中英文对照病例书写格式及参考病例.doc

Weekly Case From Family Medicine Residency Training ProgramFamily Medicine Education and Training Center of ZJUTuberculous pericarditis & pleurisy病名（Disease）： 病例来源（Case source）：Sir Run Run Shaw Hospital, School of Medicine, ZJU病例记录及总结人（Case Recording and summarizing）：LIU Yan 记录日期（Recording date，YY/MM/DD）： 2010/07/10项目ItemEnglish中文病人基本情况基本情况Patients situationA 69-year-old woman , admitted on March 12,201069岁，女性，于2010年3月12日入院主诉主诉Chief complaint(c/o)Shortness of breath for more than 40 days胸闷气急40余天现病史现病史Present illness(PI)The patient was admitted to our hospital because of recurrent fevers. She had been well until 40 days earlier, when chills, night sweats developed, without cough, sputum production, dyspnea and hemoptysis. She was admitted to a local hospital. Supportive treatment was begun and the symptoms improved(details not available) and she was sent home. A few days later, dyspnea after activities developed and gradually worsened. Increasing breathlessness on lying flat occured. She was admitted to the same hospital. A chest radicgraph obtained reportedly showed showed “bilateral pleural effusion”. A thoracentesis was performed afterwards. An intrathoracic drain tube was administered. CT scan of the chest on March 6 revealed moderate bilateral pleural effusion, partly compressed lungs and pericardial effusion The test of liver function showed ALT 134/UL, AST 85/UL. Antibiotics were prescribed, as well as medications for protecting the liver. However,the symptoms remained unchanged. The patient reported poor sleep, yet no loss of appetite and weight loss.(PS: no specific causes were identified during this hospitalization. The patient came back to our hospital again because of recurrent dyspnea after being discharged this time). 患者40余天前无明显诱因出现每日下午高热，最高体温39度，伴寒战，偶有夜间盗汗，无咳嗽咳痰，无呼吸困难，无胸痛咯血。于当地医院就诊，予支持对症治疗后好转（具体不详）。之后患者开始出现活动后呼吸困难，逐渐加重，夜间不能平卧，需高枕卧位，至当地医院就诊，发现“双侧胸腔积液”，予胸腔穿刺抽液检查示：李凡他试验（+），WBC 280/ul。予胸腔穿刺置管，2010-3-6日复查胸部CT示：两侧胸腔中等量积液，部分肺组织膨胀不全，心包积液。两中下肺斑片索条影，纵膈淋巴结影。ALT 134U/L,AST 85U/L。予左氧氟沙星依替米星等抗炎治疗,甘利欣护肝，患者上述症状无明显缓解，今为进一步诊治遂来我院就诊。门诊以“胸腔积液”收入院。自病以来，神清精神可，胃纳佳，睡眠差，二便无殊，体重无明显减轻。（附注：病人本次住院期间未明确病因，出院后因“再发胸闷气急”入我院）。、既往史既往史Past History(PH)She had a 8-year history of hypertension. Medications included antihypertensive drugs. She had an allergy to Quinolone. 高血压病8年，服用珍菊降压片，未监测血压。喹诺酮类药物过敏。社会史Social History(SH)No special social history. 无殊。家庭史Family history(FH)Her parents are healthy. Her son and husband are well.家人体健。系统回顾Rewiew of systems(ROS)No other diseases were reported.无其他疾病史。体格检查Physical Exam(PE)Temperature:36; Pulse 117 beats per minute ; Breath:20 breaths per minute; Blood pressure:145/101mm Hg. Pain score: 0. No cyanosis , skin or sclera icterus , jugular venous distension and palpable lymph node were found. Sounds of bilateral lungs were low and some crackles could be heard. Percussion of lower lobes of both lungs was dull . Cardiac rhythm was regular. No additional heart sounds and murmurs were present. No tenderness and rebound tenderness on abdomen. The liver and the spleen were nonpalpable. Shifting dullness was negative. Both legs had slight edema . Babinski signs negative.体温：36度；脉搏：117次/分；呼吸：20次/分；血压：145/101mmHg；疼痛；0分；神清，口唇无紫绀，全身浅表淋巴结未触及肿大，颈静脉无充盈怒张，胸廓无畸形，心前区无膨隆，两下肺呼吸音低，双下肺叩诊音浊，可及少量湿性罗音，未及哮鸣音，未及胸膜摩擦音。无抬举性心尖搏动，心界无扩大，心律齐，心音无亢进，P2小于A2，心前各瓣膜区未闻及病理性杂音，心前区未及震颤。腹平软，无压痛反跳痛，肝脾肋下未及，移动性浊音阴性。双下肢轻微水肿。双侧Babinski征阴性。实验室检查Labaratory1、WBC was high(Table 1) . Liver function and kidney function were normal .2、Pleural fluid tests on different dates showed: Negative for malignancy, CEA and TB (Table 2 and 3).3、 Bronchofiberscope (Bronchial Brushing) Negative for malignancy.4、Pericardial stripping was performmed. Pathology reportedly showed:(Pericardium) Necrotic granulomatous inflammation with hyperplasia of fibrous tissue and hyaline change，acid-fast staining: negative.(PS: pleural effusion Anti -TB positive ,blood Anti TB positive during second hospitalization in our department. 1、血常规示血象升高（表1），肝肾功能正常。2、多次胸水检查提示介于渗出液与漏出液之间，CEA及抗酸染色均阴性，病理检查未发现癌细胞；（表2、表3），3、纤支镜检查（纤支镜毛刷）未见癌细胞。4、手术标本病理结果示（心包）坏死性肉芽肿性炎伴纤维组织增生及玻璃样变，抗酸染色阴性。(附注：患者再次入院查胸水抗酸染色阳性，血液结核抗体（+）)影像学检查Imaging诊断1、B ultrasound of upper abdomenreportedly showed fatty liver; a dense-echo nodule inside right liver, considered to be a hemangioma,2、Chest B ultrasound： bilateral pleural effusion3、By bronchofibroscope , bilateral bronchus were clear and smooth, pigmentation on mucosa of upper left and upper right bronchus could be seen. 4、Echocardiography : enlargement of both atriums could be observed , left ventricular dilatation was restricted. Pericardium was thickened slightly with partial calcification. Moderate tricuspid valve regurgitation. Reportedly revealed constrictive pericarditis.5、CT of chest : exudation could be observed in left and right lower lobes of lungs , as well as bilateral pleural effusion, thickened pericardium, enlarged and calcified lymph nodes in mediastinum.(See images).1、肝胆脾B超：不均质脂肪肝；左肝偏强回声结节，考虑血管瘤2、胸腔超：双侧胸腔积液3、纤支镜检查：两侧支气管通畅，左上、右上支气管粘膜色素沉着斑4、心超：双房稍大，左室舒张功能异常（限制型充盈异常），心包轻度增厚伴钙化，中度三尖瓣反流，考虑缩窄性心包炎 5、肺部CT：左下肺及右肺下叶炎性渗出性改变，两侧胸腔积液，心包增厚，纵隔淋巴结肿大伴钙化，主动脉钙化；(见下图)诊断Diagnosis(DX)1、tuberculous pericarditis 2、tuberculous pleurisy 3. hypertension (2nd grade)1、 结核性心包炎2、结核性胸膜炎3、高血压病2级鉴别诊断鉴别鉴别诊断鉴别诊断Differential DX1. Lung cancer 2. pneumonia 3.Chronic heart failure 4 lymphoma1、肺部肿瘤2、肺炎 3 慢性心衰 4 淋巴瘤治疗治疗全科处理计划FM Treatment(Rx)1. antituberculosis treatment 2. surgical relief pericardial constriction1. 抗结核治疗2. 手术缓解心包压缩全科处方FM Drug Prescription(Drug Rx) Isoniazid ; Rifampicin ; Ethambutol; Pyrazinamide . 异烟肼，利福平，乙胺丁醇，吡嗪酰胺全科讨论要点1Key Point 1 in FM Discussion What the therapeutic principle of the tuberculosis?When differential diagnosis includes TB, you must think of multiple organ involvement and possible complications of 结核的治疗原则是什么？全科讨论要点2Key Point 2 in FM DiscussionHow to differentiate the exudates or the transudate?如何鉴别渗出液与漏出液？全科讨论要点3Key Point 3 in FM DiscussionWhat causes the pleural effusion?导致胸腔积液的原因有哪些？图表1：2010-4-12010