Nil(货运送菜before)

,按一下以編輯母片標題樣式,按一下以編輯母片文字樣式,第二層,第三層,第四層,第五層,*,*,Case Conference,Presented by:PGY,楊道欣,Supervisor:VS,吳冠達,Patient profile,Chart Number:14640173,Name:,蔡,x,瑞,Gender:male,Age:41 y/o,Occupation:Nil,(,貨運送菜,before),Marital status:Married,Ethnic origin:,本省籍,Place of Residence:,台南縣,Source of information:patient,Date of admission:98/06/08,Chief complaint,Fever,and,right foot pain for 2 weeks,Present Illness,Intermittent fever for about 2 wks,Rt foot painful swelling with mild,erythematous,change and local heat for about 2 wk,He was admitted to LMD and our,infection,OPD,oral antibiotics,pain killer was given,but the foot pain persisted,the range of,erythema expaned,.,Present Illness,Mild,cough,with,whitish,sputum,was,noted,No,symptoms,of,nausea,diarrhea or vomiting,no,dysuria,no,s/s,of,UGIB,no,headache,no,no neck rigidity.,ER,Lab showed increased,segment,WBC,hyperglycemia,CXR showed no specific finding,urine routine showed,pyuria,he admitted for further survey,Past history,1.Medical history,：,Hypertension,：,nil Diabetes mellitus,：,Insuline,control Steroid use history,：,nil Chronic hepatitis B,：,positive Chronic hepatitis C,：,negative Others,：,1)Gouty arthritis 2)Alcoholism 3)DU(960807 PES)4)Head injury 5)Suspected Tuberculosis peritonitis on 2008/2,6)acute,pancreatitis,since 2006/6 2.Surgical history,：,s/p appendectomy T-colon s/p repairing of,mesocolon,of T-colon and liver laceration on 960418 Exp,.Lapa,adhesiolysis,mesentary LNs,excision on 97/03/12.,Past history,Fever,unknow,origin:,Past history,Past history,Past history,Past history,Personal history,1.Smoking,：,2 PPD/day for 20+years 2.Alcohol,：,(+)1 bottle,/perday,高粱,if insomnia,quited,in recent 5-6 month 3.Betel nut,：,(+),quit for years 4.Herbal medication,：,nil 5.Allergy,：,no known allergy history,Physical examination,Vital sign:,1.General appearance:chronic ill looking,2.Consciousness:clear,3.Peripheral perfusion:distal extremity-warm,pink,no cyanosis,4.Skin:,turgor,-normal,no paper skin,color-normal color,icteria,(+),no pale,no reddish,skin rash,over his,face and neck with itching,no spider,angioma,at chest wall,no,ecchymosis,5.HEENT:Head:normal appearance,no trauma Eyes:pupil-(3,3),isocoric,;light reflex(L/R):(+/+)sclera-,-,icteria,conjunctiva-pink,no pale,no ulceration Ears:normal appearance,no discharge,no hearing impairment Nose:no,epistaxis,no nasal flaring Mouth&Throat:no pigmentation,no ulcer,no ejected tonsil,6.Neck:supple,no stiffness,no,lymphadenopathy,no mass Trachea:no deviation,no,stridor,Carotid artery:no bruit Jugular vein:no engorgement,about 6-8 cm above,sternal,angle Thyroid gland:no nodules,no,goitor,no bruit,multiple,petechiae,over face and,neek,7.Chest:Inspection:normal quality of expansion,symmetrically no respiratory accessory muscle use Palpation:measured expansion Percussion:resonance,normal decent of diaphragms Auscultation:coarse breathing sounds,no,rales,no wheezing,no,rhonchi,no crackles 8.Heart:Inspection:apical impulse at 5th,intercostal,space over left anterior middle,clavicular,line Palpation:no heave,no,parasternal,lift,no thrill,normal apical impulse Auscultation:normal regular rhythm,normal S1&S2,no murmur,9.Abdomen:Inspection:flat,no flank bulging,operation scar(+)midline and RLQ,no superficial collateral vein,no umbilical hernia Palpation:soft,diffuse tenderness.,hepatomegaly,(+),no,splenomegaly,Percussion:dullness,no knocking pain,no shifting dullness,Ausculation,:normal active bowel sounds,no bruit,no friction rub,10.Extremities:no pitting edema,no swelling,no varicose veins,no palm,erythema,flapping tremor(+/-),no muscle wasting,heat(-),redness(-)11.Nervous system:normal muscle power,normal DTR,Barbinski,s sign(R,L):(/),Diagnosis&Plan,1.,Cellulitis,2.Abdominal pain 3.Alcoholic cirrhosis of liver 4.Diabetes mellitus poor control,5.Depressed state,Clinical course,Right foot pain improved after antibiotics use,(Prostaphlin,Augmentin,PenicillinG,),Low grade fever persisted,