SOAP: EA

主訴：車禍：騎機車 開車 乘客 . 有戴安全帽.

自訴受傷部位：頭部（前額）、胸部、腹部、左右雙手臂、手掌、大腿、小腿、腳、膝、臀、胸、背

沒有其他部位受傷.

ILOC（－）. Diffuse headache（－）. Vomiting（－）. Amnesia（－）. Dyspnea（－）. Chest pain（－）. Back pain（－）.

NPO since 12:00

[ Past History ]

DM（＋－）. HTN（＋－）. Drug allergy（＋－）.

Denied pregnancy.

Tetanus toxoid within 5 yr（－）.

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E4M6V5, orientation OK.

HEENT: Not pale, non-icteric.

Pupils and EOM: intact

Neck: no tender point.

Chest: No wound, no tenderness.

BS: Clear. HS: RHB, no murmur.

Abd: Soft, no wound, no tenderness.

Ext: Freely movable, can walk without assistance.

No AUR, no stool or urine incontinence.

Muscle power: 右上肢〔5〕，左上肢〔5〕，右下肢〔5〕，左下肢〔5〕

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多處擦傷及挫傷：頭部（前額）、胸部、腹部、左右雙手臂、手掌、大腿、小腿、腳、膝、臀、胸、背

Head trauma.

Chest and abdominal contusions.

Left Right elbow, knee, ankle injury.

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Tetanus toxoid. Wound CD. Suture.

X-rays.

Explain ED work-up and treatment strategy.