英文病例
- 1、下载文档前请自行甄别文档内容的完整性，平台不提供额外的编辑、内容补充、找答案等附加服务。
- 2、"仅部分预览"的文档,不可在线预览部分如存在完整性等问题,可反馈申请退款(可完整预览的文档不适用该条件!)。
- 3、如文档侵犯您的权益，请联系客服反馈,我们会尽快为您处理(人工客服工作时间：9:00-18:30)。
Re: Mr. Emile Aver, 49 years old
Nov. 28, 2009
The attending surgeon, Dr. YANG was just contacted and following information was disclosed re the insured.
The insured was admitted into internal medicine depart of Wuhan Union Hospital—the best tertiary hospital in Wuhan—on Nov. 25 due to “fever for 2 weeks, abdominal distension and pain 1 day”.
The insured ever had operation of appendix removal in his home country.
His condition upon admission: temp 39.8 degree, quick breath rate, wet rales could be detected in both lung bases. He had abdominal distension and bad appetite but no nausea or vomiting. The insured complained constipation for days but could evacuate air. Physical exam found press pain in right lower abdomen was there. B-echography revealed local and mild effusion in right lower abdomen. Examed by “fever case differentiating center”, patient was admitted into ward by impression of “lung and abdominal infection?”. There he was administered antibiotic treatment, then symptoms got improved. Temp was lowered to 37.9 degree.
However, in this early morning severe abdominal pain suddenly started, and surgical consultation was called. Dr. YANG found press pain was there in right lower abdomen, rales still heard in both lower lungs. Followed up B-echography revealed “multiple stones in gall bladder, with biggest size 1 cm. there is no dilation of intra/extra hepatic ducts”. Abdominal MRI was also done this morning but result is pending now. At present, his Temp 38.5 degree, BP 140/90 mmHg, SaO2 95% under 3-5L/min low oxygen supply.
Today’s blood routine revealed WBC 12500, with neutrophil 90%, HGB 14.8. Blood routine on Nov. 26 showed WBC 16000, neutrophil 85%, and total biliribin on Nov. 26 was 27.5 (mild higher).
Current diagnosis: 1. Bile stone
2. Acute cholecystitis
3. Lung infection
Treating doctor advised emergent operation of “abdominal exploration, gall bladder removal”. However, patient’s wife had big concern thus did not agree. So far he was ECG monitored in common ward and conservative therapies were given: gastrointestinal tube decompression, liquid replenishing and IV
nutrition support, combined antibiotics of Cefmetazole, quinolones and Tinidazole.
Dr. YANG told me the patient was closely monitored now. As the abdominal infection will probably aggravate during observation, operation still could not be ruled out.
Dr. zhang