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Clinical Pathology Conference: Case Presentation - 67-year-old Female with Conscious Disturbance

This clinical pathology conference presents the case of a 67-year-old female patient with an chief complaint of conscious disturbance. The presentation will discuss the patient's vital signs, physical examination findings, laboratory results, and imaging studies.

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Clinical Pathology Conference: Case Presentation - 67-year-old Female with Conscious Disturbance

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Presentation Transcript

  1. 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

  2. 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 General Data

  3. Chief Complaint • conscious disturbance this morning

  4. Present Illness • Conscious disturbance since morning • No seizure • No fever • Family denied recent trauma history.

  5. Past and Personal History • No HTN • Denied DM • No known allergy • Medication history: not documented

  6. Physical Examination • General appearance • E4V1M5 • HEENT • Supple • Chest • Breathing sound: coarse • Heart sound: RHB, no cardiac murmur • Abdomen • soft and flat, no tenderness • Extremity • bilateral Babinski reflex: dorsiflexion • bilateral muscle power:3

  7. RBC: 3.25 million/uL Hb: 9.8 g/dl Hct: 28.8 % MCV: 88.6 fL MCH: 30.2 pg/cell MCHC: 34.0 g/dl RDW: 18.8 % Platelet: 7 k/uL WBC: 8300/uL Segment: 86.0 % Band: 1.0 % Lymphocyte: 9.0 % Monocyte: 4.0 % APTT: 29.1 seconds PT: 12.5 seconds INR: 1.11 Hemogram

  8. F/S: 127 mg/dl Cr: 1.1 mg/dL Na: 132 meq/L K: 3.4 meq/L Ca: 8.4 meq/L Ammonia: 71 umol/L ALT: 33 IU/L Total bilirubin: 4.1 mg/dL Direct bilirubin: 0.9 mg/dL Troponin-I: 2.5 ng/ml ABG: pH: 7.547 PCO2: 26.3 mmHG PO2: 77.0 mmHG HCO3: 22.3 mm/L SBE: -0.1 mm/L SAT: 96.9 % Biochemistry

  9. Image Study • CXR: • Unremarkable • Brain CT( 外片): • no intracranial hemorrhage, no subarachnoid hemorrhage nor mass lesion

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