问题 问答题 案例分析题

病历摘要男性,61岁。上腹胀半年,黄疸伴尿色加深半个月。患者半年前无明显诱因出现上腹部胀满不适、食欲减退、厌油腻食物,无腹痛、恶心、呕吐,无发热、皮肤巩膜黄染,尿色加深,大便呈白色陶土样,伴持续低热、全身乏力。黄疸症状进行性加重。发病以来,睡眠差,体重下降4千克。既往史:无肝胆、胃肠疾病史,无药物过敏及手术、外伤史。无饮酒嗜好。查体:T37.2℃,P90次/分,R17次/分,BP115/60mmHg。神志清楚,表情自然,自动体位,查体合作,未见肝掌及蜘蛛痣,全身皮肤巩膜黄染,双肺呼吸音清晰,未闻及干、湿性啰音,心界不大,心率90次/分,律齐,各瓣膜区未闻及杂音。腹平软,全腹无压痛,无反跳痛,肝脾肋下未触及。右肋缘下可触及肿大囊肿,无压痛。移动性浊音阴性,肠鸣音3次/分,双下肢无水肿。辅助检查:ALT452U/L,AST258U/L,TBil311.2μmol/L,DBil251.2μmol/L,CA19-93.0万U/L,凝血功能正常。要求:根据以上病历摘要,请写出初步诊断及诊断依据、鉴别诊断、进一步检查与治疗原则。

答案

参考答案:

初步诊断及诊断依据

初步诊断:1.胰头癌或壶腹周围癌2.梗阻性黄疸

诊断依据:1.病史:(1)老年男性,慢性病程。(2)典型的临床表现:以腹胀、食欲不佳等胃肠道症状为首发症状,随后出现典型的无痛性进行性黄疸症状,伴有低热、全身乏力,体重下降等全身表现。2.查体:全身皮肤及巩膜黄染。右肋缘下可触及肿大胆囊,无压痛。3.实验室检查:转氨酶升高,胆红素升高,以直接胆红素为主,肿瘤标记物CA19-9升高(3.O万U/L>上限2.5万U/L)。

鉴别诊断:1.壶腹周围癌或胰头癌2.胆总管结石3.黄疸型肝炎4.原发性肝癌

进一步检查:1.腹部B超检查。2.上腹部CT或MRI检查。3.必要时行MRCP或ERCP检查。

治疗原则:1.完善术前准备后,手术治疗。2.如无法切除可行姑息治疗:内引流术、外引流术、经皮经肝穿刺引流术(PTCD.、胆道支架置入术等。3.放疗、化疗等。

阅读理解

Mary was a 911 operator(接线员) in Los Angeles. One Thursday morning, she was surprised to get a call from a young child who said, “Mom is ill, Mom is ill”, again and again. Mary hurried to find the address of the call. She called the police. In a minute, the policemen and doctors arrived at the house. They broke the door open, and they couldn’t believe their eyes. The little child was so young that maybe she could not walk! She was sitting beside her mother and holding her mother’s hand. Tears(眼泪) were running down her face.

The doctor gave the woman some medicine and soon she woke up. Later, she told people , “Everyone was surprised that my daughter could call 911. One Monday I tried to teach her how to call 911.” “It’s the first time I’ve seen a two-year-old child call 911.”

小题1: What did Mary do every day? ______________

A.She answered the telephone calls.

B.She talked with the policemen and the doctors.

C.She played with the children.

D.She dealt with emergencies(紧急情况).小题2: How did she feel when she answered the little girl’s call? _______________

A.She was worried.

B.She was sorry.

C.She was surprised.

D.She was happy.小题3:How did the police and the doctors get into the house?_________________

A.They went in through the windows.

B.They broke the door open.

C.They didn’t go in.

D.The woman was outside. They didn’t need to go in.小题4: How could the little girl learn to call 911?________________

A.She learnt it by herself.

B.She called it by chance.(偶然地)

C.Her mother taught her one Monday

D.Her mother often taught her.小题5: How old was the little girl?_________________-

A.Only two.

B.She was nine.

C.She was five.

D.She couldn’t walk, so she must be less one.

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