1040119 會診

病情摘要:

Dear Dr,

Respectfully referring a case of 72-years-old male patient with

1) Urinary tract infection with partial treatment.
2) Chronic obstructive pulmonary disease ( history ).
3) Back pain, cause to be determined.

104/01/17
C.T. with/without contrast\Abdoman
使用非離子性顯影劑(Xenetix-350 100ML)
CT of ABDOMEN with/without contrast:
Impression:
1. Suspicious soft tissue in the right paraspinal region at T10 level.
2. No definite intraabdominal infection.
3. Others, as aforementioned above.

** Arrange L spine X ray today

We request your expertise for further evaluation and management

Thanks a lot !!!

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會診意見:

TL SPINE REVEAL NO BONY LESION AND NO FRACTURE. PATIENT BACK

PAIN IMPROVE. CONTINUE CONSERVATIVE TREATMENT. BACK
CONDITION CAN BE FOLLOW UP AT OPD

1040202 住院
入院診斷：
- Right upper abdominal pain with Murphy's signs (+)
=> suspect acute cholecystitis
- Chronic obstructive pulmonary disease
----------------------------------------------------------------------------------
出院診斷：
1.Right para-spinal tumor,benign ,T9,10 level with cannal compression s/p
minithoracotomy with tumor biopsy and pneumolysis, laminectomy of T9,10 and
spinal fusion of T7-T12
2.Reflux esophagitis under medication treatment
3.Chronic obstructive pulmonary disease without exacerbation
4.Hepatic nodule
5.Anemia due to surgical blood loss
----------------------------------------------------------------------------------
主訴：
RUQ pain for 2 days
----------------------------------------------------------------------------------

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手術日期及方法（包括手術發現）：
104/02/13 Pneumolysis with Para-spinal tumor biopsy
104/02/13 Decompression diskectomy + Posterior instrumentation

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住院治療經過：
104/03/02=Check CRP : 0.48 -->change oral antibiotic treatment
= Postoperative care was done as usual process
= Patient had a good and smooth healing course
= Under general condition stable
= Patient was discharged this morning for OPD follow up.
----------------------------------------------------------------------------------

血液檢查 Blood
日 期 WBC RBC Hb HCT MCV MCH MCHC Platelet
= = = = ====== ==== ===== ===== ===== ===== ===== =========
1040202 10790 426 12.7 39.2 92.0 29.8 32.4 396
1040210 5670 370 11.0 33.3 90.0 29.7 33.0 284
1040213 15100 446 12.7 37.0 83.0 28.5 34.3 222
1040214 12490 402 11.6 33.5 83.3 28.9 34.6 242
1040216 8320 349 9.9 29.7 85.1 28.4 33.3 221
1040217 10.5
血液檢查 Blood
日 期 Neutrophil Lymphocyte Monocyte Eosinophil Basophil
= = = = =========== =========== ========= =========== =========
1040202 79.2 13.5 6.6 0.6 0.1
1040210 74.1 16.2 7.9 1.6 0.2
1040214 90.6 4.2 5.1 0.0 0.1
1040216 86.5 5.0 6.9 1.6 0.0

血液檢查 Blood
日 期 ESR60` ESR 120` ABO Typing RH Typing
= = = = ======= ========= =========== ==========
1040210 68 115
1040212 A Positive
1040226 35 76

一般生化 Blood
日 期 BUN CRP CPK CREA K NA GOT GPT G.G.T TBIL
= = = = ==== ===== ==== ===== ==== ==== ==== ==== ====== =====
1040202 17 3.82 71 0.94 3.3 140 28 28 87 1.6
1040210 4.62
1040213 3.7 137
1040214 14 1.32 4.1 141 15 1.5
1040216 3.1 134
1040216 0.63
1040217 3.2 135
1040226 1.44
1040302 0.48

一般生化 Blood
日 期 Lipase AMY ALKP CA ALB
= = = = ======= ==== ===== ==== ====
1040202 30 115 88
1040214 7.7 3.2