病生病例讨论 英文版.doc

CIRRHOSIS硬化，肝硬化PATIENT CASEPatients Chief Complaints患者主诉Provided by wife: “My husbands very confused and he has been acting strangely. This morning, he couldnt answer my questions and seemed not to recognize me. I think that his stomach has been swelling up 膨胀again, too. He stopped drinking four years ago, but his cirrhosis肝硬化 seems to be getting worse.”HPI (History of present illness)S.G. is a 46 yo white male with a history of chronic慢性的alcoholism 酗酒and alcoholic cirrhosis.酒精性肝硬变 He was admitted to the hospital from the outpatient门诊病人 clinic诊所 with abdominal 腹部的swelling 肿胀and confusion. He has unintentionally 无意间gained 15 lbs 磅during the past four weeks. According to his wife, the patient has not been sleeping well for several weeks, has been feeling very lethargic（昏睡） for the past three days, cant seem to remember appointments 约会lately, and, uncharacteristically,不典型地 has lost his temper with her several times in the last month. S.G.s boss at work had also telephoned her last week concerned about his “unusual and violent behavior on the job.”PMH (Past medical history)l Pneumonia 肺炎9 years ago that resolved 解决with antimicrobial 抗菌的therapy 治疗l Cirrhosis 肝硬化secondary to继发 heavy alcohol use大量饮酒 diagnosed诊断4 years ago with ultrasound超声波 and liver biopsy 活组织检查( micronodular小结的cirrhosis)l H/O uncontrolled ascites腹水 and peripheral外围的 edema浮肿，水肿 (H/O: history of)l H/O two upper 上部的，较高的GI升糖指数 hemorrhages出血 上消化道出血？from esophageal食管的 varices 静脉曲张l H/O anemia贫血l H/O E. coli-induced大肠杆菌引起的 bacterial peritonitis 细菌性腹膜炎4 years agol H/O acute急性的 pancreatitis胰腺炎 secondary to alcohol abuse饮酒过度l No history to suggest cardiac心脏的 or gallbladder 胆囊disease 翻译：没有心脏或者胆囊的疾病史l No previous diagnosis诊断 of viral病毒的 or autoimmune 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l S/P appendectomy阑尾切除术 requiring blood transfusions 输血30 years agol S/P open-reduction开放复位internal内部的 fixation定影 of right femur大腿骨 secondary to继发 MVA摩托车车祸 5 years ago (SP: status post病后状态; MVA: motor vehicle accident)FH (Family history)l Father died at age 52 from liver disease of unknown etiology病因 翻译：父亲由于不明原因的肝脏疾病在52岁时去世l Mother had rheumatoid arthritis风湿性关节炎 and ulcerative colitis溃疡性结肠炎, died from massive stroke 严重中风at age 66l Maternal aunt姨母, age 71, with Graves disease Graves 病l Patient has no siblings兄弟姐妹 翻译：病人没有兄弟姐妹SH (Social history)l Educated through eighth grade 翻译：8年级毕业l Department store mens clothing manager and salesman, 17-year careerl Married for 19 years with 1 daughter, age 10 翻译：结婚19年了，有一个10岁的女儿l H/O ethanol乙醇 abuse, quit 5 years ago following MVA, previously drank 3 cases箱 of beer/week15 yearsl H/O IVDA (heroin) and intranasal鼻内的 cocaine可卡因, quit 5years ago (IVDA: intravenous静脉的 drug abuse)l Has smoked approximately 1/2 ppd for many years (ppd: packs包 per day)Meds (medications医疗护理)l Propranolol心得安（用于治疗心律不齐，心绞痛等） 10 mg po TID (po: by mouth口服, TID: three times daily)l Spironolactone螺内酯（一种利尿药） 50 mg po QD (QD: every day)l Furosemide 速尿灵20 mg po QDl MVI 多种维生素滴注1 tablet药片 po QD每天l Occasional偶尔的 ibuprofen布洛芬（抗炎，阵痛药） or acetaminophen（退热药） for headachel Patient has H/O non-compliance 违反义务with his medicationsALL(Allergy过敏症)NKDA (no known drug allergies)ROS (review of systems)l Increasing abdominal girth 胸围（周长）l () complaints of abdominal pain, fever, chills,寒冷 nausea,呕吐 vomiting,呕吐 hematemesis咯血, tarry stools柏油样便, loss of appetite,食欲减退 cough,咳嗽 chest pain胸痛, SOB (shortness of breath), 呼吸急速lightheadedness,头昏眼花的 weakness, blood in the urine（尿）, 尿中带血diarrhea,痢疾 constipation,便秘 and dry mouth口干Patient Case Question 1. Hematolysis 咯血and tarry stools拉黑便 are clinical 临床的signs of which serious potential complication 并发症of cirrhosis?Gen (general)The patient is restless, mildly 适度地jaundiced,患黄疸病的 and disoriented紊乱的 to time, place, and people. He is slow to answer questions and his answers make little sense. He is ill-appearing but in no obvious distress痛苦.VS (Vital重要的 signs)l BP 120/75, P 83 and regular ( supine仰卧的)l BP118/70, P 80 and regular( standing站立的)l RR 14 and unlabored平静的l T 98.8F orally口温37.1摄氏度l WT 171 1bs 体重77.6千克l HT 5 ft-7 inl SaO2 =97Skinl Warm, dry, and well perfused 遍布with normal turgor肿胀l Mild jaundice轻微黄疸l ( +) spider nevi on chest胸部有蜘蛛痣l ()palmar erythema肝掌l Several ecchymoses（瘀斑） on lower extremities肢端l Large “cobra” tattoo 眼镜蛇纹身on right upper arm右上臂HEENT (head, eyes, ears, nose, throat)l ()bruises淤青, masses,集中 and deformities畸形 on headl ( +) icteric sclera巩膜黄染l Pupils 瞳孔at 3 mm and reactive to light光反应灵敏l EOMI (extra-ocular眼睛的 movement intact完好无缺的)l Funduscopic exam 眼底镜检查WNL (WNL: within normal limits)l TMs clear and intact 未损伤的(tympanic membrane鼓膜)鼓膜完好无损，听力清晰l O/P pink, clear, and moist潮湿的 without erythema红斑 or lesions伤口Neck/LN (lymph nodes淋巴结)l Supple柔软的l () JVD (jugular venous颈静脉 detension轻松)l () goiter, thyroid nodules, carotid bruits, and adenopathyChestl Lungs CTA bilaterally without wheezes or crackles (CTA: clear to auscultation听诊)l Diaphragmatic excursions WNL l Good air exchangel ( +) gynecomastiaHeartl RRR (regular rate and rhythm)l Normal S1 and S2 with no S3 or S4l No m/r/g heard (m/r/g: murmur/rub/gallop)Abd (abdomen腹部)l Moderately distended, firm, and slightly tenderl ( +) prominent veins observed around umbilicusl ( +) HSM (hepatosplenomegaly)l Active BS (bowel sounds)l () guarding, rebound tenderness, palpable masses, and aortic, iliac, and renal bruitsGenit/Rect (genitalia/rectum)l Heme-negative stooll Penis normal, testicles moderately atrophic but without massesl Normal sphincter tonel ( +) hemorrhoidsl Prostate may be slightly enlarged but ()for nodules and tendernessMS/Ext (mental status/extremities)l No clubbing or edemal Good peripheral pulses at 2+ throughoutl Normal range of motion throughoutNeurol CNs grossly intactl Brisk DTRs at 2+ (DTR: deep tendon response)l Slight asterixis notedl Strength is equal bilaterallyl Confused and disorientedl Negative Babinskil Sensory grossly intactPatient Case Question 2. Identify a minimum of 15 clinical signs and symptoms that are consistent with a diagnosis of cirrhosis.Laboratory Blood Test ResultsSee Patient Case Table 18.1Patient Case Table 18.1Laboratory Blood Test ResultsNa 135meq/LWBC 4,700/mm3Mg 1.7 mg/dLK 3.5 meq/LPT 15.6secAFP 90ng/mLCl 101 meq/LPTT 45.1 secHBsAg (-)HCO3 25 meq/LNH3 250ug/dLHIV (-)BUN 12 mg/dLAST 107IU/LAnti-HCV (+)Cr 0.6 mg/dLALT 86 IU/LHCV RNA 2.8million/mLGlu, fasting 90 mg/dLAlk Phos 224 IU/LANA (-)Hb 14.0g/dLBilirubin 2.4 mg/dLFe 75ug/dLHct 39.7%Protein 6.6g/dLFerritin 200ng/mLMCV 90fLAlb 2.7 g/dLTransferrin saturation 38%Plt 34,500/mm3Ca 8.5mg/dLCeruloplasmin 37mg/dLAFP: a-fetoprotein (normal 0-15 ng/mL), ANA: antinuclear antibody, MCV: mean corpuscular volume, NH3 (normal 18-60 mg/mL)Patient Case Question 3. Is the patient anemic 贫血at this time and, if so, is the anemia normocytic正常红细胞性贫血microcytic小红细胞性贫血or macrocytic巨细胞性贫血?Patient Case Question 4. What is the most significant abnormality变态 that this patients CBC (completed blood count总红细胞数) has revealed显示?Patient Case Question 5. Based on the laboratory data, why has this patients cirrhosis肝硬化 shown a sudden and unexpected progression上升?Patient Case Question 6. Identify鉴定 four risk factors that may have contributed to导致 this patients current condition.Patient Case Question 7. Why can bacterial peritonitis 细菌性腹膜炎be ruled out as a current potential diagnosis潜在的诊断?Patient Case Question 8. What justification理由 might the patients primary health care provider have for conducting an ANA test?Patient Case Question 9. Why can hemochromatosis血色沉着病 be ruled out as a contributing factor to this patients condition?Patient Case Question 10. Why can Wilson disease be ruled out as a contributing factor to this patients condition?Patient Case Question 11. Why can autoimmune hepatitis自身免疫性肝炎 and primary biliary cirrhosis原发性胆汁性肝硬化 be ruled out as contributing factors to this patients condition?Patient Case Question 12. Is there any evidence that this patient is at high risk for osteoporosis骨质疏松症?Patient Case Question 13. Identify two abnormal laboratory tests that are consistent with符合 ascites腹水.Patient Case Question 14. Which single laboratory test strongly suggests that the patient has developed hepatic encephalopathy肝性脑病?Patient Case Question 15. How would you grade this patients encephalopathy脑病?Patient Case Question 16. What is this patients CTP score?Patient Case Question 17. What is the probability that this patient will live for one year?Patient Case Question 18. Does th