[問題] 不知道該怎麼寫
我還是學生~
線在在上身體評估~
老師給我ㄧ篇!!
要我去評估!!
如何去處置
我不知道如何下筆~~
我有些會有些不會!!
可以跟我說怎麼寫嗎??
謝謝!!
我步道如何評估!
但是我知道一些處置
入院診斷 suspect HCC
C/O RUQ pain 一般黃疸和身體需弱及感覺減退2~3個月
PI 她有時候RQU pain 2~3月
她的家人說他有近來過我們的ER
可惜 elevated liver function was noted and abd echo was
performed with liver tumor was found suspect HCC and ascites
(這邊我翻不好!所以我就打英文)
PH 她曾經有慢性C型肝炎
PE:vital sign:BT36.4度C(x),RR:18bpm,PR:58bpm,BP:115/72mmHg
Abdomen: soft&round i shape. Bowel sound:normal. Mass:RUQ. Tenderness:RUQ.
Rebound pain(-).L/S:palpable. Shifting dullness(+). Murphy's sign(-).
Costovertebal angle knocking pain(-).
Lab. Exam.:WBC:4300/mm^3 Hb:9.1mg/dl platelet:206x10^3個/mm^3
AST/ALT:180(10-30)/375(2-32)IU/L PT/PTT:11.7/13.6sec
CL/Na/K:102.6/136.9/4.26mmol/l(99-111)/(137-145)/(3.1-5.3)
BUN:20mg/dl(6-24) Cr:0.7mg/dl(0.5-1.4) Glu:103mg/dl
Anti-HAV IgM(-)_ Anti-HCV(+) HBsAg(-) AFP 24.45(20)
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