【医学生物PPT】医学伦理讨论会.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 醫學倫理討論會2009-02-13 PGY侯欣妤/ VS鐘焜明 Basic data Name:賴x彰 Gender: male Age:35 y/o Bed number: 9002B Chart Number:Date of admission: 98/02/01 Chief complaint Hemoptysis for 2 days Present illness 35 years old male had been relatively healthy Recent 1 month, he had cough with slight yellowish sputum 2 days ago, he suffered from sudden onset of hemoptysis No fever or chills, no dizziness, no dyspnea, but mild chest pain No history of pneumonia,chronic cough, trauma, body weight loss, bleeding tendency He ever visited to 佳里綜合 hospital for treatment , and then symptoms got improved. However, recurrent hemoptysis developed at 4 PM last afternoon Present illness At our ER (98.01.31 11:36pm) ? Vital sign: T/P/R36.6/97/22,BP: 180/124mmHg  CXR ? Diagnosis: Hemotysis r/o bronchiectasis ? admitted on 98/02/01 9:31am for further evaluation and management Past Medical History 1. Medical history: Hypertension --------(-) Diabetes mellitus ---(-) Chronic hepatitis B--(-) Chronic hepatitis C--(-) 2. Surgical history: nil 3. Drug allergy: No known allergy Personal History 1. Smoking: : Nil 2. Alcohol: Nil 3. Betel nut: Nil 4. Herbal medication: Nil Family History Diabetes Mellitus (-) Hypertension (-) Heart disease (-) Cancer history (-) Physical Examination Vital signs: BP: 169/109 mmHg PR: 76/ minutes RR: 19/ minutes BT: 36.5℃ Consciousness: Clear, GCS: E4M6V5 HEENT: Supple neck, no icteric sclera, no pale conjunctiva Oral: No injection, no bleeder Physical Examination Chest : Symmetric expansion, Normal respiratory pattern Clear breathing sound, no wheezing, no rales Heart : Regular heart beat, no murmur Abdomen : Soft, no distension No tenderness, no palpable mass Normal active bowel sounds Laboratory data Tentative diagnosis Hemotysis, r/o acute bronchitis Admission course Admission on 98/02/01 9:31am 98/02/02 11:30 am Consultation of chest 1.Susp