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General data
: XX : : 57 : 43910 :B100437821 : 100113212 :
: III
:
Chief complain
Abdomen pain, chillness with fever were noted since this morning
Present illness :
The 57-year-old male has history of liver cirrhosis and type 2 DM with poor control for years. He suffered from abdomen pain, chills and fever since last night. Due to the symptom got worsen, then he was sent to our ER for further evaluation and management.
Hx of cigarette smoking 2 PPD for years or social alcoholic drinking HX of Betelnut chewing: 1/2 PPD for years Height:169cm/BW:70 Kg
Occupation: nil Education: nil Religion:
Physical examination
Vital signs: BT: 37.9C, BP: 111/51 mmHg, PR:65/min, RR:22 /min, SaO2: 99% General appearance: A thin women, lying on bed with an acute ill-looking ,without cardiopulmonary embarrassment. Conscious: clear ; Acute ill-looking; GCS=15
Physical examination
Conj: mild anemia, pale, Sclera: not icteric Neck: supple, JVE(-), LAP(-), Goiter(-) Chest: no tenderness over anterior chest; coarse breathing sound, no wheezing, bil basal rales(-) Heart: no murmur, no S3/S4, no heave, no thrill, PMI at 5th intercostal margin Abdomen: soft with distension, normoactive bowel sound, bruit(-), L/S: impalpable, shifting dullness(-), mild tenderness(+) epigastric , rebouding pain(-)
Physical examination
Extremities: freely movale, cyanosis(-), pitting edema(-) Skin: echymosis(-), bedsore(-) Neurology:the cranil nerves are intact,the motor function is poor, No pathologic reflex
1103 2124
CBC-I [L110302] CBC-1 WBC HCT HGB MCH MCHC MCV PLT RBC RDW
0213 0.0
BUN 16.3 Cr 1.48
7400 0.2
Glu 202
40.2
LY%
14.1
MO%
34.4
NE%
35
98.2
138000 4.09*10^6
13.1
8.2
GPT 18
0.3
Na 145
91.3
K Amylase CRP 3.91 67.5 0.07
U/R: SG PH Leu Nit Pro Glu Ket UBG Bil Ery RBC WBC Epi Bac Cast 1.026 6.0 - + 4+ + - 0-2 0-2 2-5 - Ketone body <0.1 ; Osmo: 305
1. Thickening of peribronchial wall with increased bilateral perihilar infiltrations, suggestive of inflammatory process. 2. No cardiomegaly. 3. Tortuosity of aortic knob with calcification.
1. DJD of L-spine. 2. Old fracture of right proximal femur S/P ORIF. 3. Mild bowel ileus over abdomen, follow up.
Tentative diagonosis
Fever? Cause? Acute abdomen? Acute Gastritis?
2102 arrive ER , Vital signs: BT: 37.9C, BP: 111/51 mmHg, PR:65/min, RR:22 /min, SaO2: 99% GCS=E4M6V5->EKG, BP monitor, pulse oximeter, O2 use 2105 Keep ABC; Hx taking and PE; set IV;blood exam; CxR/KUB 2200 follow Lab data; Vital signs: BT: 38.8C, BP: 100/66 mmHg, PR:132/min, RR:20 /min
2300 Vital signs: BT: 38.5C, BP: 101/66 mmHg, PR:122/min, RR:20 /min
0040 Vital signs: BT: 37.5C, BP: 92/59 mmHg, PR:112/min, RR:19 /min 0500 Vital signs: BT: 37.6C, BP: 84/52 mmHg, PR:106/min, RR:18 /min-> IV fluid challange
0530 Vital signs: BT: 37.5C, BP: 83/53 mmHg, PR:110/min, RR:18 /min-> IV fluid challange 0600 Vital signs: BT: 37.1C, BP: 78/54 mmHg, PR:108/min, RR:18 /min-> Gelofusion 0625 Vital signs: BT:? C , BP: 81/53 mmHg, PR:105/min, RR:19 /min-> bed side sono-> B/R+CRP+ cardiac enzyme+ BNP
1104 0638
CBC-1
WBC HCT HGB MCH 20800 33.4 11.2 33 WBC DC (CBC) BA% EO% LY% 0.0 0.0 3.0 CK 136 CK-MB 18.1 Troponin-I CRP 0.04 3.02 BNP 240
PLT 72000
RBC 3.4*10^6
RDW 13.2
PTT 33.6
INR 1.11
0641 Vital signs: BT: ? C, BP: 74/41 mmHg, PR:110/min, RR:18 /min->
0704 Vital signs: BT: ? C, BP: 83/50 mmHg, PR:113/min, RR:19 /min-> abdomen CT 0712 Vital signs: BT: 37.1 C, BP: 84/55 mmHg, PR:106/min, RR:19 /min-> Chef+ Gelofusine use 0812 Vital signs: BT: ? C, BP: 94/52 mmHg, PR:66/min, RR:18 /min-> Dopamine use
CT report
Swelling of appendix measured about 1.7cm in maximal diameter with increased peripheral fat plane infiltration and small localized fluid collection is identified. According to the above findings, acute appendicitis with perforation and small abscess formation is considered
0840 Vital signs: BT: 37.2 C, BP: 85/52 mmHg, PR:106/min, RR:22 /min-> keep BP>100 mmHg 0945 Vital signs: BT: ? C, BP: 126/54 mmHg, PR:116/min, RR:20 /min->
1030 Vital signs: BT: ? C, BP: 134/55 mmHg, PR:110/min, RR:18 /min-> 1100 Vital signs: BT: ? C, BP: 127/48 mmHg, PR:119/min, RR:17 /min-> 1145 Vital signs: BT: ? C, BP: 96/52 mmHg, PR:110/min, RR:18 /min-> 1240 Vital signs: BT: ? C, BP: 149/53 mmHg, PR:108/min, RR:17 /min-> sent OR
ER stasis
: 1538
[v ]
[v]Keep ABC; follow Lab data, EKG, brain CT, CxR [v] [v] [v] [ ] [ ] [ ][ ] [ ][ ][ ] [ ](/) [ ] [ ] [ ]
&
1001104 Appendectomy
Final diagnosis
Reference