内科病例.docx

内科病例.docx

《内科病例.docx》由会员分享，可在线阅读，更多相关《内科病例.docx（14页珍藏版）》请在冰豆网上搜索。

内科病例

Case1

Male,62year-old,camefromemergencyroom

Chiefcomplaint:

coughandsputumfor20years,breathlessnessonexertionfor5years,symptomaggravationforaweek.

Presenthistory:

thepatienthadcoughandsputumof20years’duration.Recent5yearshehadshortofbreathonexertionandhissymptomprogressivelyaggravated.Aweekago,hebegantohaveyellowsputumandseveredyspnea.Althoughheusedmanydrugsathome,hisshortofbreathcouldn’tbereleased.

Physicalexamination:

cysnosisonhiship,wheezingandmoistralescanbeheardontwolungs.

PulmonaryfunctiontestshowedFEV45%predictedandFEV/FVC55%afterinhalingbronchodilator.

Analysisofarterybloodgases:

pH7.43PaCO284mmHgHCO3-46mmol/L.

Examinationofperipheralblood:

WBC12.6×109/L,N87%,L13%.

Question1pleasemakethecompletediagnoses,includingcomplications.

2whatcausedacuteexacerbationofthediseaseforrecent1week?

Case2

Male,32yearsold.

Chiefcomplaint:

feverandfatigueforonemonth,dyspneaaftermovementforoneweek.

Physicalexamination:

T38.5℃,tracheatowardtheright,theplumpcontouroftheleftlowerchest,decreasedfremitusandbreathsoundaswellasdullnessbypercussionattheleftlowerchest,norubfeeling.

ChestX-rayandlungCT:

pleuraleffusion.

Question1whatkindsoflaboratoryexaminationshouldbedonefirst?

Question2whatshouldbecautiousaboutwhenthorcentesisisbeingdone?

Question3whatisthemostimportantinpleuraleffusioninestablishingthediagnosisofmalignantpleuraleffusion?

Case3

Apreviouslyhealthy46-year-oldfemalepresentedtoalocalhospitalwitha5-dayhistoryofcough,fever,chills,anddyspnea.Hertemperaturewas38.2℃andphysicalexaminationrevealeddiminishedbreathsoundsintheleftlungfieldandcracklesintherightmid-lungfield.Chestroentgenographydemonstratedbilaterallowerlunginfiltratesandaleftpleuraleffusion.

Question:

1whatisthemostpossiblediagnosis?

2whatareyougoingtodonextinordertoverifyyourdiagnosis?

3whatkindofantibioticsshouldberecommended?

Case4

Male,67Y,chroniccoughandsputumproductionfor10years,exertionaldyspneafor3years,andexacerbationfor2weeks.Thepatienthadoftencoughed,withwhitefoam-likesputumfor10years.Andinrecent2weeks,thesymptomsaggravated,includingsevereshortbreathandwheeze,purulentsputum,limitationofactivity.Cigarettesmokingfor30years,20/d.Physicalfindings:

lightlycyanosedorallip,diminishedbreathsoundanddryralesonauscultinghibaterallung.X-ray:

hibateralpulmonarymarkingsdisordered,diaphragmaticmusclemoveddown.

Question1

Whichisthemostprobablediagnosis?

Abronchialasthma

Bbronchiectasis

CCOPD

DCOPDwithcorpulmonale

Question2

Whichmethodsbelowisthebestchoicefordefinitivediagnosis?

AlungHRCT

Bpulmonaryfunctionaltest

Cdermalallergentest

DDopplerechocardiography

Question3

Whichtherapeuticstrategyisthebesteffectivetorelivesymptom?

Aposturaldrainage

Benhancementofmyocardialcontractilityanddiuresis

Cinhaledglucocorticosteroid

Dbronchodilators

Case5

Male,34Y,gotfever2daysagoforcommoncold,T38.9℃,coughedexpectoratedalittleofyellowsputum,andalsohaddyspnea.Hehadeverdiarrheafor2times.Itwasinefficaciousfororalusecephalosporin.Physicalfindings:

P92/min,R28/min,somnolence,lightlycyanosedorallip,moistralesonauscultinghibateralinferiorlung.WBC9.2×109/L,N87%,bloodserum[Na+]↓.Bloodgasanalysis:

pH7.35,PaO257mmHg.X-ray:

lamellarshadowcanbeseeninsuperiorandinferiorlobeofleftlung,middleandinferiorlobeofrightlung.

Question

1writeoutthemostprobabletypeofpneumonia.

2whichkindofantibioticisthefirstchoice?

Case6

Male,60Y,smokingfor800number-years.Chroniccoughanddyspneafor35years,intermittentedemaoflowerlimbsfor2years.BloodgasanalysishadshowedPaO2at55-60mmHgformanytimes.Recently,thesymptomsaggravatedaftercommoncold,witholiguriaandedemaoflowerlimbsappearing.Onadmission,thepatientshowedtrance,somnolenceandobviouscyanosis.Bloodgasanalysis:

PaO250mmHg,PaCO286mmHg.

Question

1writeoutthediagnosisofthispatient?

2we’llplantotherapythepatientwithtrachealintubationandmechanicalventilation,andtheaimistolowerthePaCO2to__

Anormallevel

Bbelownormallevel

C55-60mmHg

Dretainthepresentstate

Case7

A70yearsoldmalewithahistoryofheavysmokingandmoderatelyseverechronicobstructivepulmonarydiseasehasbeenfeelingpoorly.Hereportscough,chills,pleuriticchestpain,andlow-gradefever.Chestradiographrevealsasmalldenseinfiltrateintherightlowerlobe.Gram-negativestainofthepatient’ssputumrevealsnumerousgram-negativecoccus,manyofwhichoccurinpairs.

1thepathogenicbacteriashouldprobablybe__

Asteptocococuspneumonia

Bhemophilusinfluenzae

Cklebsiellapneumoniae

Dmoraxellacatarhalis

Epseudomonasaeruginosa

2themostappropriatetherapyshouldbe__

Anoantimicrobialtherapyisrequired

Btetracycline

Cciprofloxacin

Dtrimethoprim-sulfamethoxazole

Epenicillin-calvulanicacid

Case8

a63-year-oldmanhaspneumococcalpneumoniawithextensiveair-spaceconsolidationintheleftupperandleftlowerlobes.Hecomplainsofextremeshortnessofbreathwhenpositionedwithhisleftsidedown.AnarterialbloodsampledrawninhispositionshowsaPO2of6.2Kpa（46mmHg）,10minutesearlier,anarterialbloodsampledrawnwhilehisrightsidewasdependenthasrevealedaPO2of8.2kp（66mmHg）.

ThemostlikelyexplanationforthedropinPO2whenthemanwaslyingonhisleftsideis__

Aincreasedbloodflowtothedependentlung

Breducedventilationtothedependentlung

Cincreasedairwayresistanceinthedependentlung

Daccumulationofinterstitialedemainthedependent

Eincreasedstiffofthechestwallonthedependentlung

Case9

thepatientisa19yearoldmalestudent.herchiefcomplaintisbeingfeverforfourdays,coughingfortwodays.

fourdaysagohefeltcoldthenfeverafterabasketballmatch.thehighesttemperatureisupto40degreeaccompanyingwithchilling.thosesymptomswerenotimprovedbytakingamoxicillinandparacetamol.twodaysago,hebegantocough,accompanyingwithalittlewhitesputumandrightchestpain.X-rayofchestshowsslightlypatchyshadowintheinferiorfieldofrightlungnearthediaphragm.hewasgiventhediagnosisofpneumoniaatlocalhospitalandcephradineintravenouslyfortwodays.butnoimprovementappeared.Now,hewasbadappetite,nausea,withoutvomiting,dilutedstool.heishealthypreviously.

physicalexamination:

T39.5degree,P100permin,R28permin,BP85/60mmHg.Heisconsciouswithfeveringfaceandinbadstate.nosuppurativelesioncanbefoundinhisglossopharyngealpartandskin.percussionoflowerpartofrightlungisdull.Auscultationofthatareacanfounddiminishedbreathsoundwithoutdryormoistrale.theheartrateis100perminwithregularrhythm.Theabdomenissoft,andtheliverispalpitated2cmbelowthecoast,softandtouchingpain.

laboratoryexamination:

WBC3.5g/l,N0.9,L0.1.urineproteinispositive.livetfunctiontestshowselevatedALTandALP.myocardialenzymaticspectrumshowselevatedLDHandCPK.Theconcentrationofsodiuminserumisatthelowerlimitofnormalstandard.legionellaantibodyisnegative.mycoplasmaantibodyisnegative.blood–gasanalysisshowsPH7.50,Pao258mmhg.

X–rayofchestshowslargehigherdensityparchyshadowinthemiddleandinferiorfieldofrightlung.rightcostophragmangledisappears.ECGshowssinaltachycardia.dopplerofheartshowsnormalintracardiacstructureandalittleeffusioninpericardia.

Questions

1whatistheimpressdiagnosis

2whichantibioticsshouldbechosen?

Case10

Thepatientisa38yearsoldfemalepeasant.Herchiefcomplaintisparoxysmalgasping,dyspneafortwodays.Twodaysago,shesuddenlypanted,accompanyingwithbreathlessanddyspnea,whenshewasplantingmushroominanairtightconservatory.Thesesymptomswerenotrelievedaftershelefttheconservatory.Sheishealthypreviously.Physicalexamination:

Thepatientisconscious,orthopnea,sweaty,brokenspeaking,cyanosisofthelops.Wheezecanbeheardthroughoutbothlungs.Heartrateis130perminwithregularrhythm.Blood-gasanalysis:

PH7.472,PaO256mmHg,PaCO2mmHg.Pulmonaryfunctiontestcannotbecarriedoutbecauseofherdyspnea.X-rayofchestshowsbothlungsarehypertranslucent.

Questions

1What’sthediagnosis

2thesymptomofgaspingofthepatientisobviouslyrelievedandthewheezeinbothlungsdiminishedafteradministratingglucocorticoidintravenouslyforfiveyears.Then,WhichexaminationshouldbetakenandWhichdrugshouldbegivenforthepurposeofmaintainingtreatmentforalongtime?

Case11

Thepatientisa45yearsoldmalepeasant.Hischiefcomplaintisbeingfever,coughingwithbloodysputumforhalfamonth.Deterioratingwithlargeamountofyellowfoulsuppurativesputumtwodays.Hebegantosmoketwentyyearsago,twentycigaretteseachday.Histemperatureis38.5degree.Moistralecanbeheardintheinterscapulararea.AuxillarytestshowselevatednumberofWBC,andtheproportionofneutrophilishigh.Thetuberculosisbacteriaandtumorcellinsputumarenegative.X-rayofchestshowspatchyshadowinthebacksegmentofupperlobeofrightlungwithblurredborder.Theseareatranslucentareac