全院病例讨论模板

1、病例讨论第二季度外科、手术室、放射科病例概况男性，41岁，因“反复间断咯血13年余，再发5个月，加重3天”入院 。13年前无明显诱因咯血，起初为暗黑色血块，后为鲜红色血液，量不详，伴有轻咳，痰少，自服中药及休息后能自行止血，近2年发作减少，咯血量少，每年发作1-2次，常能自行缓解。5个月前咯血再发，量及次数较前增多，为鲜红色血液，2月前于广州医科大学第一附属医院住院诊治，考虑“肺结核后遗症”，经抗炎，止血化痰处理效果不佳，自动出院。于3天前症状加重，约一饭碗，为鲜红色血液，伴轻度头晕、心慌，伴刺激咳嗽，自觉全身发热 。既往史、个人史无特殊。有吸烟史，饮酒史。家族史无特殊。体格检查无阳性体征。2

2、012年11月9日广医呼研所胸部CT+肺动脉造影示：1、肺动脉造影未见异常；2、拟左下肺前内基底段肺静脉少量附壁血栓形成；3、左上肺尖后段纤维性肺结核并含气不全。4、两上肺、右下肺背段胸膜下多发肺大泡形成。纤支镜检查：支气管粘膜充血，未见狭窄及占位病灶。肝胆脾胰肾彩超未见异常。2012年12月23日，血WBC 9.82109/L，中性粒细胞百分比78%，血红蛋白108/L，血小板正常。CRP12mg/L,ESR20mm/h。ALT35，AST29，GGT42，ALP72。GLU5.6，凝血四项与D-聚体：PT（凝血酶原时间)17.7，PT/R(凝血酶原比值)1.55，PTINR（凝血酶原国际比

3、值）1.52，Fbg1.36，TT19.0，D-聚体0.06。肾功UREA2.76，CRE84.1，UA293。痰涂片：未发现抗酸杆菌，血清肺支原体抗体（-），结核杆菌抗体（-），急诊胸部CT平扫加肺动脉CTA未见异常。经抗炎，止血处理2天效果不佳，咯血频繁，请耳鼻喉会诊，给予喉镜检查：咽喉炎。行鼻咽喉部MRI扫描未见异常。行胃镜检查未见异常。住院第三天再次行CT肺动脉造影并行肺动脉栓塞术，术后3小时咯血仍增多，继续微泵垂体后叶素等止血对症处理，住院16天出院。 病例特点病程长，再次发作，突然加重病情重病情复杂病史不完整转归不明确一、病例特点1、病程长，再次发作，突然加重。中青年，男性，反复间

4、断咯血13年余，再发5月，加重3天；2、病情重：咯血量较多，约一饭碗，为鲜红血液。 3、病情复杂：缺乏阳性体征，仅胸部CT检查及血液检查阳性，发病以来缺乏明确诊断。4、病史不完整：缺乏详细治疗史、寄生虫接触史等。5、转归不明确：行CT肺动脉造影并行肺动脉栓塞术，术后3小时咯血仍增多，继续微泵垂体后叶素等止血对症处理，住院16天出院。二、诊断本病初步诊断考虑：一、支气管内膜结核；二、左上肺纤维性肺结核；三、肺大泡；四、轻度失血性贫血；五、慢性咽喉炎。支持点：1、本病主要临床表现为咯血伴低热；2、有陈旧结核的影像表现；3、CT提示肺部含气不全，考虑局部支气管有狭窄或阻塞；4、出血后CT检查肺部未见

5、异常，考虑出血点位于左上肺含气不全区；5、再次肺动脉造影并肺动脉栓塞术后出血仍增多，考虑为支气管动脉引起的出血；6、CT示两上肺、右下肺背段胸膜下多发肺大泡形成 ；7、患者咯血，血红蛋白108/L ；8、喉镜检查：咽喉炎 。鉴别诊断1、支气管扩张（咯血常见，CT未提示可排除）2、肺ca （支持点：慢性咯血史、刺激性咳嗽，CT未见明确占位，但细小病变如支气管内膜CA未能排除）3、肺大泡破裂（多为胸腔内出血，CT未提示）4、血液病（少见，血液及骨髓检查未完善，暂不支持）5、肺寄生虫（未作粪便检查，CT未提示）116、上消化道出血（无消化道病史及体征，胃镜检查正常）7、循环系统病变（无消化系统病史及

6、体征，未完善相关检查）8、免疫系统，系统性红斑狼疮（缺乏病史及体征，未作相关检查）9、先天性疾病，肺AV瘘、肺A瘤（肺A造影不支持）10、慢支肺气肿（无病史及体征） 三、本病有何经验教训 1、放宽思维，要把少见病、罕见病考虑进去。2、完善病史及相关检查，如循环系统、支气管动脉DSA、免疫系统、血液系统等。3、可试行诊断性治疗以明确诊断，可使用抗结核药物。4、在缺乏阳性体征时，要考虑执行相关辅助检查。THANKS！Click to edit title styleThemeGallery is a Design Digital Content & Contents mall developed

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