内科病例.docx

1、内科病例Case 1Male , 62 year-old , came from emergency roomChief complaint : cough and sputum for 20 years , breathlessness on exertion for 5 years , symptom aggravation for a week .Present history : the patient had cough and sputum of 20 yearsduration . Recent 5 years he had short of breath on exertion

2、 and his symptom progressively aggravated . A week ago , he began to have yellow sputum and severe dyspnea .Although he used many drugs at home , his short of breath couldnt be released .Physical examination : cysnosis on his hip, wheezing and moist rales can be heard on two lungs .Pulmonary functio

3、n test showed FEV 45% predicted and FEV/FVC 55% after inhaling bronchodilator . Analysis of artery blood gases : pH 7.43 PaCO2 84mmHg HCO3- 46mmol/L . Examination of peripheral blood : WBC 12.6109/L , N 87% , L13% .Question 1 please make the complete diagnoses , including complications . 2 what caus

4、ed acute exacerbation of the disease for recent 1 week ?Case 2Male , 32 years old .Chief complaint : fever and fatigue for one month , dyspnea after movement for one week .Physical examination : T 38.5 , trachea toward the right , the plump contour of the left lower chest , decreased fremitus and br

5、eath sound as well as dullness by percussion at the left lower chest , no rub feeling .Chest X-ray and lung CT : pleural effusion .Question 1 what kinds of laboratory examination should be done first ? Question 2 what should be cautious about when thorcentesis is being done ?Question 3 what is the m

6、ost important in pleural effusion in establishing the diagnosis of malignant pleural effusion ?Case 3 A previously healthy 46-year-old female presented to a local hospital with a 5-day history of cough , fever , chills , and dyspnea . Her temperature was 38.2 and physical examination revealed dimini

7、shed breath sounds in the left lung field and crackles in the right mid-lung field . Chest roentgenography demonstrated bilateral lower lung infiltrates and a left pleural effusion .Question :1 what is the most possible diagnosis ?2 what are you going to do next in order to verify your diagnosis ?3

8、what kind of antibiotics should be recommended ?Case 4 Male , 67Y ,chronic cough and sputum production for 10 years , exertional dyspnea for 3 years , and exacerbation for 2 weeks . The patient had often coughed , with white foam-like sputum for 10 years . And in recent 2 weeks , the symptoms aggrav

9、ated , including severe short breath and wheeze , purulent sputum , limitation of activity . Cigarette smoking for 30 years , 20/d . Physical findings : lightly cyanosed oral lip , diminished breath sound and dry rales on ausculting hibateral lung . X-ray : hibateral pulmonary markings disordered ,

10、diaphragmatic muscle moved down .Question 1 Which is the most probable diagnosis ? A bronchial asthmaB bronchiectasisC COPDD COPD with cor pulmonale Question 2Which methods below is the best choice for definitive diagnosis ?A lung HRCTB pulmonary functional testC dermal allergen testD Doppler echoca

11、rdiographyQuestion 3 Which therapeutic strategy is the best effective to relive symptom ?A postural drainage B enhancement of myocardial contractility and diuresisC inhaled glucocorticosteroid D bronchodilatorsCase 5 Male , 34Y , got fever 2 days ago for common cold , T 38.9 , coughed expectorated a

12、 little of yellow sputum , and also had dyspnea . He had ever diarrhea for 2 times . It was inefficacious for oral use cephalosporin . Physical findings : P 92/min , R28/min , somnolence , lightly cyanosed oral lip , moist rales on ausculting hibateral inferior lung . WBC 9.2109/L , N 87% , blood se

13、rum Na+. Blood gas analysis : pH 7.35 , PaO2 57mmHg . X-ray : lamellar shadow can be seen in superior and inferior lobe of left lung , middle and inferior lobe of right lung .Question 1 write out the most probable type of pneumonia .2 which kind of antibiotic is the first choice ?Case 6 Male , 60Y ,

14、 smoking for 800 number-years . Chronic cough and dyspnea for 35 years , intermittent edema of lower limbs for 2 years . Blood gas analysis had showed PaO2 at 55-60mmHg for many times . Recently , the symptoms aggravated after common cold , with oliguria and edema of lower limbs appearing . On admis

15、sion , the patient showed trance , somnolence and obvious cyanosis . Blood gas analysis : PaO2 50mmHg , PaCO2 86mmHg .Question 1 write out the diagnosis of this patient ?2 well plan to therapy the patient with tracheal intubation and mechanical ventilation , and the aim is to lower the PaCO2 to _A n

16、ormal levelB below normal levelC 55-60mmHgD retain the present stateCase 7A 70 years old male with a history of heavy smoking and moderately severe chronic obstructive pulmonary disease has been feeling poorly . He reports cough , chills , pleuritic chest pain , and low-grade fever . Chest radiograp

17、h reveals a small dense infiltrate in the right lower lobe . Gram-negative stain of the patients sputum reveals numerous gram-negative coccus , many of which occur in pairs .1 the pathogenic bacteria should probably be _A steptocococus pneumonia B hemophilus influenzae C klebsiella pneumoniae D mora

18、xella catarhalis E pseudomonas aeruginosa 2 the most appropriate therapy should be _ A no antimicrobial therapy is requiredB tetracyclineC ciprofloxacinD trimethoprim-sulfamethoxazoleE penicillin-calvulanic acidCase 8 a 63-year-old man has pneumococcal pneumonia with extensive air-space consolidatio

19、n in the left upper and left lower lobes . He complains of extreme shortness of breath when positioned with his left side down . An arterial blood sample drawn in his position shows a PO2 of 6.2 Kpa(46mmHg) , 10 minutes earlier , an arterial blood sample drawn while his right side was dependent has

20、revealed a PO2 of 8.2kp(66mmHg) . The most likely explanation for the drop in PO2 when the man was lying on his left side is_A increased blood flow to the dependent lungB reduced ventilation to the dependent lungC increased airway resistance in the dependent lung D accumulation of interstitial edema

21、 in the dependentE increased stiff of the chest wall on the dependent lungCase 9 the patient is a 19 year old male student .her chief complaint is being fever for four days , coughing for two days . four days ago he felt cold then fever after a basketball match . the highest temperature is up to 40

22、degree accompanying with chilling . those symptoms were not improved by taking amoxicillin and paracetamol .two days ago , he began to cough , accompanying with a little white sputum and right chest pain . X-ray of chest shows slightly patchy shadow in the inferior field of right lung near the diaph

23、ragm . he was given the diagnosis of pneumonia at local hospital and cephradine intravenously for two days . but no improvement appeared . Now , he was bad appetite , nausea , without vomiting , diluted stool . he is healthy previously . physical examination: T39.5 degree , P100per min , R 28 per mi

24、n , BP 85/60 mmHg . He is conscious with fevering face and in bad state . no suppurative lesion can be found in his glossopharyngeal part and skin . percussion of lower part of right lung is dull . Auscultation of that area can found diminished breath sound without dry or moist rale . the heart rate

25、 is 100 per min with regular rhythm . The abdomen is soft , and the liver is palpitated 2 cm below the coast , soft and touching pain . laboratory examination : WBC 3.5 g/l , N0.9 , L0.1 . urine protein is positive . livet function test shows elevated ALT and ALP . myocardial enzymatic spectrum show

26、s elevated LDH and CPK . The concentration of sodium in serum is at the lower limit of normal standard . legionella antibody is negative . mycoplasma antibody is negative . blood gas analysis shows PH7.50 ,Pao2 58mmhg.X ray of chest shows large higher density parchy shadow in the middle and inferior

27、 field of right lung . right costophragm angle disappears .ECG shows sinal tachycardia . doppler of heart shows normal intracardiac structure and a little effusion in pericardia .Questions1 what is the impress diagnosis2 which antibiotics should be chosen?Case 10 The patient is a 38 years old female

28、 peasant . Her chief complaint is paroxysmal gasping , dyspnea for two days . Two days ago , she suddenly panted , accompanying with breathless and dyspnea , when she was planting mushroom in an airtight conservatory . These symptoms were not relieved after she left the conservatory . She is healthy

29、 previously . Physical examination : The patient is conscious , orthopnea , sweaty , brokenspeaking , cyanosis of the lops . Wheeze can be heard throughout both lungs . Heart rate is 130 per min with regular rhythm . Blood-gas analysis : PH7.472 , PaO2 56mmHg , PaCO2mmHg . Pulmonary function test ca

30、n not be carried out because of her dyspnea . X-ray of chest shows both lungs are hyper translucent .Questions1 Whats the diagnosis 2 the symptom of gasping of the patient is obviously relieved and the wheeze in both lungs diminished after administrating glucocorticoid intravenously for five years .

31、 Then , Which examination should be taken and Which drug should be given for the purpose of maintaining treatment for a long time ?Case 11 The patient is a 45 years old male peasant . His chief complaint is being fever , coughing with bloody sputum for half a month . Deteriorating with large amount

32、of yellow foul suppurative sputum two days . He began to smoke twenty years ago , twenty cigarettes each day . His temperature is 38.5 degree . Moist rale can be heard in the interscapular area . Auxillary test shows elevated number of WBC , and the proportion of neutrophil is high . The tuberculosis bacteria and tumor cell in sputum are negative . X-ray of chest shows patchy shadow in the back segment of upper lobe of right lung with blurred border . These are a translucent area c