病生病例讨论 英文版.docx
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病生病例讨论 英文版.docx
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病生病例讨论英文版
CIRRHOSIS硬化,肝硬化
PATIENTCASE
Patient’sChiefComplaints患者主诉
Providedbywife:
“Myhusband’sveryconfusedandhehasbeenactingstrangely.Thismorning,hecouldn’tanswermyquestionsandseemednottorecognizeme.Ithinkthathisstomachhasbeenswellingup膨胀again,too.Hestoppeddrinkingfouryearsago,buthiscirrhosis肝硬化seemstobegettingworse.”
HPI(Historyofpresentillness)
S.G.isa46yowhitemalewithahistoryofchronic慢性的alcoholism酗酒andalcoholiccirrhosis.酒精性肝硬变Hewasadmittedtothehospitalfromtheoutpatient门诊病人clinic诊所withabdominal腹部的swelling肿胀andconfusion.Hehasunintentionally无意间gained15lbs磅duringthepastfourweeks.Accordingtohiswife,thepatienthasnotbeensleepingwellforseveralweeks,hasbeenfeelingverylethargic(昏睡)forthepastthreedays,can’tseemtorememberappointments约会lately,and,uncharacteristically,不典型地haslosthistemperwithherseveraltimesinthelastmonth.S.G.’sbossatworkhadalsotelephonedherlastweekconcernedabouthis“unusualandviolentbehavioronthejob.”
PMH(Pastmedicalhistory)
●Pneumonia肺炎9yearsagothatresolved解决withantimicrobial抗菌的therapy治疗
●Cirrhosis肝硬化secondaryto继发heavyalcoholuse大量饮酒diagnosed诊断4yearsagowithultrasound超声波andliverbiopsy活组织检查(micronodular小结的cirrhosis)
●H/Ouncontrolledascites腹水andperipheral外围的edema浮肿,水肿(H/O:
historyof)
●H/Otwoupper上部的,较高的GI升糖指数hemorrhages出血上消化道出血?
fromesophageal食管的varices静脉曲张
●H/Oanemia贫血
●H/OE.coli-induced大肠杆菌引起的bacterialperitonitis细菌性腹膜炎4yearsago
●H/Oacute急性的pancreatitis胰腺炎secondarytoalcoholabuse饮酒过度
●Nohistorytosuggestcardiac心脏的orgallbladder胆囊disease
翻译:
没有心脏或者胆囊的疾病史
●Nopreviousdiagnosis诊断ofviral病毒的orautoimmune自身免疫的hepatitis肝炎
翻译:
先前没有病毒性或者自身免疫性肝炎的诊断
SURG外科
●S/Pappendectomy阑尾切除术requiringbloodtransfusions输血30yearsago
●S/Popen-reduction开放复位internal内部的fixation定影ofrightfemur大腿骨secondaryto继发MVA摩托车车祸5yearsago(SP:
statuspost病后状态;MVA:
motorvehicleaccident)
FH(Familyhistory)
●Fatherdiedatage52fromliverdiseaseofunknownetiology病因
翻译:
父亲由于不明原因的肝脏疾病在52岁时去世
●Motherhadrheumatoidarthritis风湿性关节炎andulcerativecolitis溃疡性结肠炎,diedfrommassivestroke严重中风atage66
●Maternalaunt姨母,age71,withGravesdiseaseGraves病
●Patienthasnosiblings兄弟姐妹
翻译:
病人没有兄弟姐妹
SH(Socialhistory)
●Educatedthrougheighthgrade
翻译:
8年级毕业
●Departmentstoremen’sclothingmanagerandsalesman,17-yearcareer
●Marriedfor19yearswith1daughter,age10
翻译:
结婚19年了,有一个10岁的女儿
●H/Oethanol乙醇abuse,quit5yearsagofollowingMVA,previouslydrank3cases箱ofbeer/week×15years
●H/OIVDA(heroin)andintranasal鼻内的cocaine可卡因,quit5yearsago(IVDA:
intravenous静脉的drugabuse)
●Hassmokedapproximately1/2ppdformanyyears(ppd:
packs包perday)
Meds(medications医疗护理)
●Propranolol心得安(用于治疗心律不齐,心绞痛等)10mgpoTID(po:
bymouth口服,TID:
threetimesdaily)
●Spironolactone螺内酯(一种利尿药)50mgpoQD(QD:
everyday)
●Furosemide速尿灵20mgpoQD
●MVI多种维生素滴注1tablet药片poQD每天
●Occasional偶尔的ibuprofen布洛芬(抗炎,阵痛药)oracetaminophen(退热药)forheadache
●PatienthasH/Onon-compliance违反义务withhismedications
ALL(Allergy过敏症)
NKDA(noknowndrugallergies)
ROS(reviewofsystems)
●Increasingabdominalgirth胸围(周长)
●(-)complaintsofabdominalpain,fever,chills,寒冷nausea,呕吐vomiting,呕吐hematemesis咯血,tarrystools柏油样便,lossofappetite,食欲减退cough,咳嗽chestpain胸痛,SOB(shortnessofbreath),呼吸急速lightheadedness,头昏眼花的weakness,bloodintheurine(尿),尿中带血diarrhea,痢疾constipation,便秘anddrymouth口干
PatientCaseQuestion1.Hematolysis咯血andtarrystools拉黑便areclinical临床的signsofwhichseriouspotentialcomplication并发症ofcirrhosis?
Gen(general)
Thepatientisrestless,mildly适度地jaundiced,患黄疸病的anddisoriented紊乱的totime,place,andpeople.Heisslowtoanswerquestionsandhisanswersmakelittlesense.Heisill-appearingbutinnoobviousdistress痛苦.
VS(Vital重要的signs)
●BP120/75,P83andregular(supine仰卧的)
●BP118/70,P80andregular(standing站立的)
●RR14andunlabored平静的
●T98.8Forally口温37.1摄氏度
●WT1711bs体重77.6千克
●HT5ft-7in
●SaO2=97﹪
Skin
●Warm,dry,andwellperfused遍布withnormalturgor肿胀
●Mildjaundice轻微黄疸
●(+)spidernevionchest胸部有蜘蛛痣
●(-)palmarerythema肝掌
●Severalecchymoses(瘀斑)onlowerextremities肢端
●Large“cobra”tattoo眼镜蛇纹身onrightupperarm右上臂
HEENT(head,eyes,ears,nose,throat)
●(-)bruises淤青,masses,集中anddeformities畸形onhead
●(+)ictericsclera巩膜黄染
●Pupils瞳孔at3mmandreactivetolight光反应灵敏
●EOMI(extra-ocular眼睛的movementintact完好无缺的)
●Funduscopicexam眼底镜检查WNL(WNL:
withinnormallimits)
●TMsclearandintact未损伤的(tympanicmembrane鼓膜)鼓膜完好无损,听力清晰
●O/Ppink,clear,andmoist潮湿的withouterythema红斑orlesions伤口
Neck/LN(lymphnodes淋巴结)
●Supple柔软的
●(-)JVD(jugularvenous颈静脉detension轻松)
●(-)goiter,thyroidnodules,carotidbruits,andadenopathy
Chest
●LungsCTAbilaterallywithoutwheezesorcrackles(CTA:
cleartoauscultation听诊)
●DiaphragmaticexcursionsWNL
●Goodairexchange
●(+)gynecomastia
Heart
●RRR(regularrateandrhythm)
●NormalS1andS2withnoS3orS4
●Nom/r/gheard(m/r/g:
murmur/rub/gallop)
Abd(abdomen腹部)
●Moderatelydistended,firm,andslightlytender
●(+)prominentveinsobservedaroundumbilicus
●(+)HSM(hepatosplenomegaly)
●ActiveBS(bowelsounds)
●(-)guarding,reboundtenderness,palpablemasses,andaortic,iliac,andrenalbruits
Genit/Rect(genitalia/rectum)
●Heme-negativestool
●Penisnormal,testiclesmoderatelyatrophicbutwithoutmasses
●Normalsphinctertone
●(+)hemorrhoids
●Prostatemaybeslightlyenlargedbut(-)fornodulesandtenderness
MS/Ext(mentalstatus/extremities)
●Noclubbingoredema
●Goodperipheralpulsesat2+throughout
●Normalrangeofmotionthroughout
Neuro
●CNsgrosslyintact
●BriskDTRsat2+(DTR:
deeptendonresponse)
●Slightasterixisnoted
●Strengthisequalbilaterally
●Confusedanddisoriented
●NegativeBabinski
●Sensorygrosslyintact
PatientCaseQuestion2.Identifyaminimumof15clinicalsignsandsymptomsthatareconsistentwithadiagnosisofcirrhosis.
LaboratoryBloodTestResults
SeePatientCaseTable18.1
PatientCaseTable18.1LaboratoryBloodTestResults
Na135meq/L
WBC4,700/mm3
Mg1.7mg/dL
K3.5meq/L
PT15.6sec
AFP90ng/mL
Cl101meq/L
PTT45.1sec
HBsAg(-)
HCO325meq/L
NH3250ug/dL
HIV(-)
BUN12mg/dL
AST107IU/L
Anti-HCV(+)
Cr0.6mg/dL
ALT86IU/L
HCVRNA2.8million/mL
Glu,fasting90mg/dL
AlkPhos224IU/L
ANA(-)
Hb14.0g/dL
Bilirubin2.4mg/dL
Fe75ug/dL
Hct39.7%
Protein6.6g/dL
Ferritin200ng/mL
MCV90fL
Alb2.7g/dL
Transferrinsaturation38%
Plt34,500/mm3
Ca8.5mg/dL
Ceruloplasmin37mg/dL
AFP:
-fetoprotein(normal0-15ng/mL),ANA:
antinuclearantibody,MCV:
meancorpuscularvolume,NH3(normal18-60g/mL)
PatientCaseQuestion3.Isthepatientanemic贫血atthistimeand,ifso,istheanemianormocytic正常红细胞性贫血microcytic小红细胞性贫血ormacrocytic巨细胞性贫血?
PatientCaseQuestion4.Whatisthemostsignificantabnormality变态thatthispatient’sCBC(completedbloodcount总红细胞数)hasrevealed显示?
PatientCaseQuestion5.Basedonthelaboratorydata,whyhasthispatient’scirrhosis肝硬化shownasuddenandunexpectedprogression上升?
PatientCaseQuestion6.Identify鉴定fourriskfactorsthatmayhavecontributedto导致thispatient’scurrentcondition.
PatientCaseQuestion7.Whycanbacterialperitonitis细菌性腹膜炎beruledoutasacurrentpotentialdiagnosis潜在的诊断?
PatientCaseQuestion8.Whatjustification理由mightthepatient’sprimaryhealthcareproviderhaveforconductinganANAtest?
PatientCaseQuestion9.Whycanhemochromatosis血色沉着病beruledoutasacontributingfactortothispatient’scondition?
PatientCaseQuestion10.WhycanWilsondiseaseberuledoutasacontributingfactortothispatient’scondition?
PatientCaseQuestion11.Whycanautoimmunehepatitis自身免疫性肝炎andprimarybiliarycirrhosis原发性胆汁性肝硬化beruledoutascontributingfactorstothispatient’scondition?
PatientCaseQuestion12.Isthereanyevidencethatthispatientisathighriskforosteoporosis骨质疏松症?
PatientCaseQuestion13.Identifytwoabnormallaboratoryteststhatareconsistentwith符合ascites腹水.
PatientCaseQuestion14.Whichsinglelaboratoryteststronglysuggeststhatthepatienthasdevelopedhepaticencephalopathy肝性脑病?
PatientCaseQuestion15.Howwouldyougradethispatient’sencephalopathy脑病?
PatientCaseQuestion16.Whatisthispatient’sCTPscore?
PatientCaseQuestion17.Whatistheprobabilitythatthispatientwillliveforoneyear?
PatientCaseQuestion18.Doesthispatienthaveanysignsofdehydration脱水orhepatorenalsyndrome肝肾综合征?
PatientCaseQuestion19.Thepatient’sprimarycareproviderhasdecidedtoconductextensive大量的clinical门诊的studiesforthediagnosis诊断oflivercancer.Whichsingleabnormallaboratoryvalue评价hasraisedaconcernthathepatocellularcarcinoma肝细胞癌mayhavedeveloped?
问题1:
咯血和柏油样便是肝硬化哪一种严重的潜在并发症的临床症状?
问题2:
至少找出15个肝硬化的临床症状和体征。
问题3:
这次患者有贫血吗?
如果有,那么是正常红细胞性贫血,还是小细胞性或者大细胞性呢?
问题4:
这个病人的全血细胞计数说明了哪个最显著的异常问题?
问题5:
根据实验室检验的数据,为什么这个病人的肝硬化出现了急性和意外的恶化?
问题6:
说出4个可能会导致病人出现现在的症状的风险因素。
问题7:
为什么细菌性腹膜炎不被考虑为当前潜在的诊断?
问题8:
病人的初级保健医护人员有什么理由让病人去做抗核抗体测试?
问题9:
作为病人病情的影响因素,为什么血色沉着病可以被排除?
问题10:
作为病人病情的影响因素,为什么Wilson病(肝豆状核变形)可以被排除?
问题11:
作为病人病情的影响因素,为什么自身免疫性肝炎和原发性胆汁性肝硬化可以被排除?
问题12:
是否有任何证据表明,这名病人存在患骨质疏松症的高风险?
问题13:
说出2个与腹部积水相关的异常的化验结果。
问题14:
哪一个实验数据能强有力地证明病人已经患有肝性脑病?
问题15:
你将如何给病人的脑病分等级?
问题16:
这个病人的CTP评分是什么?
问题17:
这个病人能活一年的概率是多少?
问题18:
这个病人是否有脱水和肝肾综合征的任何迹象?
问题19:
这个病人的初级保健提供者已经打算为肝癌的诊断进行广泛的临床研究。
哪一个化验的异常值表明肝细胞癌已经扩散?
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