詹宜宏妇产科on.pdfVIP

Patient data • Female • Birth date: 民國66/09/17 • 已婚 • 學歷: 中學 Chief complain • Nausea, diarrhea and flank soreness and with bilateral legs swelling Present illness • This patient received C/S due to difficult dilivery at 詹宜宏婦產科on 2005/06/12 • 2 wks ago , she started to have dull abdominal pain but didn’t pay much attention to it. • 7/18 she complained nausea, diarrhea flank soreness • Bilateral legs swelling and difficult to raise up • No Hoffman sign and calf muscle tenderness • Came to ER for help Family history • Not contributory Personal history • Smoking: 0.5~1 PPD for 12 years • Alcohol: nil • Food allergy: nil • Drug allergy: nil • Betel nut eating: nil • Oral contraceptive: nil Past history • Surgical history: C/S on 2005.06.12 • Medical history: nil Review of system • General appearance: weakness • HEENT: normal • Respiratory system: cough(+), sputum(-), dyspnea(-) • Cardiovascular: no chest pain, PND, palpitation, intermittent claudication • GI: nausea (+), abd. pain (+), vomiting (-) • GU: no hematuria, urgency and frequency • Musculoskeletal: back pain(+) legs swelling(+) no joint pain and stiffness Physical examination(1) • Weight: 65KG, Height: 163cm,GCS: E4V5M6 • TPR: 37.4℃/82/26 B.P. : 96/58 mmHg • General appearance: acute ill looking • Eye: free movable – Pupil: light reflex: prompt(+) size: isocoria 2mm/2mm – Conjunctiva: pale, sclera: icteric(-) • Throat: no tonsil enlargement • Mouth: no rash and ulcer • Neck: no JVE, mass, bruit, lymphadenopathy Physical examination(2) • Chest: symmetric expansion, breathing sound clear • Heart: regular heart beat, no murmur • Abdomen: flat, soft, mass(-), scar(+), mur