小港内科Clinicalcourse.PPT

Case presentation 98/05/05 Presented by Intern :吳勝騰 Patient profile Name:辜O雄 Chart number:Age : 74-year-old Gender: male Date of admission: 98/4/23 Chief complaint Fever up to 39’C with chills was noted in this morning.(4/23) Present illness This 74 y/o male is a case of Diabetes mellitus was diagnosed 5 years ago, under oral anti-diabetic medication control. Last month, he was admitted for jaundice. Decreased appetite and loss of body weight (2kg within 2 weeks ) were noted then. The patient also complained of tea colored urine and clay colored stool. Associated symptoms and signs last month included: fever (-), chills (-), fatigue(+) mental disturbance or behavior change (-), general weakness (+), insomnia(-) RUQ tenderness(-),hunger pain (-), post prandial pain (+), diarrhea (-), nausea (-), vomiting (-) ,tarry stool(-), bloody stool(-) Yellowing of the skin(+), itching of the skin(+) Present illness During last admission, a series of examinations were performed, and the laboratory data and image survey indicated the possibility of an obstructive leision involved his biliary tract. Under the impression of obstructive jaundice, she received ERBD insertion on 4/9 for symptom relief. Clinical course Present illness However, after discharged from our ward, fever up to 39’C attacked him again with chills on 4/23, and his family brought him to our ER for help. Associated symptoms and signs included: fever chills(+), weakness (+), fatigue(+), rhinorrhea(-), sore throat(-), nasal obstruction(-), intermittent cough with mild sputum(-), abdominal pain(-), nausea(-), vomiting(-) ,bowel habit change(-), pain, tarry stool(-), bloody stool(-), clay color stool(-) urinary frequecny(-), burnning sensation(-), dysurea(-) Yellowing of the skin(-), itching of the skin(-) Clinical course Under the impression of recurrent biliary tract infective episode, he was admitted again, and received antibiotic therapy. Current medicine Diamicron MR(●) ﹝1 ＊ BI