Chapter12（3）病例练习
1
This 57-year-old black female entered the hospital with nausea and vomiting, temperature of 100.5 ℉, and continuous pain in the right upper quadrant of the abdomen. Examination revealed rebound tenderness in the RUQ with a positive Murphy’s sign. Her skin, nails, and conjunctivae were yellowish, and she complained of clay-colored stools. Leukocyte count was 16,000. The cholecystogram indicated cholelithiasis.
A cholecystectomy was performed with ligation of the cystic duct. Bile ducts were free of stones. Postop treatment included respiratory therapy, IM for pain, an antiemetic IM, and IV fluid therapy.
The patient was discharged without complications one week after surgery. Instructions pertaining to diet, activity level, and possible adverse reactions were given and patient understood them well. She was to make an appointment with her physician for postoperative care.
2
This patient, a 38-year-old white woman, came to the Emergency Room with a urinary tract infection and a temperature of 101 ℉. She had a previously diagnosed lymphoma stabilized with chemotherapeutic agents. On admission, her hemoglobin was 7.9; her white count 3,700 with 62% polys and 11% bands. Platelet count was 72,000. Urine cultures were positive for gram-negative rods.
The patient was started on combined antibiotics. When blood culture showed Salmonella sensitive to ampicillin, this alone was continued at 2 g IV q6h. During treatment, her platelet count fell to about 40,000, probably due to the chemotherapy in combination with the infection. Septra was added to treatment in case of platelet destruction by ampicillin.
The patient was discharged with an appointment for a follow-up in one week.
3
Patients presented as a 46-year-old male with signs of pneumonia. He appeared acutely i
ll, with fever, chills, cough, blue-tinged lips, and severe dyspnea. Fine wheezes could be heard on expiration, which he said was not unusual since he
suffered from asthma. He said that his asthma was generally well controlled, but that pulmonary function tests usually show reduced lung capacity. Using a stethoscope, rales could clearly be heard. A chest x-ray confirmed the diagnosis of pneumonia and also revealed a pleural effusion. Ordered a sputum culture to determine the causative pathogen and arterial blood gases to assess the extent of respiratory impairment. Patient was admitted to the hospital for treatment. Treatment plan: intravenous antibiotics beginning immediately, to be adjusted pending results of sputum culture.
4
Patient presented as a 54-year-old male complaining of fatigue, weakness, anorexia, nausea, swelling in the legs and abdomen, itching, and yellowing of the skin. The symptoms, especially the jaundice, were highly suggestive of liver disease. With the exception of hemorrhoids and previous surgery for an inguinal hernia, patient’s history ap
peared unremarkable. On questioning, however, patient acknowledged longstanding alcoholism. Suspect cirrhosis. Ordered liver function test and a liver scan, results consistent with cirrhosis. Treatment plan: medications to alleviate symptoms, enrollment in alcohol treatment program, low protein diet.
5
Patient presented as a 5-year-old boy brought in by his mother. She was concerned that the boy learned to sit up and walk much later than her first child and now has a waddling gait. He cannot run easily, has difficulty climbing stairs, and falls down often. On examination, the boy had enlarged but weak muscles. The myasthenia and bulkiness were most pronounced in the calf muscles. The boy did not complain of myalgia, and there was no evidence of myoclonus or other irregular muscles activity.
A muscle biopsy revealed muscle atrophy with fat and connective tissue deposits. Electromyography showed short, weak bursts of electrical activity and intact nerves, ruling out atrophy of neurologic origin. Blood tests revealed elevated creatinine phosphoki
nase levels. Diagnosis: muscular dystrophy. Treatment plan: orthopedic appliances, physical therapy, and genetic counseling for family.
参考答案：
1
患者，57岁，黑人女性，因恶心、呕吐、发热（100.5 ℉）、右上腹持续疼痛而入院。检查显示右上腹有反跳痛，墨菲氏征阳性。病人皮肤、指甲、结膜均泛黄，而且大便呈陶土样。白细胞计数为：16,000。胆囊造影图提示有胆石病。
pending给病人做了胆囊切除术和胆囊管结扎术。胆管没有结石。术后包括呼吸性，必要时肌肉注射度冷丁来减少疼痛，肌肉注射止吐药，以及静脉液体注射。
手术后一周病人出院，没有并发症。有关饮食、活动度及可能的副反应的说明都告诉了病人，病人也充分理解了这些。她将会和她的医生预约做术后料理。
2
患者，38岁，白人女性，因泌尿道感染、发热（101℉），到急诊室就诊。过去，曾诊断患有淋巴瘤；化疗后稳定。入院时，血红蛋白7.9；白细胞计数3,700，多核62％，带核11％；血小板计数72,000。尿培养革兰氏阴性杆菌阳性。
患者一开始就采用抗生素联合疗法。在血培养显示有对氨苄青霉素敏感的沙门氏菌生长时，则持续使用了该抗生素进行，2克，静脉内给药，每6小时一次。期间，血小板计数降至40,000，可能由化疗合并感染引起。再上Septra ，以防氨苄青霉素引起的血小板破坏。