Physical findings:
Appearance: acute ill-looking
Consciousness: clear
Vital sign: temperature 38.5°C, pulse rate 100/min, respiratory rate 20/min, blood pressure 108/64 mmHg (premix dopamine 10ml/hr)
Chest: breath sound: clear; Heart: regular heart beat; no murmur, no thrills, no heaves
Abdomen: soft; distended; op scar (+); bowel sound: normoactive; no abdominal bruit; liver/spleen: not palpable; tenderness at left upper quadrant
Extremities: freely movable; no pitting edema, no palmar erythema, no petechiae

Course and treament 
Salmonella was isolated from blood culture on November 29. Despite of ceftriaxone therapy, high fever and severe pain responded very slowly. Higher fever and relative leukopenia were noted on December 2. Drug fever was suspected and antibiotic was shifted to ciprofloxacin on December 4. Fever subsided subsequently and follow-up blood cultures were negative. Panendoscopy was done on December 13 for persistent left subcostal pain and very poor appetite, but no significant lesion noted. General condition improved gradually. Follow-up abdominal CT on December 28 revealed progression of saccular aneurysmal dilatation of aorta at thoraco-abdomen junctional area and increased soft tissue density. Surgical intervention was performed on January 12. A fusiform thoracic aortic aneurysm about 5x5 cm in size and mural thrombus adhered to pulmonary tissue were noted. Necrotic tissue was excised and grafting with 24mm Hemashield of thoracic-abdominal aorta was performed. The debrided tissue was sterile. This patient was extubated smoothly on Jan 14 and was discharged on Jan 18.

一般檢查紀錄(General Inspection):
[ CBC+PLT ]

項目	WBC	RBC	HB	HCT	MCV	MCH	MCHC	PLT
日期	K/μL	M/μL	g/dL	%	fL	pg	g/dL	K/μL
891122	11.62	3.94	11.6	34.4	87.3	29.4	33.7	516.0
891128	8.45	3.81	11.5	33.1	86.9	30.2	34.7	458.0

STOOL (891214): Appearance: yellowish, O.B. (-) C-Reactive Protein (891128) 18.3 (normal, < 0.8 (mg/dl))

Blood Culture & Sensitivity: Salmonella O9 (group D1), susceptible to chloramphenicol, ampicillin, cefotaxime, ciprofloxacin, co-trimoxazole 

Radiology Report
89/11/22 Standing chest PA view shows:
Rotative position; low volume film; increased infiltration at R't lower lung field; bil. sharp CP angles. normal heart size; tortuous aorta with artherosclerotic change.
89/11/24, CT. With/Without co-ABDOMEN:
Bil. pleural effusion and atelectasis of the bil. lower lobe is noted. abnormal soft tissue density is noted around the aortic esophageal recess. The inflammatory process at the A recess is highly suspected. A bulging lesion with well enhancement is noted at the post. aspect of the aorta. Aneurysmal change cannot be excluded. The aortic wall showed atherosclerotic changes. Abnormal thickening and effusion are noted at bil. lower pleura. minimal atelectatic change at the left lower lung. Dot calcifications at the spleen
89/11/28, GA-67 Whole body scintigraphy in the anterior and posterior projections were performed at 24 & 48 hours after tracer injection. Findings: 1) The scans demonstrated normal distribution of the tracer activity to the liver, spleen and skeletal system. 2) One focal faint abnormal concentration of tracer activity was noted at left posterior mediastinal (or paraspinal) region which is consistent with an active inflammatory process such as abscess, pneumonia, or mycotic aneurysm of aorta
89/12/28, CT. With/Without co-ABDOMEN:
Saccular aneurysmal dilatation of aorta at thoraco-abdomen junctional area, with largest diameter about 5 cm, hypodense mass between aorta and left lateral margin of T9 and T10, hypodense rim around the enhanced lumen and partial atelectasis of adjacent lung is also found, mild left pleural effusion, mycotic aneurysm should be considered first. suspicious curvilinear lucent line in the aneurysmal dilatation, r/o aortic dissection. atherosclerosis with mural thrombus and calcification of abdomen aorta. suspicious a small enhanced nodule at segment 7 of liver, r/o hemangioma. tiny calcification in spleen. bil. renal cysts. no definite lesion in GB, pancreas, and bil adrenal glands. suspicious small nodules at RML.
Impression: Saccular aneurysmal dilatation of aorta at thoraco-abdomen junctional area, mycotic aneurysm should be considered first, r/o dissection aneurysm. r/o small hemangioma at segment 7 of liver. suspicious small nodules at RML.

Discharge Clinical Diagnosis
Thoracic aortic aneurysm due to Salmonella O9 (group D1) status post grafting