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C/O : general weakness and malaise , consciuness disturbance in recent day @Present illness : This 48 year-old male patient . He has history of cirrhosis , PUD , HCV and was under regular medication at our H in more years. This time he suffered from general weakness and malaise , consciousness disturbance... 顯示更多 C/O : general weakness and malaise , consciuness disturbance in
recent day

@Present illness : This 48 year-old male patient . He has history of cirrhosis , PUD , HCV and was under regular medication at our H in more years.
This time he suffered from general weakness and malaise , consciousness disturbance and poor appetite , abdomen distension , general malaise with weakness , tea color urine was noted.
So he was be sent to our OPD by his .
In OPD , the checked conscious was E4V5M6 , and checked BP was 112/74 mmhg , BT was 36.9 , HR was 75 bpm. The P.E showed clear of breathing sound , no wheezing sound over both lung fields , abdomen mild distension , sclera icteric(+) was noted . The Lab showed NH3:98.
So he was admitted ward for further evather evaluation and treatment.

檢體發現:
@General Review of system :No body weight loss, no fever , no chill General malaise(+) , no cold sweating

Neurological system :No headache , no syncope , no vertigo , no muscle weakness ; no sensory important , no incontinence , no tremor , no dysarthria & no dizziness.

Respiratory system :No dyspnea , no cough m no sputum , no pain , no cyanosis , no sorethroat , no rhinorrhea.

Cardiovascular system :No palpitation , no precordial pain , no radiated pain , orthopnia , no paroxynomal nocturnal dyspnosa.

Gastrointestinal system : pain(+) , nause(-) , voitting(-) , diarrhea(-) , tarry stool(-) , no mass , poor appetite(+) , distension(+) , no constipation.

Urological system :No back soreness , no dysuria , no frequency , no urgency , tea color urine(+).

Musculoskeletal system :No limited motion .

Hematologic system :No bruise , no weakness.

Dermotologic system :No ulcer , no rash.
更新: 病理診斷:
Stomach , body and antrum , endoscopic biopsy , ulcer with chronic active gastritis and helicobacter infection.
Gross finding : the specimen submitted consists of 2 tissure fragments measuring 0.3 * 0.2 * 0.2 cm fixed in formalin.
Grossly , they are tan and soft All for section
更新 2: Microscopic finding : section shows gastric mucosa with focal necrosis , inflammatory exudates , and mucosa with marked neutrophil activity , and lymphoplasma cells in the lamina propria . Microorganism , morphologically consistent with helicobacter sp.
更新 3: Are present on the epithelial surfact . No glandular atrophy , intestinal metaplasia , nor malignancy is seen.
3/13
Patient was examined.
Anosocpy : GI int hemo at 7 and 3 oclock
P : med TX.
Both knee pain for 2 days , phx : liver cirrhosis alcoholist gout.
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