2014/12 一般內科

1. Case presentation
Date:2014/12/09
Doctor: 謝宜璋醫師
PGY: 郭政諺醫師

2. Patient Profile
! Chart Number:
21628067
! Name: 曹O傑
! Gender: Male
! Age: 87
(1972/10/08)
! Height: 160cm
! Weight: 46.9kg
! BMI: 18.3
! Admission date:
2014/12/06
! Admission condition
T: 36.9°C
P:82/min
R:16/min
BP: 126/68 mmHg

3. Chief Complaint
! Progress bilateral legs edema for two days

4. Present Illness
! ER:
short of breath, dizziness,
T: 36.6°C, HR: 110/min, BR:18/min, BP:115/58mmHg
! No systemic disease before
! Legs pitting edema
- gradually onset and persisted for two days
- bilateral, grade +++
- no local heat, skin lesion
- associated symptoms: weakness, pale, short of breath
Negative finding
- No fever, No nausea/vomiting, No chest pain,
No OP history,
No decreased urine, No other edema,
No tarry nor bloody stool, No taking new drugs

5. Personal History
! Allergy: No Known
Allergy
! Travel History: Nil
! Occupation: Nil
! Contact: Nil
! Cluster: Nil
! Betelnut (Denied)
! Smoking (Denied)
! Alcohol (Denied)

6. Family history
23 yr
No DM, HTN, Mailgnancy
family hsitory

7. Past History
! 1.Pulmonay TB post-anti-tberculosis therapy history
! 2.Osteoporosis with old T10 T12 L2 L3 compression fracture

8. Physical examination
Pale conjunctiva and lips
Dry lips and tongue
Smooth breath pattern
Coarse breathing sound
Bilateral limbs pitting edema
Irregualr heart beat
Systolic heart murmur
Abdomen soft,
No tenderness,
No enlarge liver border
Tympanic percussion sound
No skin lesion,
No visible varicose

9. Chest X-ray

10. EKG

11. Laboratory Examination
! Hemogram

12. Laboratory Examination

13. Urine Analysis

14. Impression
! 1) Anemia, microcytic cause to be determined R/O GI loss
! 2) Congestive heart failure,NYHA FcIII
! 3) Osteoporosis with old T10 T12 L2 L3 compression
fracture
! 4) Malnutrition
! 5) Bilateral hearing impairment

15. Plan
! 1) Diagnostic:
-Microcystic Anemia
Examination stool ob, Arrange Pandoscope, Survey
tumor marker
- Heart failure
Arrange 2D cardio echo
Find the reason caused heart failure
! 2) Treatment:
- Blood transfusion
- Fe support
! 3) Discharge plan
- Find the reason of GI bleeding and mangement
- Find the risk factor of Heart failure and educated patient
- Vital sign stable with stable clinical appearance

16. Treatment course
! Anemia

17. Treatment course
! Anemia

18. Treatment course
! 2014/12/8~9
! Hb: 3.9 g/dl à 8.5 g/dl
(blood transfusion 5U)
with stable vital sign, no dyspnea, no dizziness now
! Wait for 2D echo and Panendoscope

19. Thanks for your listening