Family history: non-contributory.
* Vital sign: BT=37.8℃, PR: 20/min, BP115/81mmHg
* General appearance: alertness with ill-looking
* SKIN: normal skin turgor, ecchymosis over left ankle and foot, no skin rash, skin
eruption, no skin lesions, no pressure sore.
* HEENT: pale conjunctiva (+, icteric sclera (-, throat congestion (-, tonsils
enlargement (-, pupil size: L/R 3mm/3mm, LR/R +/+
* Neck: supple & soft of neck, no JVE, no thyroid goiter, no carotid bruit.
* Heart: regular HB, S1→ ; S2→, no S3/S4, Gr. 2/6 systolic murmur on apex and
LSB, no thrill, PMI in Lt 5th ICS lat-to mid-clavicular line.
* Cheat: symmetric cheat wall expansion, no spider angioma ; percussion: no
resonant. auscultation: Coarse BS, no rhonchi, no wheezing, no basal rales.
* Abdomen: soft and oveid, no caput meduse, normal bowel sound, no shifting
dullness, no local tenderness, no palpable liver or spleen, no Murphy sign, no
* Genitourinary: no hernia, no C-V angle knocking tenderness
* Extremities: no clubbing cyansis, No pitting edema, no varicose vein of bil low legs,
no joint deformities and full range of motion, no bone, joint, or muscle tenderness
* Peripheral pulsations: radial ++/++, branchial, ++/++, post tibial , ++/++, dorsal
* NEV examination: no remarked findings, GCS=E4V5M6, cranial nerve=intact,
MP=3/5, DTR=++/++, essential sensory system, Babinski’s sign: absent, bil
* Digital examination: no significant finding.
1.Fever and poor appetite, cuase?
2.Type 2 diabetes mellitus with poor control
3.Liver cirrhosis with esophagus varies, moderate splenomegaly and mild ascites. Child A
4.Peptic ulcer disease
5.Chronic ulcer, L’t heel with necrotizing fascitis post operation
6.Old cerebral infarction with right hemiparesis.
(Plan of Management and Treatment
Check SMA, U/R, Hgb AlC
IV fluid supplement with close observation