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General Data

Chief Complaint. Persistent right upper abdominal dull pain with radiation to lower abdomen for one day. Present Illness. The 61-year-old male had (1) DM under OHA control for 6 years (2) Hypertension without control (3) Gout (4) Gastric ulcer He suffered from initia

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General Data

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Presentation Transcript

    1. ???????? July 5 , 2007

    2. General Data Name: ?XX Chart No.: L102213434 Age: 61-year-old Gender: Male Admission Date: March 31, 2007

    3. Chief Complaint Persistent right upper abdominal dull pain with radiation to lower abdomen for one day

    4. Present Illness The 61-year-old male had (1) DM under OHA control for 6 years (2) Hypertension without control (3) Gout (4) Gastric ulcer He suffered from initial tarry stool passage and later bloody stool passage on March 25. => admitted to ???? Hospital .

    5. Present Illness Obstructive Jaundice=> ERCP with ERBD catheter insertion. Abdomen CT: pancreatic tumor

    6. Present Illness He suffered from right upper abdominal pain with radiation to lower abdomen on March 30. His abdominal pain improved until the morning on March 31.

    7. Present Illness General weakness, fatigue and nausea developed in the morning on March 31. He was sent to our ER for help on March 31.

    8. Physical Examination in ER Vital signs:TPR: 37.8 °C/133/24, BP: 65/47mmHg General appearance: acute ill-looking Consciousness: clear (E4M6V5) HEENT: conjunctiva: mild pale sclera: mildly icteric pupil: isocoric throat: no injected neck: supple, no palpable lymph node

    9. Physical Examination in ER Chest: symmetric expansion, clear breathing sound Heart: regular heart beat, no murmur Abdomen: soft, flat, tenderness over epigastric area and right upper quadrant of abdomen, no rebounding pain, no muscle guarding, normoactive bowel sound Extremeties: freely movable

    10. Laboratory Data in ER

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