医学英文摘要及病例

CASE HISTORY （1）
Patient CPR，a salesman of 35，married， was admitted on September 25，1998，complaining of anorexia and pain in RUQ for 5 days，and yellowish discoloration for 3 days. He started with a “flu-like illness” in the afternoon of September 18, 1998, during which he fell chilly, dizzy, and lack of strength, then, he was confined to bed, In the evening, his temperature was 38.6℃. He vomitted once with food previously ingested.
On Sept, 19, he did’nt take his breakfast because he had a persistent nausea. He rejected all sorts of greasy food and could only eat a few table- spoonfuls of porridge with some presevered vegetable and ginger.
On Sept, 20, he had no sooner vomitted out whatever he took. Meantime, he noticeed abdominal dull aching in RUQ with gaseous distension and flatus, Bowel was moved every 2～3 days with dark brown formed stools.
Urine was scanty and highly colored. He was told by his wife that his eyes and skin were yellowish tinged. On Sept, 23, but since then. his appetite improved, nausea and vomiting disappeared and abdominal pain and distension alleviated.
No previous history of jaundice, anorexia or general malaise. Never received blood transfusion or percutancous injection. None of the family members intimate friends, or colleagues was known to have Liver disease.
Physical Examination T 37℃. P 72/min, R 20/min, BP 15/10Kpa, W.D ﹠W.N. Mentality clear and cooperative. Skin and sclerae moderately jaundiced,A suggestive spider angiome is seen in the left postauricular region. Tongue coated. No general glandular enlargement. Lungs clear. Heart normal.. Liver is palpable about 2cm below costal margin and tender, Spleen is just palpable. No shifting dullness was found. Spine and extremities are normal. Knee jerks are present.
Questions: 1.What is the most possible diagnosis?
2.How to treat this case?
CASE HISTORY （2）
Patient CJW， a farmer of 25 years old， unmarried， was admitted on November 13 2001, Complainning of persistent high fever for 20 day and mental dullness for 3 days.
He started with low grade fever on October 23, 2001, during which he felt discomfort, malaise, dizzyiness, and myalgia, 5 days later, his tempraturer rised to 39～40℃. He began to feel sever headache, general bodyaching, anorexia, nausea and vomitting. He was treated with some tablet drug , 2. Tablets twice a day for 5 days in local clinic. But had no effect. The high fever persist and accompanied with diarrhea passing loose stool 1～2 times a day. Three days ago, patient had mild non-productive cough but passed dark stool ,then he became unconsiousness and delirium but no convulsion.
No previous history of fever except “measles” and “malaria” in childhood. Never received any vaccine innocalation ,had no traveling history before the illness. One month ago. His brother was ill with same disorder but the diagnosis had no confirmed. P.E. T 39℃. P 144/min, R 30/min, BP 112/75mmHg well devlopment but nutrition was poor, unconsciousness. No jaundice,no eruption, and no general glandular enlargment.
Pupils equal on both sides and reactive to light. Neck soft. Lungs clear. Techgcardia with normal heart sound abdominal soft and of distention. No tenderness. Liver is 1cm and spleen 3cm below costal margin. Spine and extremities are normal, Knee jerks are present. Kernig’s signs and Brudxinski’s signs negative, no pathological reflexes.
Lab. Finding: blood: WBC 4.7×109/L, N 0.75, L 0.25
ALT: 60u/L
Urine: protien(+)
Stool: dark, OB(++)
Serological test: HBsAg(+) eAg(+) Anti-HBc(+)
Questions: 1. What is the most possible diagnosis? Why?
2. How to treat the patient?
Medical Record of COPD
Name：Liang Ya jun Occupation: driver
Sex：male Date of admission: Jan ,17,2007
Age: 70 years old Date of record: Jan,17,2007
Nationality: Han Narrator of history: Himself
Birth place: Beijing Level of history: reliable
Chief complaint: Cough with productive of sputum for 30 years, wheeze for 10 years, and got worse for 3 days.
History of present illness: 30 years ago after exposure to cold weather, the patient suffered from a cough, with purulent sputum, without fever、fatigue、night sweats、hemoptysis. With the
anti-infection therapy, He was cured. Since then he was often recurrent 2-3 times every year after catching a cold or having pulmonary infection. 20 years ago, he was diagnosed the chronic bronchitis, and he had to be admitted 1-2 times 1 year for the therapy. 10 years ago, he felt shortness of breath, particularly after sports ,and 5 years ago, he began edema in his legs and feet.
3 days ago, he felt worse without any reson. He coughed all night, couldn’t lie down during sleep, sometimes with dyspnea. The sputa was sticky and purulent. But no fever. He took the oral ampicillin and aminophylline by himself ,but they didn’t work. Then he came to emergency department of TianTan Hospital. The results of blood routine was: WBC:12500/mm3, N:82.3%. The X-ray of lung: The veins of 2 pumonarys are coarse and irregular, right-lower pulmonary arterial trunk >15mmHg, cardiac apex being globular appearance and more elevated and emphysema. He was given some drugs of anti-infection, but the effect is not good. To be well treated, he was incharged of acute episode of COPD.
These days, he felt weakness, poor of appetite, the urine and stool are normal, his weight did not change.
Past history:He has had Hypertension for 30 years, DM for 4-5 years . 1986: myocardial infarction, full recovery / No subsequent investigation.
Social History: Smoking for 50 years ,the amount is about half a cigarette case per day. Never drink. Born and lives in Beijing, Never been to area of pestilence. Married for 45 years with 2 children and both of them are healthy.
Family history: No family history of chronic disease and genetic disease.
Review of Systems
Respiratory system: Same as the history of present illness.
Gastrointestinal tract: No current indigestion. No vomiting/ dysphagia/ diarrhea/ constipation/ abdominal pain.
Cardiovascular system: No current chest pain. No palpitation/loss of consciousness.
Genitourinary system: No urinary systems.
Nervous System: No headache/ syncope/ vertigo/ balance problem. No dizziness/ limb weakness/ sensory loss. No disturbance of vision/ hearing/ smell/ speech.
Musculoskeletal system: No joint pain/ stiffness/ extremity pain/ decreased range of motion. No disability.
Allergies History: penicillin-skin rash
Physical examination
T: 37.2℃R: 24bpm P: 101bpm BP: 110/60mmHg
General: well. No anemic looking. consciousness is clear. His action is free .
Skin: No petechiae, purpura, Anlcteric. No cutaneas Lesions or rashes. His feet is Ⅱdegree edema .
Nodes: Surface nodes unpalpable.
Eyes: conjunctive normal.No icterus, hemorrhage. Lids without lesions. Pupils equal, round and react to light and accommodation.
Neck: Supple, Trachea midline. Thyroid not enlarged and without nodules. Jugular veins flat. Venous pulses normal.
Chest: Tubbish chest contour. No catfale, pain.
Lungs: Inspection:respiration equal,24bpm,rhythm regular.
Palpation:with symmetrical full expansion.No thrills.
Percussion:No percussion dullness.
Auscultation: coarse. Sometimes there are moist and dry rales in both lungs. There is no sounds of pleural friction.
Heart: Inspection: No visible lifts.
Palpation:rate:101bpm. Rhythm is regular. No lifts thrills,heaves.
Percussion: Heart border normal as follows:
Right(cm) Rib Left(cm)
2 Ⅱ 2
2 Ⅲ 4.5
3 Ⅳ 6
Ⅴ8
MCL=8cm
Auscultation: rate:101bpm,rhythm is irregular, P 2> A 2. No splitting of heart sound.No cardiac murmurs or pericardial sound.
Abdomen: Inspection:No scars or visible masses.Venous pattern normal.
Palpation: Soft, no pain, mass, thill or fluid wave. Liver and spleen not palpable.
Percussion:Liver sonant normal.
Auscultation:Bowel sound 3bpm.No bruit.
Nerve: Higher function normal.
Cranial nervesⅰ-Ⅻ: normal.
Upper and lower limbs: power, tone, coordination, sensation all normal.
Laboratory and diagnostic tests
Blood routing: WBC 12500/mm3, N 82.2%.
Arterial blood-gas : PH 7.35 PO2 58mmHg PCO2 70mmHg BE 5mmol/L.
X-RAY: The veins of 2 pumonarys are coarse and irregular, right-lower pulmonary arterial
trunk >15mmHg, cardiac apex being globular appearance and more elevated and emphysema. Summary
70-year-old male smoker with a family history and previous history of chronic bronchitis, presents with 20-year history of cough, sputum, wheeze and got worse for 3-day, which is unrelieved by ampicillin and aminophylline. On examination, there are moist and dry rales in both lungs.Blood routing: WBC 12500/mm3, N 82.2%.X-RAY: The veins of 2 pumonarys are coarse and irregular, right-lower pulmonary arterial trunk >15mmHg, cardiac apex being globular appearance and more elevated and emphysema.The most likely diagnosis is an acute episode of COPD(chronic obstructive pulmonary disease).
Diagnosis: Acute episode stage of COPD(chronic obstructive pulmonary disease)
Chronic bronchitis
Obstructive emphysema
Chronic pulmonary heart disease
Decompensation stage of cardiac and lung functions
Type 2 respiratory failure
Coronary heart disease
Old myocardial infarction
Sinus heart rate
Heart border normal
Cardiac function 2 classic
Hypertension 3 classic
2 type Diabetes mellitus
Dr. XX
A Sample of Complete History
PATIENT'S NAME: Mary Swan
CHART NUMBER: 660518
DATE OF BIRTH:10-5-1993
SEX: Female
DATE OF ADMISSION: 10-12-2000
DATE OF DISCHARGE: 10-15-2000
Final Discharge Summary
Chief Complaint:
Coughing, wheezing with difficult respirations.
Present Illness:
This is the first John Hopkins Hospital admission for this seven-year-old female with a history of asthma since the age of 3 who had never been hospitalized for asthma before and had been perfectly well until three days prior to admission when the patient development shortness of breath and was unresponsive to Tedral or cough medicine.
The wheezing progressed and the child was taken to John Hopkins Hospital Emergency Room where the child was given epinephrine and oxygen. She was sent home. The patient was brought back to the ER three hours later was admitted.
Past History:
The child was a product of an 8.5-month gestation. The mother had toxemia of pregnancy. Immunizations: All. Feeding: Good. Allergies: Chocolate, dog hair, tomatoes.
Family History:
The mother is 37, alive and well. The father is 45, alive and well. Two sibs, one brother and one sister, alive and well. The family was not positive for asthma, diabetes, etc.
Review of Systems:
Negative except for occasional conjunctivitis and asthma.
Physical Examination on Admission:
The physical examination revealed a well-developed and well-nourished female, age 7, with a pulse of 96, respiratory rate of 42 and temperature of 101.0℉. She was
in a mist tent at the time of examination.
Funduscopic examination revealed normal fundi with flat discs. Nose and throat were somewhat injected, particularly the posterior pharynx. The carotids were palpable and equal. Ears were clear. Thyroid not palpable. The examination of the chest revealed bilateral inspiratory and expiratory wheezes. Breath sounds were decreased in the left anterior lung field. The heart was normal. Abdomen was soft and symmetrical, no palpable liver, kidney, or spleen. The bowel sounds were normal. Pelvic: Normal female child. Rectal deferred. Extremities negative.
Impression:
Bronchial asthma, and pharyngitis.
Laboratory Data:
The white count on admission was 13,600 with hgb of 13.0. Differential revealed 64 segs and 35 lymphs with 3 Eos. Adequate platelets. Sputum culture and sensitivity revealed Alpha hemolytic streptococcus sensitive to Penicillin. Chest x-ray on admission showed hyperaeration and prominent bronchovascular markings. The child was started on procaine Penicillin 600,000 unites IM q.d in accordance with the culture and sensitivity of the sputum.
Hospital Course:
The child was given Penicillin IM as stated above. Ten drops of Isuprel were added to the respirator every 2 hours. The patient improved steadily. She took her diet well. She was discharged on 10-15-2000 in good condition.
Operation procedure: none
Condition on discharge: Improved
Diagnosis: Asthma. Pharyngitis. Possible right upper lobs pneumonia.。