2015年7月28日 星期二

Patient information 7/28


Age88 years old

Chief Complaints
Loose motions (for 3 days)  
Decreased micturition (for 2 days)  

My patient was apparently alright 2 weeks back and then started experiencing abdominal pain (in the groin) which was sudden in onset and not progressive. It was associated with vomiting and fever with chills and rigors.
Then he started experiencing loose motions ( 3-4 times a day for 3 days) and no micturition for 2 days. There is no significant Past or family history
He takes tobacco 2-4 times a day for the past 40 years now.
He also has decreased appetite and weight loss and is on a vegetarian diet.

Examination
General examination shows pallor and he appears cachectic, shows clubbing in the left hand.
There are no other positive findings.

Abdominal Exam.
There appears to be bilateral swellings on the sides of the abdomen.
Palpatory, percussion and auscultatory findings are otherwise normal.
 
The patient's information power point it in below website:
https://drive.google.com/file/d/0BwxSJWj5eUYMaFBlNXpwb0lsTWs/view?usp=sharing 
主因:
排便(3天)
無排尿(2天)

我的病人在兩個禮拜前是相當正常的,然後開始瞬間的腹部疼痛(腹股溝)而不是漸進的。這和嘔吐、怕冷和寒戰發熱相關。然後他開始大便(在3 3-4次),2天沒有排尿
沒有明顯的家族病史及症狀
1天抽2~4跟香菸並抽了40
他吃素食並減少了食欲開始減肥

測試:
一般檢查顯示臉色蒼白和出現不好的症狀,並且左手有腫脹的症狀
沒有發現其他病況

腹部測試:
上腹部兩側雙側似乎有腫脹
叩觸診、叩診和聽診結果正常

下面的連結是此病人資訊的PPT:
https://drive.google.com/file/d/0BwxSJWj5eUYMaFBlNXpwb0lsTWs/view?usp=sharing
 

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