain
• Location left chest
• Duration persist
• Frequency ?
• Onset Sudden onset
• Character compressive pain
• Aggravating factor breathing
• Relieving factor changing position
• Radiatoin shoulder
• Other associated symptoms and signcold sweating
  (-), mild dyspnea.
• Due to above reasons, he was brought to ER for
  medical aid at 19 oclock on May 3, 2007.

6
Past history

• Asthma(-)
• Drug allergy (-)
• Admission history
• Acute pharyngotonsilitis 87/08/2225
• cc intermittent fever with leukocytosis on 8/10
• Admitted to pediatric ward.

7
Physical examination

• Body weight60Kg
• Consciousness E4M6V5
• Vital sign
• BP 130/79, PR 68bpm, T 37?, RR 24 times/min
• Head
• Conjunctiva
• Sclera
• Oral mucosa
• Neck Supple, LAP ( ) JVE ( )
• Chest
• Crepitus was found around both clavicular area.
• Breathing sound decreased over left upper lung
  field
• Chest sono no occult pneumothorax
• Heart sound
• Abdomen
• Bowel sound
• Palpation
• Percussion
• Extremities

8
(No Transcript)
9
Admitted to Pediatric surgery ward
5/4 0030
BT 36.2 BP110/64 P62bpm
SpO299 Consciousness clear
5/4 0130
10
Chest PA
11
Chest CTNon-enhanced
12
Chest CT Enhanced
1. Penumomediastinum with air upper extension to
retropharyngeal region amd bilateral posterior
cervical spaces. 2.Soft tissue emphysema in
right shoulder region, higher level of back and
anterior chest wall and air extension to epidural
space. 3. Minimal amount of left pneumothorax.
13
Bronchoscopy

• Clinical diagnosis
• Pneumorrhachis associated with spontaneous
  pneumomediastinum
• Comment
• Vocal cord symmetric , no paralysis
• Carina blunt, suspect related to
  pneumomediastinum
• Trachea No evidence of tear or perforation
• LMB and RMBOK, no evidence of tear or
  perforation
• Right upper lobe bronchus variation of anatomy

14
Lab data
CBC
Biochemistry
back
15
Diagnosis

• Spontaneous pneumomediastinum,
• Pericardial and extensive subcutaneous emphysema.

16
Management an follow up

• Admitted to thoracic surgery
• Esophagogram was done and revealved no
  extravasion of contrast
• Empiric antibiotics were given
• Cefazolin Gentamycin
• Chest PA was followed and condition improved
• MBD and OPD follow up.

17
Esophagogram
18
Esophagogram
19
Esophagogram
No contrast extravasation from the esophagus in
this study.
20
Thanks for your attention