CC
Right ankle painful swelling noted 2 days ago

PI
This 47-year-old female has been bobust and denied any systemic diseases. She claimed that she had car accident and got fracture of right ankle in Feb, 2008. She received internal fixation susgery and was regularly followed-up in  Hospital. No abnormalities of bony structures of bony structure were noted. She noted sudden onset of fever episodes on 9/16. No cough/rhinorrhea, no diarrhea, no dysuria were noted. She found her right ankle painful swelling with erythematous change on 9/17. No skin eruption was noted. Exposure to insect bite or wild plants was denied. She visited ER for help. Vital signs at ER revealed: BT 36.8 degrees, PR 80/min, RR 14/min and BP 139/98 mmHg. PE revealed right ankleswelling extending to lower portion of the calf. Mild tenderness was noted. CBC disclosed no obvious leukocytosis(WBC=6100/cumm) and microcytic anemia. CRP=134.62 mg/L. Elevated liver function tests were also noted(ALT/AST=84/101 IU/L). Under the impression of cellulitis, she was admitted for further eveluation and management.


PH
1. Diabetes mellitus: denied
2. Hypertension: denied
3. OP histroy: internal fixation of right ankle in 2008/02

PSOH
Cigarette Smoking: denied
Alcohol: denied
Occupation history
Contact history: denied
Travel history: denied


Review systems
mgeneraln
@usual weightG-				recent weight changesG-
@feverG39					weaknessG-
@fatigueG-					
mskinn
@rashG-						eruptionsG-
@drynessG-					cyanosisG-
@jaundiceG-					changes in skinGcellulitis
@hairG-						nailsG-
mmusculoskeletal systemn
@joint pain or stiffnessG-		arthritisG-
@goutG-						backacheG-
@muscle painG-				crampG-
@swellingGcellulitis			rednessGcellulitis
@limitation in motor activityG-	


FH
as pedigree


Current Medicine
nil


Allergy
alcohol and certain unknown drug


PE
  Consiousness: alert
  Vital sign:BP:  133/91  mmHg, PR:60 bpm, RR:20cpm, BT:37.4 J 
 Conjuntiva: not pale, sclera: anicteric
  Neck: supple, no jugular vein engorgement, no lymphadenopathy   
  Chest: symmetric expansion
       Breath sound: clear BS, no wheezing, no crackles
       Heart sound: regular heart beat, no murmur
  Abdomen: global shape, no tenderness, no mass lesion
         Bowel sound: normoactive
         Percussion: tympanic(+)
         Liver/Spleen: impalpable
         Murphy sign (-), McBurney sign (-)
         No bilateral flank knocking pain
  Bilateral lower extremity: movable, no pitting edema



ALD

ݮ߰i
   :Blood
   :     
(ɶ)
970918 (0000)2008/09/

߰i
   :Blood
   :     
(ɶ)
970918 (0000)2008/09/

ͤ
   :Blood
   :           GLU      AST      ALT      CRP      BUN     CREA
(ɶ)               mg/dL     IU/L     IU/L     mg/L    mg/dL    mg/dL
970918 (0000)970918 1
970918 (1109)              123      101       84   134.62       16     0.73

   :Blood
   :           NA        K
(ɶ)    m mol/L  m mol/L
970918 (0000)
970918 (1109)     137      3.5

@G
   :Blood
   :           WBC      RBC      HGB      HCT      MCV      MCH
(ɶ)            x1000/uL x10^6/uL     g/dL        %       fl       Pg
970918 (0000)970918 1
970918 (1100)              6.1     5.34     10.9     33.2     62.2     20.3

   :Blood
   :         MCHC      PLT      RDW     NEUT    EOSIN     BASO    LYMPH
(ɶ)          % x1000/uL        %        %        %        %        %
970918 (0000)
970918 (1100)    32.7      239     14.6     71.0      1.3      0.4     20.5

   :Blood
   :         MONO    Blast Promyelo    Myelo     Meta     Band      Seg
(ɶ)          %        %        %        %        %        %        %
970918 (0000)
970918 (1100)     6.8

   :Blood
   :        Eosin     Mono    Lymph     Baso Atypical  Normobl
(ɶ)          %        %        %        %        %  /100wbc
970918 (0000)
970918 (1100)




TDI
1. Celulitis of right ankle
2. microcytic anemia


Problem list
(1)Celulitis of right ankle:
  @X-ray: no bone destruction
 Plan :
  @Oxacillin 2gm Q6H from 9/18

(2)microcytic anemia:
  @no menorrhagia(w̪b~gAJggW)
 Plan :
  @suspected IDA
  @Serum iron, ferritin, transerrin and TIBC
  @Stool routine

(3)elevated liver function tests:
  @HBV(-)
  @HCV: uncertain
  @jaundice?
 Plan :
  @Check T/D bilirubin
  @ALK-P and G-GT


PLan

 Gˬd  ͤˬd 
v@@
 DnĪ:Oxacillin 2gm Q6H 
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