文档介绍：Patient data
• Female
• Birth date: 民國 66/09/17
•已婚
•學歷: 中學
plain
• Nausea, diarrhea and flank soreness and
with bilateral legs swelling
Present illness
• This patient received C/S due to difficult dilivery
at 詹宜宏婦產科 on 2005/06/12
• 2 wks ago , she started to have dull abdominal
pain but didn’t pay much attention to it.
• 7/18 plained nausea, diarrhea & flank
soreness
• Bilateral legs swelling and difficult to raise up
• No Hoffman sign and calf muscle tenderness
• Came to ER for help
Family history
• Not contributory
Personal history
• Smoking: ~1 PPD for 12 years
• Alcohol: nil
• Food allergy: nil
• Drug allergy: nil
• Betel nut eating: nil
• Oral contraceptive: nil
Past history
• Surgical history: C/S on
• Medical history: nil
Review of system
• General appearance: weakness
• HEENT: normal
• Respiratory system: cough(+), sputum(-), dyspnea(-)
• Cardiovascular: no chest pain, PND, palpitation,
intermittent claudication
• GI: nausea (+), abd. pain (+), vomiting (-)
• GU: no hematuria, urgency and frequency
• Musculoskeletal: back pain(+) legs swelling(+) no
joint pain and stiffness
Physical examination(1)
• Weight: 65KG, Height: 163cm,GCS: E4V5M6
• TPR: ℃/82/26 . : 96/58 mmHg
• General appearance: acute ill looking
• Eye: free movable
– Pupil: light reflex: prompt(+) size: isocoria 2mm/2mm
– Conjunctiva: pale, sclera: icteric(-)
• Throat: no tonsil enlargement
• Mouth: no rash and ulcer
• Neck: no JVE, mass, bruit, lymphadenopathy
Physical examination(2)
• Chest: symmetric expansion, breathing sound clear
• Heart: regular heart beat, no murmur
• Abdomen: flat, soft, mass(-), scar(+), murphy’s sign(-),
rebound pain(-), tenderness(+)
• Extremities: legs swelling(+), no cyanosis, pitting edema,
Lab data
• CRP: mg/dL
• WBC: 10490 uL
• Stool OB (-)