7 2554

50 .

PCU

CC: 3

Present illness
3 .

1-3
2-3
8
1
Ibuprofen (400) 1 tab o prn

Nortriptyline x 1 o hs

1 Prednisolone (5) 4x3 o pc,

Amitriptyline (10) 1x1 o hs

1 .
3 1

Relevant history
4-5

Tension headache
2-3

F/U OPD Eye 2553 fundoscope ->

normal F/U . 2554 -> peripheral

degeneration 6

 Past History
2548 AUB -> Myoma uteri
2548- . 2552 Dx CML present w/ bleeding

diathesis Rx Glivec (100) 1x3 -> 2x2 o pc ->

CCR Loss cytogenetic response Ph
chromosome 7% -> titrate dose
Glivec 600 mg/d -> resistance . 2552
on Nilotinib (200) 2x2 o pc status
CMR, CCR
Dysthymia
. 2554 calcied along left supraspinatous
tendon F/U PMR

 Past History
Hyperthyroid? 20 yr PTA on antithyroid x 10 yr

Subacute thyroiditis admit 2552 Rx Prednisolone (5)

2x3 o pc I131 x 1
right nephrostomy 2535 why?
Chronic dyspepsia Gastroscope 2552; Mild gastritis

Psychosocial
10+

 Medical history
plasil
Current medicine
Nilotinib (200) 2x2 o pc
Prednisolone (5) 4x3 o pc
Tramol (50) 1x3 o pc
o simvastatin (10) 1x1 o hs Ativan (1) 1x1 o hs
consult neuro 2554

Physical examina3on
GA; A middle aged woman looked depress, alert,

cooperative
Vital signs
BT
PR

36.8 C
RR 18 breaths/min
78 bpm BP 110/70 mmHg

HEENT
Not pale, no jaundice
Pupils 3 mm RTL BE
Sti neck negative
No facial palsy
Heart; normal s1, s2 no murmur
Lungs; clear

 Abdomen; soft, not tender, sx scar (midline

laparotomy)
Ext; no edema, no petichiae
Neuroexam;
Motor grade 5 all
Sensory intact
DTR 2+ all
Clonus - / -
BBK <-> / <->
Cerebellar signs; Intact

Problem
LIST

Approach

CBC
Hb 11.5
Hct 36.5
WBC 15,300 (PMN 89.4 L 8.2 Eo 0.1)
Plt 332,000

CT Brain
No denite mass lesion in the brain parenchyma. No
midline shift. No displacement or dilatation of ventricles.
Injection of contrast material shows no abnormal
enhancement.

IMPRESSION; Negative study

Eimorn Mairiang,M.D.(244)
Radiologist

 BUN 13.3

Chol 243

Cr 0.7
Na 140

TP 7.7
Alb 4.2

K 3.8
HCO3 31.6
Cl 102

Glb 3.5
Tb 0.3
DB 0.1

Ca 9.5
P 3.6

ALT 14
AST 16

Mg 2.2

ALP 79

LDL 131

Coagula3on
PT 9.2
INR 0.9
PTT 23.15