急診醫學年會臨床病理討論會课件

1、急診醫學年會臨床病理討論會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 急診醫學年會臨床病理討論會General Datao 67-year-old femaleo Triage 病患主訴因意識模糊 o Vital sign :nBT 36.2 nHR 121/minnRR 20/minnBP 113/72 mmHgnGCS: E4V1M5急診醫學年會臨床病理討論會Chief Complainto conscious disturbance this morning急診醫學年會臨床病理討論會Present Illne

2、sso Conscious disturbance since morningo No seizureo No fevero Family denied recent trauma history.急診醫學年會臨床病理討論會Past and Personal Historyo No HTNo Denied DMo No known allergyo Medication history: not documented急診醫學年會臨床病理討論會Physical Examinationo General appearancenE4V1M5o HEENTnSuppleo ChestnBreathin

3、g sound: coarsenHeart sound: RHB, no cardiac murmuro Abdomen nsoft and flat, no tendernesso Extremitynbilateral Babinski reflex: dorsiflexion nbilateral muscle power:3 急診醫學年會臨床病理討論會Hemogramo RBC: 3.25 million/uLo Hb: 9.8 g/dlo Hct: 28.8 %o MCV: 88.6 fLo MCH: 30.2 pg/cello MCHC: 34.0 g/dlo RDW: 18.8

4、%o Platelet: 7 k/uLo WBC: 8300/uLo Segment: 86.0 %o Band: 1.0 %o Lymphocyte: 9.0 %o Monocyte: 4.0 %o APTT: 29.1 secondso PT: 12.5 secondso INR: 1.11 急診醫學年會臨床病理討論會BiochemistryoF/S: 127 mg/dloCr: 1.1 mg/dLoNa: 132 meq/LoK: 3.4 meq/LoCa: 8.4 meq/LoAmmonia: 71 umol/LoALT: 33 IU/LoTotal bilirubin: 4.1 mg/dLoDirect bilirubin: 0.9 mg/dLoTroponin-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 % 急診醫學年會臨床病理討論會Image Studyo CXR:n Unremarkableo Brain CT( 外片):