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重庆医科大学:《诊断学》课程教学资源(授课教案)09 病历与诊断

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重庆医科大学:《诊断学》课程教学资源(授课教案)09 病历与诊断
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置庆医科大学脑床学院载未讲满 重庆医科大学临床学院教案及讲稿 课程名称诊断学 年级2005 授课专业临床医学 教师陈建斌 职称教授 授课方式 √大课示教学时2 题目章节病历与诊断方法 教材名称《诊断学》 作者陈文彬、潘祥林 出版社人民卫生出版社 版次第6版 了解病历具有临床诊治疾病、教学科研、法律依据等方面的重要意义 2 掌握住 1 Learn medical records have important significance of clinical diagnosis and treatment ofdiseases,teaching and research,legal basis. 2 Master how to compile inpatient case history. 3 Be familiar with the steps and processes ofdiagnosis. 诊断步骤及诊断过程的思维方法 难点 thinking-way ofsteps and processes ofdiagnosis 掌握住院病历的编写 全面诊断的内容 1 Master how to compile inpatient case history. 点 2 Contentsofcomplete diagnosis 外 求 掌握基本专业术语 教学 多媒体课件 毛段 Multimedia courseware 中华内科学 Chinese science 实用内科学 Practical science 见 教学组长: 教研室主任: 年月 日 制表时间:2004年8月

重庆医科大学临床学院教案讲稿 制表时间:2004 年 8 月 1 重庆医科大学临床学院教案及讲稿 课程名称 诊断学 年级 2005 授课专业 临床医学 教 师 陈建斌 职称 教授 授课方式 √大课 示教 学时 2 题目章节 病历与诊断方法 教材名称 《诊断学》 作者 陈文彬、潘祥林 出 版 社 人民卫生出版社 版次 第 6 版 教 学 目 的 要 求 1.了解病历具有临床诊治疾病、教学科研、法律依据等方面的重要意义 2.掌握住院病历的编写 3.熟悉诊断步骤及诊断过程的思维方法 1 Learn medical records have important significance of clinical diagnosis and treatment of diseases, teaching and research, legal basis. 2 Master how to compile inpatient case history. 3 Be familiar with the steps and processes of diagnosis. 教 学 难 点 诊断步骤及诊断过程的思维方法 thinking-way of steps and processes of diagnosis 教 学 重 点 1.掌握住院病历的编写 2‘全面诊断的内容 1 Master how to compile inpatient case history. 2 Contents of complete diagnosis 外语 要求 掌握基本专业术语 教学 方法 手段 多媒体课件 Multimedia courseware 参考 资料 中华内科学 Chinese science 实用内科学 Practical science 教研 室意 见 教学组长: 教研室主任: 年 月 日

露庆医科大学临床半院载案讲满 教学内容 辅助手段 时间分配 病历是医务工作人员在诊疗工作中形成的文字、符号、图表、影象、切5分钟 片等资料的总和。它是医务人员通过问诊、查体、实验室检查及器械检查 治疗、护理等全部医疗活动收集的资料,进行逻辑思维整 病历编写 编写病历的基本要求 1.内容真实,不能臆想和虚构 2 格式规范 3.描述精练 ,用词恰当 4.填写全面,字迹清晰 Medical records are the sum of datum including letter.symbols. charts,vido,the medical staff.They were ollected by themwith inqury,medical xamnion laboratory examination,appliance examination,diagnosis and distinguish diagnosis in the medical care and treatment of the patient,and they are the true record about the whole medical work Medical history compiling Basic requirement 1 content must be true 2 format must be specification 3 descriptionmust beproficiency and wordsmust be appropriate 4 filling must be comprehensive and handwriting must be clearance 病历的种类、格式与内容 10分钟 资住院医师书写。 格式与内容 姓名: 职业: 年龄: 婚姻: 性别: 入院日期: 民族: 采史日期: 籍贯: 供史者: 住址: 主诉 现病史 制表时间2004年8月

重庆医科大学临床学院教案讲稿 制表时间:2004 年 8 月 2 教学内容 辅助手段 时间分配 病历是医务工作人员在诊疗工作中形成的文字、符号、图表、影象、切 片等资料的总和。它是医务人员通过问诊、查体、实验室检查及器械检查、 诊断与鉴别诊断,治疗、护理等全部医疗活动收集的资料,进行逻辑思维整 理形成的全部医疗工作的真实记录。 病历编写 编写病历的基本要求 1. 内容真实,不能臆想和虚构 2. 格式规范 3. 描述精练, 用词恰当 4. 填写全面, 字迹清晰 Medical records are the sum of datum including letter, symbols, charts, video, slice etc. from the medical staff working in clinics. They were collected by them with inquiry, medical examination, laboratory examination, appliance examination, diagnosis and distinguish diagnosis in the medical care and treatment of the patient, and they are the true record about the whole medical work Medical history compiling Basic requirement 1 content must be true 2 format must be specification 3 description must be proficiency and words must be appropriate 4 filling must be comprehensive and handwriting must be clearance 病历的种类、格式与内容 1.住院病历 完整正规的病历, 要求在病人入院后 24 小时内完成,由实习医师、低年 资住院医师书写。 格式与内容 姓名: 职业: 年龄: 婚姻: 性别: 入院日期: 民族: 采史日期: 籍贯: 供史者: 住址: 主诉 现病史 5 分钟 10 分钟

置庆医科大半脑床半院载未讲满 即往史 一般情况,传染病、寄生虫、预防接种史、过敏史、外伤 手术史 个人史 族史 Kind and formatand content 1.Inpatient case history Medical records must be completed by interne or junior risident 24 hours after patientadmission to the hospital. format and content Name: profession: Age. marriage: av. Date of Admission Nationality Date of record: Native place: Complainer of history: Address: Chief complaints esent illness Review of system Personal history Family history 主诉:病人就医的主要症状、体征及持续时间 要求简明精练,一般不超过1-2句,20字左右。在一些特殊情况下,疾 制表时间:2004年8月

重庆医科大学临床学院教案讲稿 制表时间:2004 年 8 月 3 即往史 一般情况,传染病、寄生虫、预防接种史、过敏史、外伤 手术史 个人史 家族史 Kind and format and content 1.Inpatient case history Medical records must be completed by interne or junior risident 24 hours after patient admission to the hospital. format and content Name: profession: Age: marriage: Sex: Date of Admission: Nationality: Date of record: Native place: Complainer of history: Address: Chief complaints History of present illness Review of system Personal history Family history 主 诉:病人就医的主要症状、体征及持续时间 要求简明精练,一般不超过 1-2 句,20 字左右。在一些特殊情况下,疾

露庆医科大学临床半院载案讲满 病己明确诊断,住院目的是进行某项特殊治疗者,可用病名。 Chiefcmpnts:chief symptoms physical signs and their durations It must be simple and proficiency which contains 20 words.If the patient's disease has been definitely diagnosed,the disease name can be used. 现病史 是病史中的主体,包括从发病至本次就诊时疾病的发生、发展、及其变化的 全过程,其内容包括: L起病的情况:患病时间、发病缓急、前驱症状、可能的病因和诱因 2主要症状的特点:主要症状的部位、 性质 待续时间及程度 3病情的发展与演变:病情是持续性还是间隙性发作,是进行加重还是逐步 好转,缓解或加重的因素等de 4.伴随症状 5鉴别诊断有关的明性岸状、休征 6,诊疗经过:何时、何处就诊,作过何种检查,诊为何病,治疗药物的剂量 与效果 7.一般情况:食欲、大小便、精神、体力、睡眠等 8.目前未愈的其它疾病:可分段叙述或综合记录 History of present illness: It is the main body of medical records which describes in detail about occurrence.development and change of patient's illness. 1 occurrence of illness:including time,acute or chronic prodrome,with or without inducing factors 2 the characteristic of the chief symptoms:including position property,duration,degree 3 development and evolvement of the illness:persistent or intermittent,be better or be worseetc. 4 accompanyingsymptoms 5 negativesymptoms and physical signs ofdistinguish-diagnosis 6 the process of diagnosis and treat:including when,where,what examination,dosage and effect of medicine 7 General condition:appetite,stool urination,energy,thesia sleep 8 other disease uncured presently 匹往中 10分钟 过去的一般健康情况:是否体弱多病,劳动力如何 2.传染病及寄生虫感染史 3预防接种史及传染病接触史:接种的时间及反应 4过敏史:寻麻疹、哮喘及药物过敏史 5外伤手术中 6.系统回顾:呼吸系统 循环系统 制表时间:2004年8月 4

重庆医科大学临床学院教案讲稿 制表时间:2004 年 8 月 4 病已明确诊断,住院目的是进行某项特殊治疗者,可用病名。 Chief complaints: chief symptoms, physical signs and their durations It must be simple and proficiency which contains 20 words. If the patient’s disease has been definitely diagnosed, the disease name can be used. 现病史 是病史中的主体,包括从发病至本次就诊时疾病的发生、发展、及其变化的 全过程,其内容包括: 1.起病的情况:患病时间、发病缓急、前驱症状、可能的病因和诱因 2.主要症状的特点:主要症状的部位、性质、 持续时间及程度 3 病情的发展与演变:病情是持续性还是间隙性发作,是进行加重还是逐步 好转,缓解或加重的因素等 de 4.伴随症状 5.鉴别诊断有关的阴性症状、体征 6.诊疗经过:何时、何处就诊,作过何种检查,诊为何病,治疗药物的剂量 与效果 7.一般情况:食欲、大小便、精神、体力、睡眠等 8.目前未愈的其它疾病:可分段叙述或综合记录 History of present illness: It is the main body of medical records which describes in detail about occurrence, development and change of patient’s illness. 1 occurrence of illness: including time, acute or chronic, prodrome, with or without inducing factors 2 the characteristic of the chief symptoms: including position, property, duration, degree 3 development and evolvement of the illness: persistent or intermittent, be better or be worse etc. 4 accompanying symptoms 5 negative symptoms and physicalsigns of distinguish-diagnosis 6 the process of diagnosis and treat: including when, where, what examination, dosage and effect of medicine 7 General condition: appetite, stool urination, energy, thesia, sleep 8 other disease uncured presently 既往史 1.过去的一般健康情况:是否体弱多病,劳动力如何 2.传染病及寄生虫感染史 3.预防接种史及传染病接触史:接种的时间及反应 4.过敏史:寻麻疹、哮喘及药物过敏史 5.外伤手术史 6.系统回顾:呼吸系统 循环系统 10 分钟

置庆医科大半脑床半院载未讲满 消化系统 效尿系结 肌肉骨骼系统 神经系统 Review ofsystem: 1 general condition in the past:for example:bad or well 2 history of infectious disease 3 history of preventive inoculation or contact history of infectious disease 4 history of allergy to drug,food etc 5 history ofoperation 6 Systemic review:Respiratory system: Circulatory system Digestive system: Urinary system: Blood system: Endocrine system: Musculoskeletal system Nervous system: 个人史 ,出身居住史:在各地居住的时间,在疫区生活的情况 2生活习惯史:有无嗜好(烟、酒、常用药品、麻醉毒品)及其用量和年限 3职业和工作条件:参加工作的时间、年限,职业,有无工业毒物、放射物 质接触史 4.治游史:有否不洁性交 5.婚姻史:未婚或己婚, 结婚年龄,配偶健康情况 6月经及生育史:记录方式,妊娠及生育次数和年龄,分娩情况,有无流产 早等 Personal history: 1 history ofbornand living 2 history ofhabit oflife 3 profession and labor condition 4 history ofunclean sexual behavior 5 history ofmarriage 6 history ofmenstrual and childbearing 制表时间:2004年8月

重庆医科大学临床学院教案讲稿 制表时间:2004 年 8 月 5 消化系统 泌尿系统 造血系统 内分泌系统及代谢 肌肉骨骼系统 神经系统 Review of system: 1 general condition in the past: for example: bad or well 2 history of infectious disease 3 history of preventive inoculation or contact history of infectious disease 4 history of allergy to drug, food etc. 5 history of operation 6 Systemic review : Respiratory system: Circulatory system: Digestive system: Urinary system: Blood system: Endocrine system: Musculoskeletal system: Nervous system: 个人史 1.出身居住史:在各地居住的时间,在疫区生活的情况 2.生活习惯史:有无嗜好(烟、酒、常用药品、麻醉毒品)及其用量和年限 3.职业和工作条件:参加工作的时间、年限,职业,有无工业毒物、放射物 质接触史 4.冶游史:有否不洁性交 5.婚姻史:未婚或已婚,结婚年龄,配偶健康情况 6.月经及生育史:记录方式,妊娠及生育次数和年龄,分娩情况,有无流产、 早产等 Personal history: 1 history of born and living 2 history of habit of life 3 profession and labor condition 4 history of unclean sexual behavior 5 history of marriage 6 history of menstrual and childbearing

君庆医科大学临床半院表来讲满 体格检查 R: BP: 一般情况 发育、面容、表情、体位、神志 皮肤粘膜 淋巴结 头部及器官头颅: 耳: 鼻: 口: 部 Physical examination P: R: BP: General condition development、facial features、expression、 position,consciousness Skin and mucous ymph Node Head Skull:: Eyes: Ears: Nose: Mouth: 制表时间:2004年8月 6

重庆医科大学临床学院教案讲稿 制表时间:2004 年 8 月 6 体格检查 T: P: R: BP: 一般情况 发育、面容、表情、体位、神志 皮肤粘膜 淋巴结 头部及器官 头颅: 眼: 耳: 鼻: 口: 颈部 Physical examination T: P: R: BP: General condition development、facial features、expression、 position、consciousness Skin and mucous Lymph Node Head Skull:: Eyes: Ears: Nose: Mouth: Neck

置庆医科大半脑床半院载未讲满 南部 陶廓 肺部:视、触、叩、听 心脏:视、触、叩、听 视、触、叩、听 生殖器 肛门及直肠 脊柱 四肢及血管 神经反射 外科或专科检查发现 Chest Outline of chest Lungs:inspection、palpation、percussion auscultation Heart:inspection、palpation、percussion auscultation Abdomen nspection、palpation、percussion auscultation genitalia Anus and recta spine Limb and blood vessel nerveecho Surgery condition 辅助检查 病历摘要 短文的形式写主、客观的表现,扼要总结字数以不 超过300字为宜。包括:病人姓名、性别、年龄、婚 烟、入院日期:主诉,现病史,与现病史有关的过 去史、个人史和家族史;体检、实验室及器械检查 的重要阳性和有鉴别诊断意义的阴性结果 珍疗计划: 入院诊断: 医师签名xxxx 制表时间:2004年8月

重庆医科大学临床学院教案讲稿 制表时间:2004 年 8 月 7 胸部 胸廓 肺部:视、触、叩、听 心脏:视、触、叩、听 腹部 视、触、叩、听 生殖器 肛门及直肠 脊柱 四肢及血管 神经反射 外科或专科检查发现 Chest Outline of chest Lungs :inspection、palpation、percussion、 auscultation Heart:inspection、palpation、percussion、 auscultation Abdomen inspection 、 palpation 、 percussion 、 auscultation genitalia Anus and recta spine Limb and blood vessel nerve echo Surgery condition 辅助检查 病历摘要 以短文的形式写主、客观的表现,扼要总结字数以不 超过 300 字为宜。包括:病人姓名、性别、年龄、婚 姻、入院日期;主诉,现病史,与现病史有关的过 去史、个人史和家族史;体检、实验室及器械检查 的重要阳性和有鉴别诊断意义的阴性结果 诊疗计划: 入院诊断: 医师签名 xxx /xx

重庆医科大学脑床半院藏来讲满 Accessory Examination History Abstract The abstract must be written in assay which is a sum-up ofthe llness of patientand is not over 300 words.It comprises the patient's name,sex,age,marriage,date ofadmission chief complaints,history ofpresent illness,review ofsystem,personal istory,familial history,physical examination and important ositive results ofaccessory examination. The plan ofdiagnosisand treatment Admission diagnosis Physiciansign:xxx/xx 门诊病历 5分钟 1病历封面护士在分诊逐填写姓名、性别、年龄、工作单位、住址、过敏史 2.就诊年、月、日 3就诊主诉、现病史、既往史 4.与诊断本病有关的阳性体征及有鉴别诊断意义的阴性体征 5记录检查项目及结果、用药剂量、复诊要求等 6.门诊初步诊断 7.急诊病人就诊时,应记录就诊的时刻,还必须记录BP、P、R、T、意识状 态,抢救经过.如抢救无效死亡者记录死亡时间、死亡诊断、死亡原因 入院录 住院病历的简要形式.要求在24小时内完成.由高年资住院医师书写 2 Outpatient case history 1)Nurse must fill the cover of the medical record including name. sex,age,job,address and history ofallergy 2)date of see a doctor 3)chief complaints.history ofpresent illness,review ofsystem 4)positive ive to diagnosis and negative physical d agnosis )items of examination results of examination dosage of medicine and further consultation with a doctor 6)primary diagnosis emergency patient must be recorded time of see a doctor blood-pressure,pulse,respiration,temperature,consciousness and salvage course.death-time.death-diagnosis and death-reason must be recorded if salvage is failed. 3 record of admission Itsa brief of case history which should finished 24 hours afte patient admission to the hospital by senior physician. 制表时间:2004年8月

重庆医科大学临床学院教案讲稿 制表时间:2004 年 8 月 8 Accessory Examination History Abstract The abstract must be written in assay which is a sum-up of the illness of patient and is not over 300 words. It comprises the patient’s name ,sex ,age, marriage, date of admission chief complaints , history of present illness , review of system, personal history, familial history , physical examination and important positive results of accessory examination. The plan of diagnosis and treatment Admission diagnosis Physician sign: xxx /xx 门诊病历 1.病历封面护士在分诊逐填写姓名、性别、年龄、工作单位、住址、过敏史 2.就诊年、月、曰 3.就诊主诉、现病史、既往史 4.与诊断本病有关的阳性体征及有鉴别诊断意义的阴性体征 5.记录检查项目及结果、用药剂量、复诊要求等 6.门诊初步诊断 7.急诊病人就诊时, 应记录就诊的时刻, 还必须记录 BP、P、R、T、意识状 态, 抢救经过. 如抢救无效死亡者记录死亡时间、死亡诊断、死亡原因 入院录 住院病历的简要形式. 要求在 24 小时内完成. 由高年资住院医师书写 2 Outpatient case history 1) Nurse must fill the cover of the medical record including name, sex, age, job, address and history of allergy 2) date of see a doctor 3) chief complaints, history of present illness, review of system 4) positive physical signs relative to diagnosis and negative physical signsrelative to authenticate diagnosis 5) items of examination ,results of examination ,dosage of medicine and further consultation with a doctor 6) primary diagnosis 7) emergency patient must be recorded time of see a doctor , blood-pressure, pulse , respiration , temperature, consciousness and salvage course. death-time, death-diagnosis and death-reason must be recorded if salvage is failed. 3 record of admission It is a brief of case history which should finished 24 hours after patient admission to the hospital by senior physician. 5 分钟

置庆医科大学床半院藏讲满 疾病诊断步骤和临床思维方法 4分钟 实践一认识—再实践再认识 诊断步骤 调查了解搜集资料(第一实践过程) 病史 体格检查 实验室及其它辅助检查 吉立性 系性整树 分析综合 推理、 提出初步诊断 。疾病的表现复杂多 ÷病人主、客观表现会受到许多因素的影响 冬假阴性和假阳性问题 必是堂大小 有无影响检查结果的因素 结果与其它临床资料是否相符 (三)反复实践验证诊断 由于受疾病发生、发展过程和表现程度的限制,受科学技术条件和人们认识 水平的限制对疾病的认口也认须在动态中不斯深化 因此初步诊断提出以 后,还需要在临床实践中反复验证是否正确,只有经过不断的验证和修 才能得到正确而完整的诊断。 Approaches of diagnosis and methods of clinic-thinking Practising-understanding-repractising-reunderstanding 1Approaches of diagnosis 1)Survey and understand and collect data(the first practice phase) history ofillness amination xamination Requirements:authenticity,systematic,integrity 2)Comprehensive analysis,reasoning and give primary diagnosis complex ofillness many factors influence the behaving of patient the problem of false negative and false positive quantity oferror factors affecting examine results +1 0 Recognition of diseases must be penetrated endlessly on development for the confinement of the diseases'occurrence development and manitestation.for the confinement of scientific specification and people's cognitive level.Accordingly,it is demanded to authentication repeatedly in clinical practice after the preference of preliminary diagnosis.It is only authenticating and correcting again and again that obtainingexactitude and complete diagnosis. 制表时间:2004年8月

重庆医科大学临床学院教案讲稿 制表时间:2004 年 8 月 9 疾病诊断步骤和临床思维方法 实践—认识—再实践—再认识 一、诊断步骤 (一)调查了解搜集资料(第一实践过程) 病史 体格检查 实验室及其它辅助检查 要求:真实性、系统性、完整性 (二)分析综合、推理、提出初步诊断 ❖ 疾病的表现复杂多样 ❖ 病人主、客观表现会受到许多因素的影响 ❖ 假阴性和假阳性问题 ❖ 误差大小 ❖ 有无影响检查结果的因素 结果与其它临床资料是否相符 (三)反复实践验证诊断 由于受疾病发生、发展过程和表现程度的限制,受科学技术条件和人们认识 水平的限制,对疾病的认识也必须在动态中不断深化。因此初步诊断提出以 后,还需要在临床实践中反复验证是否正确,只有经过不断的验证和修正, 才能得到正确而完整的诊断。 Approaches of diagnosis and methods of clinic-thinking Practising-understanding-repractising-reunderstanding 1 Approaches of diagnosis 1) Survey and understand and collect data(the first practice phase) history of illness physical examination laboratorial examination Requirements: authenticity, systematic, integrity 2) Comprehensive analysis, reasoning and give primary diagnosis * complex of illness * many factors influence the behaving of patient * the problem of false negative and false positive * quantity of error * factors affecting examine results * if results are consistent with other clinical data 3)Practice repeatedly to authenticate diagnosis Recognition of diseases must be penetrated endlessly on development, for the confinement of the diseases’ occurrence、 development and manifestation, for the confinement of scientific specification and people’s cognitive level. Accordingly, it is demanded to authentication repeatedly in clinical practice after the preference of preliminary diagnosis. It is only authenticating and correcting again and again that obtaining exactitude and complete diagnosis. 4 分钟

露庆医科大学临床半院载案讲满 病例举例 患者文凤英,女,34岁。因心累、气促2+月,腹泻1月,加重伴发热 7天于1997年7月16日入院。 2月前受凉后咳嗽、咳痰、胸痛,诊断为上感”,治疗后仍觉心累、 并于卧位直立后出现头晕、黑蒙。1月前不明原因出现腹泻,为黄 色水样便,每日6-8次, 量多, 无粘液脓血。 7天前,无诱因出现发热 体温波动于38℃-39℃,经青霉素治疗3天后,降为正常。1天前再度复发 ,摄片时晕倒在地,而急诊入院。患病来,精神及食欲差,体重下降 10kg 查体:T37.3℃,P84次/分,R20次/分,BP14/10Kpa,消瘦,急 性病容,痛苦表情,自动体位。胸廓对称,吸气时见“三凹征;叩诊心 界不大 心率只4次分律文 ,各瓣膜区未闻及杂音。 97年7月 17日,血常规:WBC8 0×109L,N0.73,L0.25,RBC 3.68×1012L,Hb117gL,PLT237×1012L. 97年7月23日SR76mmh 三次胸片均无异常,入院后3天肺上份淡薄状阴影约2cm 随着病情的发展,在以后的大查房中发现双上肢肱二头肌反射亢进,双侧霍 曼征 双侧巴彬斯基征(+ 注意到神经系统病变,考忠颈部脊髓占位病变。 MR:颈1-2平面椎管内有一团块,大小约3×2×1.3cm3,将脊髓推向前 壁压偏,呈与脂肪相似的信号,疑为髓外脂肪瘤?或含脂肪成分的其他肿瘤 转入外科千1997年8月11日手术.硬箭后见C12箱背外 位病 大木约4×× ,质 与脊髓 背侧及村 密粘连,界线不清,仅行肿瘤大部切除术。术后病检:C1-2髓外硬膜下脂 瘤。 Case ofa particular disease forexample The patient.Wen e ying. female,34 years old.The patien was admitted because chest distress and accelerated breathing more than two months,more severe and was accompanied with fever seven days on July 16th1997 Two months ago the patient occurred cough expectoration and chest complaint after catching a cold,was diagnosed as "uppe respiratory infection'The patient also felt chest distress and accelerated breathing after treatments,moreover,the patient felt dizziness and amaurosis after standing from decumbent position.One month ago,for no obvious reasons,the patient occurred diarrhea yellow watery stool,6 to 8 vices one day,no mucilaginous bloody purulent stool.Seven days ago,without obvious reasons,the patient occurred fever,the body temperature fluctuated between 38 C and 39C decreased d to normal three days after treatment of the penicillin.One day ago,the symptoms occurred once again,was admitted in a hurry after falling into a swoon when she was taking the Photographs.During her illness,her mentality and appetite were not very good.Shelost weight for 10 kilogran Physical examination:temperately:37.3C,Pulse:84/min, 制表时间.2004年8月 10

重庆医科大学临床学院教案讲稿 制表时间:2004 年 8 月 10 病例举例 患者文凤英,女,34 岁。因心累、气促 2+月,腹泻 1 月,加重伴发热 7 天于 1997 年 7 月 16 日入院。 2 月前受凉后咳嗽、咳痰、胸痛,诊断为“上感”,治疗后仍觉心累、 气促,并于卧位直立后出现头晕、黑蒙。1 月前不明原因出现腹泻,为黄 色水样便,每日 6-8 次,量多,无粘液脓血。7 天前,无诱因出现发热, 体温波动于 38℃-39℃,经青霉素治疗 3 天后,降为正常。1 天前再度复发 ,摄片时晕倒在地,而急诊入院。患病来,精神及食欲差,体重下降 10kg 查体:T 37.3℃,P 84 次/分,R 20 次/分,BP 14/10Kpa,消瘦,急 性病容,痛苦表情,自动体位。胸廓对称,吸气时见“三凹征”;叩诊心 界不大,心率 84 次/分,律齐,各瓣膜区未闻及杂音。 97 年 7 月 17 日,血常规:WBC 8.0×109/L,N 0.73,L 0.25,RBC 3.68 ×1012/L,Hb117g/L,PLT 237×1012/L。 97 年 7 月 23 日 SR 76mm/h 三次胸片均无异常,入院后 3 天肺上份淡薄状阴影约 2cm 随着病情的发展,在以后的大查房中发现双上肢肱二头肌反射亢进,双侧霍 夫曼征(+),双侧巴彬斯基征(+)。 注意到神经系统病变,考虑颈部脊髓占位病变。 MRI:颈 1-2 平面椎管内有一团块,大小约 3×2×1.3cm3,将脊髓推向前 壁压偏,呈与脂肪相似的信号,疑为髓外脂肪瘤?或含脂肪成分的其他肿瘤。 转入外科于 1997 年 8 月 11 日手术:硬脊髓后见 C1-2 脊髓背侧髓外占 位病变,大小约 4×2×2cm3,淡黄色,质软,与脊髓背侧及相邻神经根紧 密粘连,界线不清,仅行肿瘤大部切除术。术后病检:C1-2 髓外硬膜下脂肪 瘤。 Case of a particular disease for example The patient, Wen Fengying, female, 34 years old. The patient was admitted because chest distress and accelerated breathing more than two months, more severe and was accompanied with fever seven days on July 16th ,1997. Two months ago ,the patient occurred cough、 expectoration and chest complaint after catching a cold, was diagnosed as “upper respiratory infection”. The patient also felt chest distress and accelerated breathing after treatments, moreover, the patient felt dizziness and amaurosis after standing from decumbent position. One month ago, for no obvious reasons, the patient occurred diarrhea, yellow watery stool, 6 to 8 vices one day, no mucilaginous bloody purulent stool. Seven days ago, without obvious reasons, the patient occurred fever, the body temperature fluctuated between 38 °C and 39°C,it was decreased to normal three days after treatment of the penicillin. One day ago, the symptoms occurred once again, was admitted in a hurry after falling into a swoon when she was taking the Photographs. During her illness, her mentality and appetite were not very good. She lost weight for 10 kilograms. Physical examination: temperately:37.3°C, P u l s e : 8 4 /mi n

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