急診醫學年會臨床病理討論會.ppt

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 o 67-year-old female o Triage 病患主訴因意識模糊 o Vital sign : nBT 36.2 nHR 121/min nRR 20/min nBP 113/72 mmHg nGCS: E4V1M5 Chief Complaint o conscious disturbance this morning Present Illness o Conscious disturbance since morning o No seizure o No fever o Family denied recent trauma history. Past and Personal History o No HTN o Denied DM o No known allergy o Medication history: not documented Physical Examination o General appearance nE4V1M5 o HEENT nSupple o Chest nBreathing sound: coarse nHeart sound: RHB, no cardiac murmur o Abdomen nsoft and flat, no tenderness o Extremity nbilateral Babinski reflex: dorsiflexion nbilateral muscle power:3 Hemogram o RBC: 3.25 million/uL o Hb: 9.8 g/dl o Hct: 28.8 % o MCV: 88.6 fL o MCH: 30.2 pg/cell o MCHC: 34.0 g/dl o RDW: 18.8 % o Platelet: 7 k/uL o WBC: 8300/uL o Segment: 86.0 % o Band: 1.0 % o Lymphocyte: 9.0 % o Monocyte: 4.0 % o APTT: 29.1 seconds o PT: 12.5 seconds o INR: 1.11 Biochemistry oF/S: 127 mg/dl oCr: 1.1 mg/dL oNa: 132 meq/L oK: 3.4 meq/L oCa: 8.4 meq/L oAmmonia: 71 umol/L oALT: 33 IU/L oTotal bilirubin: 4.1 mg/dL oDirect bilirubin: 0.9 mg/dL oTroponin-I: 2.5 ng/ml o 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 o CXR: n Unremarkable o Brain CT( 外片): n