英文病历(发热待查)

Name: Aiyu Sun

Age: 37

Gen der: Female

Race: the Han n ati on ality Birth Place: H on gHu City

Marital Status: Married Occupatio n: Farmer

Address: Group Six, WeiGou Village, Fen gKou Town, Hon gHu City, Hubei Province In forma nt: Aiyu Sun

Date of admissio n: June 3,2010

Date of history take n: June 3,2010

Chief Complai nt:

Feeli ng hot, palpitati on, polyphagia for four mon ths, fever for five days

History of Prese nt Ill ness:

The patient felt hot, palpitation, polyphagia in Feburary, without obivious motivation. The symptoms appeared with shiveri ng of hands and the head, irritability, exophthalmos of both eye balls gradually. The symptoms appeared without compla ints of diarrhea, magersucht, hoarse ness, blurred visio n and so on. The patie nt did not go to receive any medical treatme nt. From April, the symptoms above became more severe, with powerless of limbs. The patie nt went to local hospital on 27th, April. Examination result: FT3>25pg/ml f ,FT4>8npg/dl f ,TSH<0.01ulU/ml J ;WBC

6.11*109/L, N

7.01*109/L; ALT 52u/L f ,AST 41u/L. The patient was diagnosed as

“ hyperthyroidism, cacergasia of liver ” . The patient took Tapazole 5mg tid , propanolol, inosine

drugs for liver protection and WBC raising from then on. The symptoms described above was relieved after taking these medicines. On 12nd, May, the bood routine was still normal: WBC 5.8*109/L, N 3.1*109/L. But five days ago, without obivious motivation, the patient had a pharynx ache, fever, which was highest at 38.7 C, with headache and catarrhus. The patient was diagnosed as “ upper respiratory infection, hyperthyroidism, agranulemia ” and gave antiinfectic therapy. But the fever con ti nu ed, the therapy effect was not well. The patie nt comes to our hospital today. The blood routine today is WBC 0.15*109/L J N0*109/L nd the outpatient

department receives the patient to our ward as “ hyperthyroidism, agranulemia ”.

During the course of disease, sleep and psyche were acceptable. Polyphagia lasted. Stool and

urine were as usual. Physical stre ngth desce nded. Weight was stable.

Past History:

Gen eral Health Status: good V moderate poor

In fectious Disease: V no yes(if any, please write dow n date of on set, brief diag no stic and therapeutic, course ) Typhoid fever Dyse ntery Malaria Schistosomiasis Leptospirosis

Tuberculosis Epidemic hemorrhagic fever others

Allergic history: V no yes (cli nical mani festati on: allerge n: )

Trauma and/or operation history: V no yes

Review of Symptoms: Respiratory system: V no

yes

Repeated phary ngeal pain: chronic cough: dyspnea:

expectorati on: chest pain:

Hemoptysis: asthma:

Circulatory system: V no

yes

Palpitati on: exert ional dysp nea: cyano sis: hemoptysis:

Edema of lower extremities: chest pain: syn cope:

hyperte nsion:

Digestive system: V no yes Hematochezia: jaun dice:

Urinary system: V no yes

Polyuria: rete nti on of urine: incon ti nence of urine: hematuria:

Pyuria:

no cturia:

puffy face:

Hematopoietic system: V no yes

Ano rexia:

dysphagia: Emesis: mele na: sour regurgitati on: eructati

on: nausea: abdo minal pain: diarrhea:

hematemesis:

Fatigue: dizz in ess:

gin gival hemorrhage: epistaxis:

subcuta neous hemorrhage: Metabolic and endocrine system: V no yes Bulimia: ano rexia: hot in tolera nee: hyperhidrosis: cold in tolera nee:

Polydipsia:

ame no rrhea: tremor of han ds: Marked obesity: marked emaciati on: hirsutism: Hyperpigme ntatio n: sexual function cha nge: character cha nge: alopecia: impote nee: ame no rrhea:

Musculoskeletal system: V no yes

Migrati ng arthralgia:

arthralgia: Dysarthrosis: myalgia: artrcocele: arthremia: muscular atrophy: Neurological system: V no yes Dizz in ess: headache: paresthesia:

Insomnia: somnolence: syn cope: Disturba nee of con scious ness: paralysis: hypo mn esis: con vulsi on: vertigo:

Visual disturba nee:

Pers onal history: Reside nt history in en demic disease area: V no yes Smoking: V no yes: about _______ years

Drinking: V no occasi onal freque nt: about ___ years average _____ m l/day

Others:

Lumbar pain: urinary freque ncy: urinary urge ncy: dysuria: oliguria:

In April 2009, the patient was diagnosed as “ polypof vocal cord ”n our hospital and got medic ine thrapy.

Men strual history:

Men archal age: 21 years old duration 5 days/ interval 30 days

Last men strual period: 2010.5.1 menopausal age: 13 years old

Amount of flow: small V moderate large

dysme no rrheal: prese nee V abse nee

Marital and obstetrical history:

Married age: 21 years old pregnancy 4 times natural labour: 3 times

Aborti on: 2 times premature labour: 0 times still birth: 0 times

Dystocia and its course:0

Family history:

(pay atte nti on to the in fectious and hereditary disease related to the prese nt ill ness)

Father: Mother: Others: V healthy ill:

V healthy ill:

deceased cause:

Physical Exam in ati on

Gen eral con diti ons:

Temperature: 37.3 C °pulse:88 times per minute (V regular irregular) Blood pressure:139/84mmHg respirati on: 20 times per mi nute (V regular irregular) Development: V normal Hypoplasia

Nutriti on: good V moderate poor cachexia

Facial expression: V normal acute chronic other( )

Posture: V active semi-recli ning positi on other ( )

Mental status: V clear confusion somnolence delirium coma

Gait: V normal abnormal cooperation: V yes no

Skin and mucosa:

Color: V no rmal pale cyano sis sta ined yellow pigme ntati on

rash: V no yes: (type: distribution: )

subcuta neous hemorrhage: V no yes (type: distributi on: )

Hair distributi on: V no rmal hypertrichosis oligotrichosis alopecial(locati on: ) Temperature and moisture: V normal cold warm dry moist dehydration

Edema: V no yes ( locati on and degree )

Liver palmar : V no yes spider angioma: V no yes (location: )

Others: no

Lymph no des:

enl argeme nt of superfacial lymph no de: V no yes (locati on and descripti on: ) Head: without abno rmity

Cran ium: without abno rmity

Eye: exophthalmos: exophthalmos of both eye balls

eyelid: without desce nsus

conj un ctiva: without edema

sclera: without sta ined yellow

Cornea: V normal abnormal ( od os )

Pupil: V equally round and equal in size: unequal (od os )

Pupil reflex: V normal delayed (od os ) absent (od os ) others:

Ear: discharge of exter nal auditory can al: V no rmal (left right quality: ) Mastoid tendern ess : no (left right )

disturba nee of rough heari ng test: yes V no

Nose: flaring of alae nasi: V no yes

stuffy discharge: V no yes

tendern ess over para nasal sinu ses: V no yes(locati on: )

Mouth: lip: red

Mucosa: without ulcerati on

Ton gue: stretched ton gue is in the middle

Gum: no mal

Tonsil: I °nlargement of both sides

Phary nx: con gesti on

sound: V no rmal hoarse ness teeth: formal abse nt carie

Neck:

n eck rigidity V no yes (dista nee betwee n sternum and man dible: ___ tran svers fin gers) Carotid artery: V no rmal pulsati on in creased pulsati on marked diste nti on

Trachea: V middle deviation (leftward rightward )

Hepatojugular vein reflux: n egative

Thyroid: no rmal V en larged bruit

Chest:

Chest wall: V normal barrel chest prominence or retraction: (left right ) Precordial prominence: V no yes percussion pain over sternum: V no yes

Breast: no rmal

Lun g:

In spect ion: no rmal respiratory moveme nt

Palpati on:

vocal tactile fremitus: no rmal

pleural rubbing sensation: V no yes

Subcutaneous crepitus sensation: V no yes

Percussion: V resonanc dullness Flatness Hyperresonance tympany

lower border of lung: (detailed percussi on in respiratory disease) midclavicular

line : right:_6=cm left:_ __cm

midaxillary line: right: 8_cm left:_8__cm

scapular line: right:_10__cm left:_10 cm

Auscultati on: breath ing sound : V no rmal abno rmal

Rales: V no yes (moist dry ) locatio n:

Heart:

英文病历(发热待查)

Name: Aiyu Sun Age: 37 Gender: Female Race: the Han nationality Birth Place: HongHu City Marital Status: Married Occupation: Farmer Address: Group Six, WeiGou Village, FengKou Town, HongHu City, Hubei Province Informant: Aiyu Sun Date of admission: June 3 , 2010 Date of history taken: June 3 , 2010 Chief Complaint: Feeling hot, palpitation, polyphagia for four months, fever for five days History of Present Illness: The patient felt hot, palpitation, polyphagia in Feburary, without obivious motivation. The symptoms appeared with shivering of hands and the head, irritability, exophthalmos of both eye balls gradually. The symptoms appeared without complaints of diarrhea, magersucht, hoarseness, blurred vision and so on. The patient did not go to receive any medical treatment. From April, the symptoms above became more severe, with powerless of limbs. The patient went to local hospital on 27th, April. Examination result: FT3>25pg/ml↑,FT4>8npg/dl↑,TSH<0.01uIU/ml↓;WBC 6.11*109/L, N 7.01*109/L; ALT 52u/L↑, AST 41u/L. The patient was diagnosed as “hyperthyroidism, cacergasia of liver”. The patient took Tapazole 5mg tid , propanolol, inosine，drugs for liver protection and WBC raising from then on. The symptoms described above was relieved after taking these medicines. On 12nd, May, the bood routine was still normal: WBC 5.8*109/L, N 3.1*109/L. But five days ago, without obivious motivation, the patient had a pharynx ache, fever, which was highest at 38.7°C，with headache and catarrhus. The patient was diagnosed as “upper respiratory infection, hyperthyroidism, agranulemia” and gave antiinfection therapy. But the fever continued, the therapy effect was not well. The patient comes to our hospital today. The blood routine today is WBC 0.15*109/L↓, N0*109/L↓↓↓, and the outpatient department receives the patient to our ward as“hyperthyroidism, agranulemia”. During the course of disease, sleep and psyche were acceptable. Polyphagia lasted. Stool and urine were as usual. Physical strength descended. Weight was stable. Past History: General Health Status: good √moderate poor Infectious Disease: √no yes(if any, please write down date of onset, brief diagnostic and therapeutic, course ) Typhoid fever Dysentery Malaria Schistosomiasis Leptospirosis Tuberculosis Epidemic hemorrhagic fever others Allergic history: √no yes (clinical manifestation: allergen: ) Trauma and/or operation history: √no yes

病例讨论 - 发热待查

病历讨论病史：患者郑**，男，25岁,因“反复发热2个月余”为主诉于2006年07月 11日10时40分步行入院。缘于入院前2个月前无明显诱因出现畏寒，乏力，继而发热，体温波动于38.3－38.5℃，伴膝关节酸痛，发热时食欲欠佳，无其它关节酸痛，无夜间盗汗、无纳差，无咳嗽、咳痰，无咯血，无胸痛、胸闷，无呼吸困难，无腹胀，无恶心、呕吐，无双下肢浮肿，无皮疹，无尿频、尿急、尿痛，大便次数较平时增多，2-3次/天，糊状、色偏黑，。就诊于**医院查血常规：WBC 10.2×10^9/L,肥达氏反应阴性，予以“阿奇霉素、左氧氟沙星、利福平”等治疗,未见明显好转。昨起出现血便，约250ml,1次/天,暗红色，伴下腹痛便后缓解。今为进一步诊疗，转诊我院，门诊拟“发热待查”收住入院。发病以来，患者精神状态一般，睡眠及食欲正常，小便正常，体重下降约10公斤。既往有胃炎病史，否认既往有肝炎、肺结核等传染病史，否认外伤手术史，否认输血史，否认药物过敏史，预防接种史具体不详。婚育史：未婚未育。入院查体：T：38.4℃P：80 次/分R：20 次/分BP：110/72mmHg 神清，全身皮肤粘膜无皮疹、焦痂及出血点，全身浅表淋巴结未扪及肿大，睑结膜及口唇稍苍白，咽无充血，双侧扁桃体无肿大，颈软，双肺呼吸音清，未闻及干湿性罗音。心率80次/分，律齐，各瓣膜听诊区无明显的病理性杂音。腹软，全腹无压痛、反跳痛，未触及包块，肝脾肋下未触及。肛门指检未及明显肿块，指套无血迹。脊柱、四肢无畸形，关节无红肿、疼痛及皮下结节，双下肢无浮肿，巴氏征阴性。入院后相关检查： (2006.7.11）：血常规WBC 10.5×10^9/L ，N 79.9% ，Hb 95g/L，PLT 270×10^9/L；急诊全套：GLU 8.4mmol/L，BUN 2.2mmol/L，K 3.3mmol//L,Ca 1.9mmol/L；血凝：PT 14.8s，DD 0.79ug/ml；（2006.7.12）：尿常规：胆红素1＋，酮体1＋；粪便常规：白细胞1＋，霉菌1＋； HAA ：阴性； NAP积分：281分；血沉：54mm/L；（2006.7.13）自身免疫性抗体：－；基因芯片：无异常；（2006.7.15）：粪便找碳酸杆菌：未找到；胸部CT平扫未见明显异常征象；（2006.7.17）：HIV －；肠镜：结肠溃疡性质待定，病理送检结肠粘膜组织，呈慢性炎症，粘膜糜烂，肉芽增生，间质多量淋巴细胞浸润，恶性淋巴瘤待排，建议短期规范抗炎治疗后复查；免疫组化染色：淋巴细胞CD20 ＋，CD79a + ，CD3 2＋，CD45RO

发热待查之经验分享

发热待查之协和经验

发热是最常见的临床症状，但发热的原因却不尽相同，涉及的疾病也极其纷繁复杂。还有部分患者长期发热，虽四处求医仍诊断不明。因此，对长期不明原因发热的诊断，常被认为是最富挑战性的临床问题。不明原因发热(FUO，feverofunknownorigin)又称发热待查，其经典定义于1961年由皮特斯多夫(Petersdorf)和比森(Beeson)基于对100例患者进行的前瞻性研究所提出：①发热时间持续≥3周;②体温多次>38.3℃; ③经过≥1周完整的病史询问、体格检查和常规实验室检查后仍不能确诊。

发热待查常见病因及其构成变迁发热待查的病因包括感染性疾病、结缔组织病、肿瘤性疾病及其他疾病，其中有部分患者虽然经过系统检查仍不能明确病因。北京协和医院感染科病房以收治FUO及疑难重症感染性疾病患者为主。我们回顾性分析了2004年至2010年间收治的997例FUO患者的病因构成，其中，感染性疾病占48.0%，结缔组织病占16.9%、肿瘤性疾病占7.9%，其他疾病占7.1%，诊断未明占20.1%(图1)。结合我科此前对1985-1989年间130例FUO病例以及2000-2003年间449例FUO病例进行的病因总结，我们绘制了26年间不明原因发热病因变迁图(图2)，发表于《中华医学杂志英文版》(ChinmedJ)2013年第5期。综合我院26年间FUO病因变迁分析显示，感染性疾病、结缔组织病和其他疾病在FUO病因构成中无显著变化，肿瘤性疾病所占比例明显降低(由16.9%降至7.9%)，发热原因未明的比例显著增加(由10%升至20.1%)。近年来国外文献中所报告的FUO诊断不明病例约占全部FUO病例的51%，也呈现明显上升趋势。FUO患者诊断未明的比例呈上升趋势，分析原因可能是，随着CT和磁共振成像(MRI)等影像技术的普及，病原学培养技术的提高，新研发的血清学检测项目越来越多，以及聚合酶链式反应(PCR)技术在临床检测中的应用等等，常见疾病的确诊效率提高，而符合经典FUO定义的病例却越来越复杂。发热待查诊断思路及工具详细、反复的病史询问和全面仔细的体格检查依旧是确定FUO病因的最基本、最重要的方法。在病史询问中，应特别注意对局部症状、旅行史、动物接触史以及用药史等的询问，应重视常见疾病的不典型临床表现。常用的辅助检查包括：血常规，血树突状细胞(DC)检测，血培养(须进行3次)，血生化，红细胞沉降率(ESR)、C反应蛋白(CRP)、类风湿因子(RF)、磷酸肌酸激酶(CK)及抗核抗体(ANA)检测，血清蛋白电泳，尿常规及相差镜检，尿培养，结核菌素(PPD)试验，骨髓穿刺，胸腹部CT等等。如果检查结果指向某个脏器病变，应进一步行相关实验室检查、影像学检查或活组织检查。在我们医院的数据中，结核病一直高居FUO病因构成的首位。在2004-2010年间的病因分析中，结核病病

熊继柏：湿热发热病案,兼谈承气

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