Case Gen 3

S.Wichien
17/6/2554

Patient identification

33

.

History
CC : 6 . .
PI : 6 . .

2
3 . .

History

8
10

Physical examination
BT 38.2 c, PR 110, RR 24, BP 140/90
HEENT
Pink conjunctivae, Mild jaundice
CLN : impalpable

Heart
Normal S1 S2, no murmur

Lung
Normal breath sound

Physical examination
Abdomen
-Mild distended abdomen

-Tender as figured
-No guarding
-No mass
-Decreased bowel sound

-Surgical scar as figured

Physical examination
Extremity
No pitting edema

PR
Mild warmness
Yellowish soft feces
No mass
No rectal shelf

Physical examination
Sign of chronic liver disease
Parotid gland enlargement
Spider naevi +ve
Palmar erythema

Lab
CBC
HB 11, Hct 36.1, WBC 5200
PMN 86%
Plt 109,000

Lab
LFT
Chol 175, TP 8.6, alb 4.5, glob 4.8
TB 4.8, DB 2.4
ALT 55, AST 130, ALP 243

HBV/HCV = -ve

Lab
UA
Sp.gr 1.024, WBC 5-10, RBC 5-10

BUN 8.6 / Cr 0.8

Ultrasound bedside

No IHD dilatation
Collapsed gall bladder
Small gall stones
Minimal ascites

Lab
Serum Amylase 57
Urine amylase 222

Admit day 1


H/C = gram negative bacilli *2 specimen

Follow up

CT abdomen

Management
Pre op Dx
Acute appendicitis
Alcoholic cirrhosis

Thank you