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conscious drowsy (lab data (CBC/DC (WBC 9.94
RBC 3.82
Hb/HCT 10.8/31.7
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conscious drowsy
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taking history
過去病史：肝硬化、酗酒、食道靜脈瘤、慢性腎衰竭
家族史：無
醫療史：同過去病史
TOCC:無職業、無出國
ROS:沒有測量體重、疲倦、無發燒、視覺聽覺無改變
心胸：無感冒症狀、活動會喘、擤鼻涕會流鼻血、無胸悶胸痛
腹部：本身有吃lactulose，吃完東西就會拉肚子、無腹痛腹脹
泌尿：解尿無困難、無疼痛
四肢：無外傷、無水腫
according to his wife's statement, he has slowly response and sleepiness all day for four days, So they came to Dr. Liu's OPD on 5/17, confusion of consciousness and sclera icteric were noticed. The lab data of ammonia was 125 mg/dl, and suggested to admission, the he was admitted for further evaluation and treatment on 5/18
PE
HEENT:鞏膜黃疸、眼瞼無蒼白、右鼻腔出血、lip pink、 口腔無潰瘍
無壓痛、甲狀腺無腫大、頸靜脈無凸出
心胸：心音無雜音、規律；呼吸音雙下葉rales，呼吸對稱、
呼吸性喘(wheezing)、呼吸次數：35次/分
腹部:圓潤、微凸、柔軟，無臍凸、無明顯血管分佈，聽診四象限均有腸蠕音，15次/分，叩診無疼痛，呈鼓音，觸診無明顯腫大器官，無壓痛，rebound tenderness(-)、
shifting dullness(未做)、murphy's sign(-)、rovsing's sign(-)、psoas's sign(-)、肝頸反流(未做)
四肢：pause 2+,無水腫、皮膚暗陳無光哲
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imaging
abd ECHO(3/13):splenomegaly,ascites/moderate
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