急診醫(yī)學(xué)年會(huì)臨床病理討論會(huì)ppt課件

1、2021年普通醫(yī)學(xué)系臨床病理討論會(huì)Clinical Pathology Conference 病史篇報(bào)告者：第 年住院醫(yī)師 General Datao 67-year-old femaleo Triageo 病患主訴因意識(shí)模糊o o Vital sign :o BT 36.2 o HR 121/mino RR 20/mino BP 113/72 mmHgo GCS: E4V1M5Chief Complainto conscious disturbance this morningPresent Illnesso Conscious disturbance since morningo No s

2、eizureo No fevero Family denied recent trauma history.Past and Personal Historyo No HTNo Denied DMo No known allergyo Medication history: not documentedPhysical Examinationo General appearanceo E4V1M5o HEENTo Suppleo Chesto Breathing sound: coarseo Heart sound: RHB, no cardiac murmuro Abdomen o soft

3、 and flat, no tendernesso Extremityo bilateral Babinski reflex: dorsiflexion o bilateral muscle power:3 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 %o Platelet: 7 k/uLo WBC: 8300/uLo Segment: 86.0 %o Band: 1.0 %o Lymphocyte:

4、9.0 %o Monocyte: 4.0 %o APTT: 29.1 secondso PT: 12.5 secondso INR: 1.11 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:o pH: 7.547o PCO2: 26.3 mmHGo PO2: 77.0 mmHGo HCO3: 22.3 mm/Lo SBE: -0.1 mm/Lo SAT: 96.9 % Image Studyo CXR:o Unremarkableo Brain CT( 外片): o n