程士彬查房记录1.doc

瓷?晡猁 最尪梃ㄛ鹹ㄛ35呡ㄛ瓷偶瘍 C693553 翋秪醱窒腹笫5堎豻ㄛ樓笭圈邧狟眱腹笫2堎豻ㄛ衾2000-12-15彶?朳囀褪﹝ 遞氪2000爛7堎場ㄛ拸隴珆袀茼堤珋鹵?桉薣摯晇醱窒阨笫ㄛ魂雄綴熬?ㄛ拸續繚覜?痌袨ㄛ拸楷?﹝帤竘?蛁砩摯杻忷揭燴﹝7堎菁ㄛ奻咂痌袨樓笭ㄛ膝覜椰薯ㄛ壽誹呫芫﹝婓絞華瓟埏脤裕朳髡夔ㄛ悛續都寞ㄛ芛窒CTㄛ帤楷珋祑都﹝8堎婓絞華瓟埏脤樅袨甮髡夔﹜倠窒CT尨淏都﹝9堎婓毞抭瓟埏脤續都寞尨續粥啞75mg/dlㄛ樅袨甮髡夔尨T4 113.8mmol/l(淏都硉57.92-154.44),T3 0.59nmol/l(0.69-2.1), TSH 0.377nIu/l(0.49-4.67), 淖剿峈樅腴,跤迵樅袨甮匼?20mg BID,督蚚珨笚綴, 堤珋妘郗蔥腴ㄛ號梠﹝樟哿督蚚奻扴狻昜ㄛ9堎菁堤珋邧狟眱揤側俶阨笫﹝9-20婓衶假瓟埏蛂埏笥谿ㄛ帤夔隴?淖剿ㄛ 跤迵瞳續狻昜綴ㄛ阨笫秏豖綴堤埏ㄛ堤埏綴樟哿督蚚樅袨甮匼?20mg Bidㄛ邧狟眱阨笫摯號梠衱膝樓笭﹝2000-11-11婓扂埏藷淖脤樅髡尨T3 0.6ng/dl, T4 3.12pg/ml,TSH 3.932uIu/ml, TUP 1.63, 續都寞尨粥啞續75mg/dlㄛ,悛都寞淏都,裕朳眲?尨TP 3.0g/dl , ALB 1.20g/dl, A/G0.7ㄛCHO 348mg/dlㄛ TG301mg/dlㄛca 6.9mg/dl﹝蕉藉朳瓷軘磁痌ㄛ跤迵厒續揭燴ㄛ甜樟哿督蚚樅袨甮匼?笥谿ㄛ隙模綴ㄛ瓷?輛珨祭樓笭ㄛ邧狟眱阨笫摯號梠樓笭ㄛ甜荌砒網柲﹝2000-12-12懂扂埏摹淖脤萇賤窐淏都ㄛBUN7mg/dl˙ Cr 0.6mg/dl,續都寞尨Pro﹜GLU淏都ㄛ跤軑厒續瞳續ㄛ甜跤軑啞粥啞10gㄛ峈輛珨祭隴?淖剿摯笥谿彶?朳囀褪﹝遞氪赻?瓷眕懂ㄛ妘郗腴ㄛ儕朸淏都ㄛ极笭崝樓15Kgㄛ拸壽誹芫﹜嫖徹鏗﹜濘霾珋砓﹜拸諳﹜桉補﹝ 暫厘妢ㄩ拸杻忷﹝ 跺?妢ㄩ汜酗衾控儔ㄛ觼鏍ㄛ昢觼ㄛ髒衄觼狻諉揖妢ㄛ拸砮阨諉揖妢﹝柲捈16爛ㄛ20 盓/毞﹝ 模逜妢ㄩ瘁?昒續瓷﹜夢陑瓷﹜朳婄瓷脹疻換 ?埏脤极ㄩT 37.9⊥ Pㄩ88棒/煦 Rㄩ24棒/煦 Bpㄩ110/95mmHg Wt 77 Kg 珨啜?錶褫,?痺梜臚拸紳啞﹜酴?ㄛ拸堤贀悛唯ㄛ拸裕梪﹜眯絇謻﹝邧狟眱苤虯?痺尕棉缽﹝酘耜珚恮褫摯1.5cm沭坰欴賦凳, ?豻窒弇?桶邀匙賦帤摯笫湮﹝樅袨甮祥湮﹝裕勳噙闕隙霜涽(-)﹝邧狟煎網柲秞秏囮,帤恓摯補坁蹕秞﹝陑婄帤摯祑都﹝號傘陃袨ㄛ號峓97cmㄛ狟號摯掖窒眕狟?痺阨笫ㄛ帤獗庛釵倰摯?雄疏ㄛ裕?帤夔揖摯ㄛ Murphy`s涽ㄗ-ㄘㄛ裕?﹜邧朳?萰芫ㄗ-ㄘㄛ膛狟苤?郖萰湴嘆秞ㄛ?豻窒弇萰淖嘆秞ㄛ痄雄俶觙秞ㄗ+ㄘㄛ釵霪秞3棒/煦ㄛ秞覃祥詢蕩ㄛ帤恓摯悛奪娸秞﹝秝黨摯秝墨阨笫ㄛ邧狟眱隴珆揤側俶阨笫ㄛ邧苤虯俋灉奻20cm揭虯峓41.5cm﹝汜燴毀扞淏都ㄛ瓷燴毀扞帤竘堤﹝ 落翑潰脤ㄩ 2000-11-21 悛都寞ㄩ WBC6.6*109/LㄛGR71.2%ㄛHGB131g/LㄛPLT135*109/L 2000-11-21 續都寞 LEU25/UL PRO 75mg/dl 2000-11-21 裕朳髡夔ㄩCr 0.70mg/dlㄛBUN10mg/dlㄛTP3.0g/dl, ALB1.2g/dl K 3.88mmol/ Na 132.8mmol/l Cl 107.1mmol/l GLU85mg/dl CHO 348mg/dl TG 301mg/dl ALT 7u/l AST17u/l LDH 111u/l 2000-11-21 號窒B閉ㄩ 裕囀隙汒棉ㄛ筐奪0.4cm, 藷闕1.1cm, ?綠2.8cm, 號阨﹝ 2000-12-12 朳? K 3.9mmol/l Na 136mmol/l Cl 111mmol/l Cr 0.6mg/dl BUN 7mg/dl GLU 81mg/dl CO2 21mmol/l 2000-12-12 續都寞 PH 6.0 PRO (-) GLU(-) ?埏淖剿: 腹笫埻秪渾脤