Clinical Pathology Conference 病史篇

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Presentation transcript:

Clinical Pathology Conference 病史篇 2009年一般醫學系臨床病理討論會 Clinical Pathology Conference 病史篇 報告者：第 年住院醫師

General Data Vital sign : 67-year-old female Triage 病患主訴因意識模糊 BT 36.2 ℃ HR 121/min RR 20/min BP 113/72 mmHg GCS: E4V1M5

Chief Complaint conscious disturbance this morning

Present Illness Conscious disturbance since morning No seizure No fever Family denied recent trauma history.

Past and Personal History No HTN Denied DM No known allergy Medication history: not documented

Physical Examination General appearance E4V1M5 HEENT Supple Chest Breathing sound: coarse Heart sound: RHB, no cardiac murmur Abdomen soft and flat, no tenderness Extremity bilateral Babinski reflex: dorsiflexion bilateral muscle power:3

Hemogram RBC: 3.25 million/uL Hb: 9.8 g/dl Hct: 28.8 % MCV: 88.6 fL MCH: 30.2 pg/cell MCHC: 34.0 g/dl RDW: 18.8 % Platelet: 7 k/uL WBC: 8300/uL Segment: 86.0 % Band: 1.0 % Lymphocyte: 9.0 % Monocyte: 4.0 % APTT: 29.1 seconds PT: 12.5 seconds INR: 1.11

Biochemistry ABG: pH: 7.547 PCO2: 26.3 mmHG PO2: 77.0 mmHG F/S: 127 mg/dl Cr: 1.1 mg/dL Na: 132 meq/L K: 3.4 meq/L Ca: 8.4 meq/L Ammonia: 71 umol/L ALT: 33 IU/L Total bilirubin: 4.1 mg/dL Direct bilirubin: 0.9 mg/dL Troponin-I: 2.5 ng/ml ABG: pH: 7.547 PCO2: 26.3 mmHG PO2: 77.0 mmHG HCO3: 22.3 mm/L SBE: -0.1 mm/L SAT: 96.9 %

Image Study CXR: Brain CT( 外片): Unremarkable no intracranial hemorrhage, no subarachnoid hemorrhage nor mass lesion

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