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Clinical Pathology Conference 病史篇

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Presentation on theme: "Clinical Pathology Conference 病史篇"— Presentation transcript:

1 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

2 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

3 Chief Complaint conscious disturbance this morning

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

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

6 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

7 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

8 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: mmHG PO2: mmHG HCO3: mm/L SBE: -0.1 mm/L SAT: 96.9 %

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

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