病历 case histroy 2011.3.8. 一般事项 date of admission /marital status /present address...

病历 病历 case histroycase histroy病历 病历 case histroycase histroy

2011.3.82011.3.8

• 一般事项 date of admission /marital status /present address /correspondence / occupation

• 主诉 chief complaints现病史 present illness / history of present illness既往史 past medical history家族史 family history 个人病史 personal history / social history曾用药物 medications过敏史 allergies系统回顾 system review / review of system

体检 physical examination

• 一般状况或全身状况 general appearance 头眼与耳鼻喉 head,eyes,ear,nose,throat

• 胸部与心肺 CHEST,heart,and lungs腹部 abdomens四肢 extremities神经系统 nervous system,Neurological

• 骨骼肌系统 Musculoskeletal泌尿生殖系统 Genitourinary

化验室资料 laboratorydata

血液检查 blood test 化学 7 项指标 chem.-7心脑电图 electrocardiogram / electroencephalogram , 略作 EKG/EEGX 线检查 X-ray examination, x-ray slides

• CT 扫描 computerized x-ray tomography • 其他检查资料 other lab data

• 印象与诊断 impression and diagnosis住院治疗情况 hospital course 出院医嘱 discharge instructions / recommendations出院后用药 discharge medications

Medical Records for Admission • General information•

Name: Huahua• Age: three• Sex: Female• Race: Han• Nationality: China• Address: NO.23, Xicheng Road, Lucheng District, Wenzhou,

Zhejiang. Tel: 85763723• Parents Name: father Zhang Hesheng• Mother Yang Chiulian• Date of admission: September 18th, 2009• Date of record: 11Am, May 8th, 2001• Complainer of history: patient’s mother• Reliability: Reliable

•Chief complaint: sore throat for 48 h,.respiratory distress for 12h.

Present illness

• .A previously healthy 3-year-old girl was brought to our emergency room in severe respiratory distress. She had a sore throat for the past 48 h, mild fever and minor respiratory difficulty without cough.

• Since onset, her appetite was not good, and both her spiritedness and physical energy are bad. Defecation and urination are normal.

Past history

Past medical history was significant for prematurity (35 weeks’ gestation) and transient tachypnoea.

Physical examination• Vital signs included: temperature 38.2°C, blood pr

essure 75/40 mm Hg, heart rate 185 beats/min and respiratory rate 60breaths/min.

• The patient was in a critical condition with a diminished level of consciousness. She showed tachypnoea, laboured and abdominal breathing, nasal flaring, perioral cyanosis and pale skin. Hypoventilation and rales were also present. Crepitus was palpable over the neck and upper chest.

Investigation

• Arterial blood PO2 was 58 mm Hg, PCO2 34 mm Hg and oxygenation 70% with an inspired oxygen

• fraction (FiO2) of 50%. White blood cell count was normal.

• C-reactive protein and procalcitonin were elevated

Chest radiograph The initial chest radiograph showed pneumomediastinum with subcutaneous emphysema, right pneumothorax, bilateral increased lung density and left lower lobe air bronchogram.

Hospital Course• The patient was intubated and transferred

to the intensive care unit (ICU). A chest tube was placed for pneumothorax drainage.

• Despite supportive measures and re-expansion of the right lung, the patient’s condition deteriorated in the following 36 h. A chest CT scan was obtained in order to evaluate extension and complications of the disease.

CT• This revealed a sizeable pneu

momediastinum with subcutaneous air, areas of ground-glass attenuation and air-space consolidation in-volving the entire lung parenchyma, bilateral small pleural effusions and residual air in the right pleural space. There were no bullae.

QUESTION?

1.What is the most likely diagnosis? differential diagnosis?

2.Which examination should we do ?

3.How to treat this patient?