急診醫學年會臨床病理討論會.pptVIP

2009年一般醫學系臨床病理討論會 Clinical Pathology Conference 病史篇 報告者：第 年住院醫師 General Data 67-year-old female Triage 病患主訴因意識模糊 Vital sign : BT 36.2 ℃ HR 121/min RR 20/min BP 113/72 mmHg GCS: E4V1M5 Chief Complaint conscious disturbance this morning Present Illness Conscious disturbance since morning No seizure No fever Family denied recent trauma history. Past and Personal History No HTN Denied DM No known allergy Medication history: not documented Physical Examination General appearance E4V1M5 HEENT Supple Chest Breathing sound: coarse Heart sound: RHB, no cardiac murmur Abdome