July 19th, 2011

21
. .

3 . (
2 ) +

2 .
()

1 .
10

(
)

4-5
( 8 .)

IVDU , unsafe sex

V/S :

BT39.8 C RR 22 /min PR 106 bpm

BP 113/67 mmHg ()
BP 117/74 mmHg ()
GA :
A Thai male, fully concious, look tired
BW 51 kg, HT 172 cm, BMI = 17.23
HEENT: Not pale conjunctivae, anicteric sclerae,
superficial lymph node impalpable, no oral thrush,
mild dry lips and tongue
Heart : RegularS1S2, no murmur
Lung : Normal breath sound, no adventitious sound

Abdomen: Soft, mild tender periumbilical

region, rebound tenderness-ve, normal bowel
sound, liver and spleen not palpable
Ext : No petechiae, no pitting edema, no rash
Neurological Exam: E4V5M6, pupil 3 mm
RTLBE, motor grade V all, intact sensation

Acute diarrhea
Mild to moderate dehydration

Stool exam : brown color

loose consistency
WBC RBC mucous Parasite not seen

CBC
Hct
43.4 %
Hb
15.3 g/dL
WBC
7,500 /ul (N 61%, L 17%, Mono 9%)
Plt
37,000 /ul
MCV
90.5 fl
RDW
13.6
Normochromic Normocytic
PBS

NCNC, no schistocyte
Normal, PMN predominate
Decrease 4-5 / HF

Electrolyte
BUN /Cr 13.0/0.9

Na
K
Cl
HCO3
Ca
Mg
PO4

136
3.6
99
27.6
8.8
1.8
2.1

LFT

AST
ALT

23
20

UA :

Sp.gr 1.005
pH 6.5
albumin ve
glucose ve
ketone ve
WBC
RBC 0-1