2021年慢性胃炎急性发作病历.pdf

《2021年慢性胃炎急性发作病历.pdf》由会员分享，可在线阅读，更多相关《2021年慢性胃炎急性发作病历.pdf（6页珍藏版）》请在淘文阁 - 分享文档赚钱的网站上搜索。

1、资料收集于网络如有侵权请联系网站删除谢谢精品文档医院住 院 病 案内 1 科：床住院号：姓名：性别：女病案号：年龄：81 岁婚况：丧偶职业：居民出生地：XX 民族：汉国籍：中国家庭住址或单位：邮编：402260 入院时间：/11/30 10:40m 病史采集时间：/11/30 10:40m 病史陈述者：患者可靠程度：较可靠发病季节：问诊：主诉：反复中上腹疼痛不适40+年，复发加重1天。现病史：40+年前患者无明显诱因出现中上腹持续性疼痛，饱胀不适，饥饿时和餐后加重，无恶心、呕吐，无呕血、黑便，无头昏、头痛、咳嗽、咳痰、畏寒发热等，自行在外服用“胃药”后缓解，具体用药不详；以后每因饮食不慎、不节

2、或无明显诱因反复发作，不随精神情绪加重或减轻，或在门诊诊治，或自行服用“斯达舒、胃必治、丽珠得乐、吗叮啉”等，病情缓解即停药，未正规诊治。1天前患者进食油腻食物后中上腹疼痛再次发作，为持续性疼痛，上腹饱胀，伴恶心、胸闷，患者自服“速效救心丸10 粒Tid，吗丁啉10mg Tid”，病情无缓解，患者为得到进一步诊治，故今日到我院，门诊以“慢性胃炎、冠心病”收入我科。此次患病以来，无肩背部疼痛，疼痛无阵发性加剧、无转移，无呕吐、胸骨后疼痛、呼吸困难、意识障碍，精神差，进食量少，睡眠差，大小便正常。既往史：既往体质一般，否认结核、肝炎、伤寒等传染病史，无外伤、手术、输血史。预防接种史不详。反复胸骨后

3、、心前区压榨感伴胸闷3年，上述症状常因劳累而出现，自服“速效救心丸”后约35 分钟上述症状消失，曾到我院门诊就诊，诊断为“冠心病”予“心脑康、速效救心丸等”治疗；活动后心累、乏力，休息后明显缓解1年。余系统回顾无重要发现。精品w o r d 学习资料 可编辑资料-精心整理-欢迎下载-第 1 页，共 6 页资料收集于网络如有侵权请联系网站删除谢谢精品文档过敏史；否认食物、药物、金属等过敏史。其他情况：生居于XX，无疫区居留史，不饮酒、吸烟，平素高盐饮食，无其它特殊嗜好，丧偶，爱人死因不详，子女体健，否认家族遗传病史和同类疾病史。体格检查T36.4oc P44 次/分R18 次/分BP94/64m

4、mHg 发育正常，营养中等，正力体型，平车推入病房，强迫体位，神清语晰，急性痛苦面容，查体合作，对答切题。舌质红，苔黄腻，脉弦。全身皮肤湿、温度正常，弹性尚可，未见黄染、皮疹及瘀点、瘀斑。全身浅表淋巴结未扪及肿大。头颅无畸形，无包块，无压痛，巩膜无黄染，结膜无充血，双侧瞳孔等大等圆，直径约0.3cm，对光反射灵敏。双耳听力正常，外耳道无溢液，乳突区无压痛。鼻外观无畸形，无分泌物，副鼻窦区无压痛，唇红，咽部无充血，双侧扁桃体不肿大。颈软，颈静脉无充盈，气管居中，甲状腺不大。胸廓无畸形，肋间隙无增宽及变窄，双肺呼吸动度一致，胸式呼吸为主，无胸膜摩擦音及皮下捻发感，语颤正常，叩诊呈清音，肺下界和肝浊

5、音界正常，双肺呼吸音粗，双肺未闻及干、湿鸣。心前区无隆起，心尖搏动在第五肋间左锁骨中线处，未扪及震颤，心界临界大，心率44 次/分，律齐，各瓣膜听诊区未闻及病理性杂音。未见异常周围血管征。腹软，中上腹压痛，全腹无反跳痛，肝脾于肋下未扪及，莫菲氏征阴性，麦氏点无压痛，肝肾区无叩痛，移浊（）。肠鸣音约4-6 次/分。脊柱四肢未见畸形，无红、肿，活动不受限，双下肢无水肿。肛门、外生殖器未查。生理反射存在，病理征未引出。辅 助 检 查：电 解 质、肾 功：正 常；随 机 血 糖：5.9mmol/L；血 分 析：WBC6.1 109/L,RBC3.581012/L,Hb121g/L,HCT:0.338l

6、/l；PLT：1641012/L，L18.1%,M6.5，G75.4%；腹部 B超：1、胆囊壁略毛糙2、肝脏、胰腺、脾脏、肾脏未见异常；心电图：1、窦性心动过缓 2、房室传导阻滞3、偶发室性早博4、肢体导联低电压。入院诊断：中医诊断：胃痛肝胃郁热西医诊断：1、慢性胃炎急性发作精品w o r d 学习资料 可编辑资料-精心整理-欢迎下载-第 2 页，共 6 页文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9

7、文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9

8、O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9

9、文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9

10、O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9

11、文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9

12、O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9

13、资料收集于网络如有侵权请联系网站删除谢谢精品文档2、冠状动脉粥样硬化性心脏病劳累型心绞痛心功能级心界临界大窦性心动过缓房室传导阻滞偶发室性早博3、慢性胆囊炎首次病程记录年 11 月 30 日 4Pm 精品w o r d 学习资料 可编辑资料-精心整理-欢迎下载-第 3 页，共 6 页文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8

14、L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 H

15、M9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8

16、L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 H

17、M9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8

18、L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 H

19、M9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9资料收集于网络如有侵权请联系网站删除谢谢精品文档患者，女，81 岁，因“反复

20、中上腹疼痛不适40+年，复发加重 1天。”于年 11 月 30 日 10:40Am入院。其病史特点如下：1、患者老年女性，病程长，病情反复，此次起病急；2、40+年前患者无明显诱因出现中上腹持续性疼痛，饱胀不适，饥饿时和餐后加重，无恶心、呕吐，无呕血、黑便，无头昏、头痛、咳嗽、咳痰、畏寒发热等，自行在外服用“胃药”后缓解，具体用药不详；以后每因饮食不慎、不节或无明显诱因反复发作，不随精神情绪加重或减轻，或在门诊诊治，或自行服用“斯达舒、胃必治、丽珠得乐、吗叮啉”等，病情缓解即停药，未正规诊治。1天前患者进食油腻食物后中上腹疼痛再次发作，为持续性疼痛，上腹饱胀，伴恶心、胸闷，患者自服“速效救心丸

21、10 粒Tid，吗丁啉10mg Tid”，病情无缓解，患者为得到进一步诊治，故今日到我院，门诊以“慢性胃炎、冠心病”收入我科。此次患病以来，无肩背部疼痛，疼痛无阵发性加剧、无转移，无呕吐、胸骨后疼痛、呼吸困难、意识障碍，精神差，进食量少，睡眠差，大小便正常。3、反复胸骨后、心前区压榨感伴胸闷3年，上述症状常因劳累而出现，自服“速效救心丸”后约 3 5分钟上述症状消失，曾到我院门诊就诊，诊断为“冠心病”予“心脑康、速效救心丸等”治疗；活动后心累、乏力，休息后明显缓解1年。4、查体：T36.4oc，P44 次/分，R18 次/分，BP94/64mmHg。发育正常，营养中等，正力体型，平车推入病房，

22、强迫体位，神清语晰，急性痛苦面容，查体合作，对答切题。舌质红，苔黄腻，脉弦。双肺呼吸音粗，双肺未闻及干、湿鸣。心前区无隆起，心尖搏动在第五肋间左锁骨中线处，未扪及震颤，心界临界大，心率44 次/分，律齐，各瓣膜听诊区未闻及病理性杂音。未见异常周围血管征。腹软，中上腹压痛，全腹无反跳痛。生理反射存在，病理征未引出。5、辅 助 检 查：电 解 质、肾 功：正 常；随 机 血 糖：5.9mmol/L；血 分 析：WBC6.1 109/L,RBC3.581012/L,Hb121g/L,HCT:0.338l/l；PLT：1641012/L，L18.1%,M6.5，G75.4%；腹部 B超：1、胆囊壁略毛

23、糙2、肝脏、胰腺、脾脏、肾脏未见异常；心电图：1、窦性心动过缓 2、房室传导阻滞3、偶发室性早博4、肢体导联低电压。综上所述，中医诊断：精品w o r d 学习资料 可编辑资料-精心整理-欢迎下载-第 4 页，共 6 页文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 Z

24、Y5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9

25、I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 Z

26、Y5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9

27、I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 Z

28、Y5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9

29、I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9资料收集于网络如有侵权请联系网站删除谢谢精品文档胃痛肝胃郁热依据：胃脘处持续性疼痛，饱胀不适，饥饿时和餐后加重。舌质红，苔黄腻，脉弦数。辨证

30、分析：患者体丰，为痰湿之体，长期饮酒，脾胃湿热内生，其郁而化热，横逆犯胃，阻滞气机则胃痛；此次饮食不节，加重病情，故胃脘疼痛加重；因积滞未消，故持续性疼痛；气机阻滞，升降纳运失常，故脘腹胀满，不思饮食。舌质红，苔黄腻，脉弦数，是内有实热之征。诊断明确，无需鉴别。西医诊断：1、慢性胃炎急性发作依据：（1）、患者老年女性。（2）、反复中上腹疼痛不适40+年，复发加重 1天。曾长期服“斯达舒、胃必治、丽珠得乐、马叮啉”等，病情缓解。（3）、此次起病急，有饮食不节的诱因。（4）、查体：急性痛苦面容。腹软，中上腹压痛。（5）电子胃镜可进一步确诊。2、冠状动脉粥样硬化性心脏病（劳累型心绞痛，心功能级，心界

31、临界大，窦性心动过缓，房室传导阻滞，偶发室性早博）依据：（1）、老年女性患者，病程长，平素高盐饮食。（2）、反复胸骨后、心前区压榨感伴胸闷3年，上述症状常因劳累而出现，自服“速效救心丸”后约35 分钟上述症状消失，曾到我院门诊就诊，诊断为“冠心病”予“心脑康、速效救心丸等”治疗；活动后心累、乏力，休息后明显缓解1年。入院时临床表现有胸闷。（3）、查 T36.4oc，P44 次/分，R18 次/分，BP94/64mmHg。心前区无隆起，心尖搏动在第五肋间左锁骨中线处，未扪及震颤，心界临界大，心率44 次/分，律齐，各瓣膜听诊区未闻及病理性杂音。（4）、心电图：1、窦性心动过缓 2、房室传导阻滞3

32、、偶发室性早博4、肢体导联低电压。动态心电图可进一步确诊。3、慢性胆囊炎依据：（1）、患者老年女性。病程常。（2）、反复中上腹疼痛不适40+年，此次在进食油腻食物后出现中上腹疼痛。（3）、查 Murphy 征阴性。（4）、B 超：胆囊壁略毛糙。诊断明确，无需鉴别。诊疗计划：1、内科护理常规；2、病重，留伴；3、二级护理；4、低盐低脂清淡软食；精品w o r d 学习资料 可编辑资料-精心整理-欢迎下载-第 5 页，共 6 页文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:C

33、V3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3

34、I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:C

35、V3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3

36、I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:C

37、V3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3

38、I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:C

39、V3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9资料收集于网络如有侵权请联系网站删除谢谢精品文档5、完善相关检查；6、西医以抑酸，扩管，改善冠状动脉血流，改善微循环，对症治疗；7、中医治以“疏肝泄热，和胃止痛”，方以“龙胆泻肝汤合金铃子散”加减；龙胆草15g栀子20g黄芩10g柴胡10g生地20g黄连10g吴茱萸6g川楝子15g 白芍15g延胡索20g郁金10g鸡内金10g丹参20g甘草6g 上方加水500 毫升，煎取300 毫升，每日一剂，分三次口服。8、辨证施护：忌辛辣刺激、肥甘厚腻之品，注意休息，调摄情志。年 12 月 1日 9Am 某某主治医师查房记录今日某某主治医

40、师查房：患者诉中上腹疼痛明显缓解，仍饱胀不适、恶心、胸闷，今日出现气促、阵发性咳嗽、咯少量白色粘液痰，痰不易咯出。未诉其它不适。精神好转，进食量少，睡眠可，大小便正常。查体：T37.4oc，P54 次/分，R18 次/分，BP113/63mmHg。自主体位，神清语晰，查体合作，对答切题。舌质红，苔黄腻，脉弦。双肺呼吸音粗，双肺闻及大量干鸣音及散在少量不固定湿罗音。心前区无隆起，心尖搏动在第五肋间左锁骨中线处，未扪及震颤，心界临界大，心率54次/分，律齐，各瓣膜听诊区未闻及病理性杂音。腹软，中上腹压痛，全腹无反跳痛。生理反射存在，病理征未引出。胸片：1、右下肺炎变2、主动脉弓钙化3、左心室增大。

41、某某主治医师查房后指出：病史无补充，今日补充诊断：右下肺炎，余诊断及诊断依据同意主管医生；老年患者肺炎病程长，感染不易控制，死亡率高，故应降阶梯使用抗生素，今日加用阿莫西林克拉维酸钾抗感染，氨茶碱解出支气管痉挛，酮替芬防治支气管痉挛，地塞米松5mg沐舒坦15mg 高频雾化以湿化呼吸道，必嗽平、肺力咳胶囊止咳化痰对症治疗；目前患者血容量已正常，今日停用低分子右旋糖酐，余治疗不变；嘱患者多饮水，保持室内空气流通。已遵嘱执行。向患者及家属说明：根据病情需患者吸氧改善肺功能。但患者强烈拒绝，家属同意不吸氧。故今日停吸氧。精品w o r d 学习资料 可编辑资料-精心整理-欢迎下载-第 6 页，共 6

42、页文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM

43、9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L

44、9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM

45、9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L

46、9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM

47、9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9文档编码:CV3Y9I1W3B8 HM9O4N3J3I5 ZY5M9T8Y8L9