case report of XXX(英文病例汇报).pptx

《case report of XXX(英文病例汇报).pptx》由会员分享，可在线阅读，更多相关《case report of XXX(英文病例汇报).pptx（15页珍藏版）》请在淘文阁 - 分享文档赚钱的网站上搜索。

1、CompanyLOGOCase report TheThirdWardofTheDepartmentofGastroenterologyThe Third Section of The Department of GastroenterologyMedical Records for Admisson Medical Number:Y1571532 General informationName:XXXAge:Twenty OneSex:MaleRace:HanNationality:ChinaAddress:XinYang,Henan.Occupation:Excavator driverM

2、arital status:UnmarriedDate of admission:Nov 11th,2015Date of record:8Pm,Nov 11th,2015Complainer of history:patients father and himselfReliability:ReliableChief complaint:Reduplicatednauseaandvomitforsixandahalfmonths.The Third Section of The Department of GastroenterologyPresent illness:Thepatientf

3、eltsuddennauseaandvomitedthefoodhetookinwithnorecognizablecauseaboutsixandahalfmonthsago.Hedidntpayattentiontoitandthoughthehadatesomethingwrong.The Third Section of The Department of GastroenterologyPresent illness:Abouttwoweekslater,thenauseousandvomitorysymptomappearedagainandhefeltsourregurgitat

4、ionandheartburnatthesametime.SohewenttothefirstaffiliatedhospitalofSuZhouUniversity.The Third Section of The Department of GastroenterologyPresent illness:Theendoscopicexaminationshowedhehadduodenalulcersandrefluxesophagitis.Andthepathologicalreportoftheulcerswaschronicinflammationwithproliferationo

5、flymphocytes.ThentheRabeprazolewhichhadshowacurativeeffectwasgiventohim.The Third Section of The Department of GastroenterologyPresent illness:Buttwomonthslaterafterthetreatment,theabove-mentionedsymptomappearedagainandbecamemoreserioussohewenttothefirstaffiliatedhospitalofSuZhouUniversityagainforfu

6、rtherthreatment.The Third Section of The Department of GastroenterologyPresent illness:TheabdominalCT,MRIandMRCPallshowedthedilatationofthebileducts（boththeintra-hepaticandextrahepaticbiled-ucts）andthepancreaticducts.Besides,theabdominalCTsho-wedtheenlargementofpancre-aswiththeprobabilityofpancr-eat

7、icdivisum.Thenhewasdiag-nosedaspancreatitisandthesymptomatictreatmentwasappliedbuttheeffectwasnotcomfor-table.The Third Section of The Department of GastroenterologyPresent illness:SohewenttothefirstaffiliatedhospitalofZhengZhouUniversity.TheabdominalCTshowedtherewereso-meenlargedlymphnodesintheabdo

8、minalcavityandtheduodenalwallhadbecamethickened.Thepathologicalex-aminationreportoftheduodenalwallshowedhewasdia-gnosedTlymphoma.The Third Section of The Department of GastroenterologyPresent illness:Foraccuratediagnosis,hisfamilysentthepathologicalslidetothreetophospitalsofChinainBeijing.Netherthep

9、athologydepartmentofourhospitalnortheYouyihospitalcouldexcludethediagnosisoftheTlymphoma,butthepathologydepartmentofthehospitaloftheBeijingUniv-ersityhaddiagnosedthathewasnotapatientwithTly-mphoma.The Third Section of The Department of GastroenterologyPresent illness:Onemonthagohewenttotheemergencyd

10、epartmentofourhospitalfortreatment.Thepathologicalexaminationoftheduodenalwallshowedth-erewassevereacuteinflame-mationwiththeinfiltrationofmanyeosnophils.Theintesti-nalfeedingtubewasappliedbutfilled.The Third Section of The Department of GastroenterologyPresent illness:Eightdaysago,thepatientwasacce

11、ptedbecauseof“reduplicatednauseaandvomitforsixandahalfmonths”.Sincethediseasecomingon,thepatienthadlosed18kgweights.The Third Section of The Department of GastroenterologyPast history:Thepatientishealthybefore.Nohistoryofinfectivediseases.Noallergyhistoryoffoodordrugs.The Third Section of The Depart

12、ment of GastroenterologyImpression:Unexplained stenosis of the duodenum:CrohnDiseaseoftheduodenum?Tlymphomaoftheduodenum?Tuberculosisoftheduodenum?Behcetdisease？Nonspecificinflammation？Malignanttumor?The Third Section of The Department of GastroenterologyPast history:Operative history:Neverundergoin

13、ganyoperation.Infectious history:Nohistoryofsevereinfectiousdisease.Allergic history:Hewasnotallergictopenicillinorsulfamide.Respiratory system:Nohistoryofrespiratorydisease.Circulatory system:Nohistoryofprecordialpain.Alimentary system:Nohistoryofregurgitation.Genitourinary system:Nohistoryofgenitourinarydisease.Endocrine system:Noacromegaly.Noexcessivesweats.Kinetic system:Nohistoryofconfinementoflimbs.Neural system:Nohistoryofheadacheordizziness.The Third Section of The Department of Gastroenterology