【医学生物PPT】倪旻白_VS.ppt

业精于勤荒于嬉 行成于思毁于随 →【医学生物PPT，欢迎收藏分享】豆丁网友 Case Report Intern 倪旻白/VS 鐘焜明 Chief Complaint Change in mental status and headache for one month. Present Illness The 69 year-old female patient had the past history of (1) ESRD on regular H/D(qw2 , 4 , 6) at 永康榮民醫院 for 5 years; (2) Type 2 DM for 30+ years under regular insulin control ; (3) DM foot s/p B-K amputation; (4) PAOD with secondary infection in 94/12; (5) Left DM foot (1st and 2ndtoe gangrene) s/p debridement + STSG on 94/12/24. last hospitalization: right renal abscess and sepsis ( Klebsiella pneumoniae bacteremia ) in 97/09.?????? Present Illness In recent one month, she had suffered from right eye corneal ulcer with pain and was under our OPH OPD treatment. Change in mental status and headache for one month. Vomiting and chills occurred today after hemodialysis. No fever, no abdominal pain. ER? Admisson Past History Medical history: type2 DM with insulin control for 30+ years ESRD on H/D for 5 years; Cata s/p for 8 years; AVF FOR 4+ years; DM foot s/p B-K amputation; right peripheral arterial obstructive disease with secondary infection in 94/12; Left DM foot (1st and 2ndtoe gangrene) s/p debridement + STSG on 94/12/24 Personal History 1.Cigarette smoking: denied 2.Alcohol consumption: denied 3.Family history: denied Allergy History: 1.Drug: denied 2.Food: denied Review of Systems General: body weight loss(-),weakness(+), fatigue(+), fever(-), chills(+) Head: headache(+), head injury(-) Eye: blurred vision(+) , diplopia(-) , pain(+) GI：nausea(-) , vomiting(+) Musculo-skeletal: limitation of motion(+) Physical Examination Vital sign: BP 131/74 mmHg, BT 36 ℃, HR: 82 BPM, RR 20 /min General appearance: weak , no fruity nor urine smell Consciousness: drowsy HEENT: Eye: OD: severe corneal ulcer , impending perforation, severe infiltration OS: blindness no Racoon eye, no Battles sign Nose: no otorrhea, no rhinorrhea