搜索
1This57-year-oldblackfemaleenteredthehospitalwithnauseaandvomiting,temperatureof100.5℉,andcontinuouspainintherightupperquadrantoftheabdomen.ExaminationrevealedreboundtendernessintheRUQwithapositiveMurphy’ssign.Herskin,nails,andconjunctivaewereyellowish,andshecomplainedofclay-coloredstools.Leukocytecountwas16,000.Thecholecystogramindicatedcholelithiasis.Acholecystectomywasperformedwithligationofthecysticduct.Bileductswerefreeofstones.Postoptreatmentincludedrespiratorytherapy,IMmeperidinep.r.n.forpain,anantiemeticIM,andIVfluidtherapy.Thepatientwasdischargedwithoutcomplicationsoneweekaftersurgery.Instructionspertainingtodiet,activitylevel,andpossibleadversereactionsweregivenandpatientunderstoodthemwell.Shewastomakeanappointmentwithherphysicianforpostoperativecare.2Thispatient,a38-year-oldwhitewoman,cametotheEmergencyRoomwithaurinarytractinfectionandatemperatureof101℉.Shehadapreviouslydiagnosedlymphomastabilizedwithchemotherapeuticagents.Onadmission,herhemoglobinwas7.9;herwhitecount3,700with62%polysand11%bands.Plateletcountwas72,000.Urinecultureswerepositiveforgram-negativerods.Thepatientwasstartedoncombinedantibiotics.WhenbloodcultureshowedSalmonellasensitivetoampicillin,thisalonewascontinuedat2gIVq6h.Duringtreatment,herplateletcountfelltoabout40,000,probablyduetothechemotherapyincombinationwiththeinfection.Septrawasaddedtotreatmentincaseofplateletdestructionbyampicillin.Thepatientwasdischargedwithanappointmentforafollow-upinoneweek.3Patientspresentedasa46-year-oldmalewithsignsofpneumonia.Heappearedacutelyill,withfever,chills,cough,blue-tingedlips,andseveredyspnea.Finewheezescouldbeheardonexpiration,whichhesaidwasnotunusualsincehesufferedfromasthma.Hesaidthathisasthmawasgenerallywellcontrolled,butthatpulmonaryfunctiontestsusuallyshowreducedlungcapacity.Usingastethoscope,ralescouldclearlybeheard.Achestx-rayconfirmedthediagnosisofpneumoniaandalsorevealedapleuraleffusion.Orderedasputumculturetodeterminethecausativepathogenandarterialbloodgasestoassesstheextentofrespiratoryimpairment.Patientwasadmittedtothehospitalfortreatment.Treatmentplan:intravenousantibioticsbeginningimmediately,tobeadjustedpendingresultsofsputumculture.4Patientpresentedasa54-year-oldmalecomplainingoffatigue,weakness,anorexia,nausea,swellinginthelegsandabdomen,itching,andyellowingoftheskin.Thesymptoms,especiallythejaundice,werehighlysuggestiveofliverdisease.Withtheexceptionofhemorrhoidsandprevioussurgeryforaninguinalhernia,patient’shistoryappearedunremarkable.Onquestioning,however,patientacknowledgedlongstandingalcoholism.Suspectcirrhosis.Orderedliverfunctiontestandaliverscan,resultsconsistentwithcirrhosis.Treatmentplan:medicationstoalleviatesymptoms,enrollmentinalcoholtreatmentprogram,lowproteindiet.5Patientpresentedasa5-year-oldboybroughtinbyhismother.Shewasconcernedthattheboylearnedtositupandwalkmuchlaterthanherfirstchildandnowhasawaddlinggait.Hecannotruneasily,hasdifficultyclimbingstairs,andfallsdownoften.Onexamination,theboyhadenlargedbutweakmuscles.Themyastheniaandbulkinessweremostpronouncedinthecalfmuscles.Theboydidnotcomplainofmyalgia,andtherewasnoevidenceofmyoclonusorotherirregularmusclesactivity.Amusclebiopsyrevealedmuscleatrophywithfatandconnectivetissuedeposits.Electromyographyshowedshort,weakburstsofelectricalactivityandintactnerves,rulingoutatrophyofneurologicorigin.Bloodtestsrevealedelevatedcreatininephosphokinaselevels.Diagnosis:musculardystrophy.Treatmentplan:orthopedicappliances,physicaltherapy,andgeneticcounselingforfamily.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。给病人做了胆囊切除术和胆囊管结扎术。胆管没有结石。术后治疗包括呼吸性治疗，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治疗，2克，静脉内给药，每6小时一次。治疗期间，血小板计数降至40,000，可能由化疗合并感染引起。再上Septra治疗，以防氨苄青霉素引起的血小板破坏。患者出院，嘱其一周后复查。3一男性病人，46岁，有肺炎症状，看上去呈急性病状，伴随发烧、冷颤、咳嗽、双唇发绀，并有严重的呼吸困难。出气时伴有细微的喘气声，据病人讲自从他换上哮喘之后就常有此症状。病人还讲他的哮喘一般来讲控制得还好，但是肺功能测试常显示肺容量受损。用听诊器可听到清晰的啰音。胸部X光照片除了证实肺炎的诊断，还显示了胸膜有渗出物。让病人分别进行痰培养以确定治病病菌和动脉血气分析以确定呼吸受损程度。病人入院治疗。治疗安排：立即进行抗生素静脉滴注，等待痰培养的结果出来后再进一步调整。4一男性病人，54岁，感觉疲乏、虚弱、食欲不振、恶心、腹部和小腿肿胀、发痒和肤色发黄。这些症状，特别是黄疸极有可能暗示了肝部病变。除了因痔疮和从前因腹股沟疝气有过外科手术外，病人没有其他特殊的病史。然而在病情询问时，病人承认有过长时期的酒精中毒。怀疑有肝硬化，让病人进行肝功能测试和肝部扫描。检查结果和初诊一致。治疗安排：用药减轻症状，让病人参加戒酒治疗班，采用低蛋白饮食。5病人是一个五岁的小男孩，由妈妈带来就诊。母亲担心这孩子开始坐立和学步都比她的第一个孩子晚，现在走步时也步履蹒跚，跑步和爬楼梯都有困难，还时常摔跤。检查时发现男孩肌肉大而无力，而这种肌无力和肌庞大在腓肠肌上特别的显著。男孩无主述，检查时也无证据显示有肌阵挛和其他非正常的肌肉活动。肌活检显示在脂肪和结缔组织沉淀上有肌萎缩现象。肌电图检查显示神经完整，有短暂、微弱的电脉冲，排除了神经源的肌萎缩。血液检查显示肌氨酸酐磷酸激酶水平有所升高。诊断是肌营养不良（杜兴氏）。治疗安排：整形外科治疗，物理治疗，家庭遗传病史咨询。