炎症病例讨论Word格式.docx
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Dr.VernonA.Rayford(Medicine–Pediatrics):
A29-year-oldwomanwasadmittedtothehospitalbecauseoffeverandincreasingabdominalpain.
Thepatienthadspasticquadriplegiaduetocerebralpalsybuthadbeeninherusualstateofhealthuntilapproximately2weeksbeforeadmission,whenintermittentfevers,withtemperaturesupto37.7°
C,developed.Onedaybeforeadmission,painintheleftflankandleftlowerquadrantdeveloped,andshenotedfoul-smellingurine.Duringthenightbeforeadmission,theoraltemperatureroseto39.1°
C,associatedwithnauseaandpaininthechest,bothlegs,andtheabdomen,whichradiatedtotheback,bothflanks,andthemidscapularregion.Shetookibuprofen,andherparentsbroughthertotheemergencydepartmentatthishospitalintheearlyafternoon.
Thepatientratedthepainat8onascaleof1to10,with10indicatingthemostseverepain.Shehadcerebralpalsywithspasticquadriplegia,obesity,iron-deficiencyanemia,polycysticovarysyndromewithirregularmenses,recurrenturinarytractinfections,andnephrolithiasis.Aureteralstenthadbeenplacedtemporarily10yearsearlierbecauseofanobstructingstoneintheleftureter.Shedrankalcoholsociallyanddidnotsmokeoruseillicitdrugs.Shelivedwithherparentsandasiblinginanurbanarea,andshehadrecentlybrokenupwithherboyfriend.Sheusedawheelchairandrequiredassistancecuttingfood.Shefollowedalow-oxalatediet.Shereportednocontactwithsickpersonsandnoexposuretoticks,andshewasnotsexuallyactive.Herfatherandpaternalgrandfatherhaddiabetesmellitus,herfatherhadreactivearthritis(formerlyknownasReiter’ssyndrome),onegrandfatherhadrelapsingpolychondritis,andtwograndparentshadcoronaryarterydisease.
Onexamination,thepatient,whowasinawheelchair,wasalertandcommunicative.Thetemperaturewas37.5°
C,thebloodpressure119/63mmHg,thepulse108beatsperminute,andtheoxygensaturation96%whileshewasbreathingambientair.Therewasmildtendernessofthesternum,whichwasreproducedwithdeepinspirations,andtendernessoftheleftcostovertebralangle.Theabdomenwassoftandtendertopalpationontheleftside,withthemostseveretendernessintheleftlowerquadrant;
therewasnoreboundorguarding.Radialpulseswere2+.Theremainderoftheexaminationwasconsistentwithspasticquadriplegia.
Theplateletcountandlevelsofserumelectrolytes,glucose,calcium,phosphorus,magnesium,totalprotein,albumin,globulin,amylase,andlipasewerenormal,asweretestsofrenalfunction;
othertestresultsareshowninTable1.Reviewoftheperipheralbloodsmearrevealedanisocytosis红细胞大小不均(2+),polychromatocytosis多染细胞增多症(1+),hypochromatocytosis色素过少性血细胞增多症(2+),andmicrocytosis小红细胞症(3+).Urinalysisrevealedclearamber琥珀色urinewithaspecificgravityof1.025,apHof6.0,2+bilirubin,1+protein,andtraceamountsofketonesandurobilinogen;
aculturewassterile.
Whilethepatientwasintheemergencydepartment,narcoticanalgesiawasadministeredintravenously,andherpaindecreasedtoascoreof7outof10.Eighthoursafterarrival,thepatientvomitedonce;
ondansetronwasadministered.Computedtomography(CT)oftheabdomenwasperformedaftertheoralandintravenousadministrationofcontrastmaterial,butitwascomplicatedbyextravasationofthecontrastmaterialattheintravenoussiteintherightarm.Thestudyshowedmalrotationoftheleftextrarenalpelvis,multiplecorticaldefectsintheleftkidneythatwereconsistentwithscarring,andaurinarycatheterintheurethra.Thespleenwasmildlyenlarged(14.8cminthecraniocaudaldimension;
upperlimitofthenormalrange,12to13).Therewereprominentperiportal,mesenteric,inguinal,andretroperitoneallymphnodes,upto1.4cmindiameter,withtracefreefluidinthepelvis.Thepatientwasadmittedtothehospitalearlythenextmorning.
Onthedayofadmission,thetemperaturewas38.1°
C.Thepain(ratedas8outof10)persisted,andnarcoticanalgesiawasadministeredintravenously.Nauseaandvomitingrecurredbutlessenedaftertheadministrationofprochlorperazine丙氯拉嗪(中枢神经系统药物).Treatmentwithdalteparinsodium达肝素钠(抗凝血药)wasbegun.Arepeatcultureoftheurinegrewraremixedbacteria.Thechestradiographshowedlowlungvolumesandnoopacities混浊thatweresuggestiveofpneumonia.Thenextday,ultrasonographyofthekidneysandthevenoussystemofthelowerextremitieswasnormal,withnoevidenceofhydronephrosisordeepvenousthrombosis.
Duringthethird,fourth,andfifthhospitaldays,theserumiron-bindingcapacityandlevelsofiron,ferritin铁蛋白,folate,andvitaminB12werenormal;
otherlaboratory-testresultsareshowninTable1.Onthethirdday,thetemperatureroseto38.5°
C.Urinalysisrevealedleukocytes(>
100whitecellsperhigh-powerfield),andaurineculturegrewProteusmirabilis奇异变形杆菌andEscherichiacoli;
bloodculturesremainedsterile.Ciprofloxacin环丙沙星wasadministered.Thenextday,acherry-redrashdevelopedonthepatient’sfeetandresolvedspontaneouslyafterseveralhours.Ultrasonographyoftheabdomenwasnormal.Low-gradefeversoccurredintermittentlythereafter,andsevereabdominalpain(8outof10)persisted;
itwasgreatestintheleftupperquadrant,withradiationtotheleftflank,andwasassociatedwithnauseaandintermittentvomiting.
Onthefifthday,testingforantibodiestoBorreliaburgdorferi伯氏疏螺旋体,cytomegalovirus(CMV),andhepatitisBandCviruseswasnegative,asweretestsforantinuclearantibody,CMVantigenemia抗原血症,andheterophileantibody;
othertestresultsareshowninTable1.ACTscanoftheabdomen,aftertheintravenousadministrationofcontrastmaterial,showedpersistentmildsplenomegalywithperipheralwedge-shapedareasofhypoattenuation低衰减thatwereconsistentwithinfarcts;
otherfindingswereunchangedfromtheCTperformedonadmission.
Testsformalariaandantibodiestothehumanimmunodeficiencyvirus(HIV)andheparin–plateletfactor4werenegative,aswerenucleicacidtestingforehrlichia,Coombs’directantibodytest,cold-agglutininscreening,andtestingforlupusanticoagulant;
hemoglobinelectrophoresis血红蛋白电泳andlevelsoffibrinogen,homocysteine高半胱氨酸,lipoprotein(a),β2-glycoproteinI,antithrombinIII,andproteinC(functional)werenormal.OthertestresultsareshowninTable1.Bloodculturesremainedsterile.Transthoracicechocardiographywasnormal,withnoevidenceofvalvularvegetations.
Onthe10thday,diagnostictestresultswerereceived.
DifferentialDiagnosis鉴别诊断
Dr.DanielP.Hunt:
Iamawareofthediagnosis.Mydifferentialdiagnosiswillfocusoncluesearlyinthecourseofthispatient’sillnessthatmightleadtoanearlypresumptivediagnosisthatcouldbeefficientlyconfirmedwithminimallaboratorytesting.
Twoweeksbeforeadmission,feverdevelopedinthispatient,withnootherreportedsymptoms.Itwouldbeessentialfortheadmittingphysiciantoexploresymptomsthatmightlocalizeasourceforthefever.Specifically,weshouldbesurethatshehadnotnotedsymptomsofrespiratoryorurinaryinfection.Inviewofthehistoryofrecurrenturinarytractinfections,weshouldalsobesurethatshehadnotinitiatedtreatmentwithantibioticsbeforeshepresentedatthehospital.Afterthissmolderingillness,shehadarelativelysuddenonsetofacuteabdominalpain,flankpain,andfoul-smellingurine.Theinitialexaminationrevealedfever,mildtachycardia,tendernessofthesternum胸骨andleftcostovertebralangle,andleftsidedabdominaltenderness,particularlyintheleftlowerquadrant.
Abdominalpain腹痛分析
位置含义:
Inpatientspresentingtoanoutpatientclinicwithanewonsetofabdominalpain,thelocationofthepainmayormaynotbepredictiveoftheunderlyingpathologicfeatures.Inonestudy,sensitivitywashighforpainintheepigastricregion上腹部,indicatinggastroduodenalprocesses;
forrightsubcostal肋骨下的pain,indicatinghepatobiliarydiseases;
andformid-to-lowerabdominalpain,indicatinggynecologic妇科学的diseasesamongwomen.Thisstudysuggeststhatweprobablyshouldnotfocusourdifferentialdiagnosisonorgansintheleftlowerquadranttotheexclusionofotherabdominalorgans.
可能诊断:
However,weneedtostartsomewhere,sowewillbeginwiththemostlikelycausesofpainintheleftlowerquadrant左下象限,左下腹部inayoungwoman:
salpingitis输卵管炎,ectopicpregnancy,irritablebowelsyndrome,inflammatoryboweldisease,inguinalhernia腹股沟疝,nephrolithiasis肾结石,anddiverticulitis憩室炎.Themedicalhistoryindicatesthatthepatientisnotsexuallyactive,makingsalpingitisandectopicpregnancyunlikely.Theabsenceofclinicallysignificantbowelsymptomslessens减少thelikelihoodofirritablebowelsyndromeorinflammatoryboweldisease.Aninguinalherniawouldhavetobeincarcerated箝闭的,狭窄的togeneratethedescribeddegreeofpain,andthisshouldhavebeenevidentonexamination.Weareleftwithdiverticulitisandnephrolithiasis,anddiverticulitisislesslikelythannephrolithiasisinarelativelyyoungwoman.
Thepresenceoffever,tendernessintheleftcostovertebralangle,andleft-sidedabdominaltenderness腹部压痛,particularlyintheleftlowerquadrant,suggestsarecurrentureteralstonewithassociatedpyelonephritis肾盂肾炎,particularlyinviewofthepatient’shistory.Itwouldbehelpfultoknowwhetherthepainwascolicky疝气痛的,asithadbeenduringherpreviousepisodes发作ofnephrolithiasis,andwhetherithadbeenpresentinalesserdegreeduringher2-weekillness.Akidneystonewithpyelonephritis肾盂肾炎isunlikelybecauseofthenormalwhite-cellcountandtheabsenceofdysuria排尿困难.Theresultsoftheinitialurinalysis尿分