全院病例討論模板

1、病例討論第二季度外科、手術(shù)室、放射科病例概況男性，41歲，因“反復間斷咯血13年余，再發(fā)5個月，加重3天”入院 。13年前無明顯誘因咯血，起初為暗黑色血塊，后為鮮紅色血液，量不詳，伴有輕咳，痰少，自服中藥及休息后能自行止血，近2年發(fā)作減少，咯血量少，每年發(fā)作1-2次，常能自行緩解。5個月前咯血再發(fā)，量及次數(shù)較前增多，為鮮紅色血液，2月前于廣州醫(yī)科大學第一附屬醫(yī)院住院診治，考慮“肺結(jié)核后遺癥”，經(jīng)抗炎，止血化痰處理效果不佳，自動出院。于3天前癥狀加重，約一飯碗，為鮮紅色血液，伴輕度頭暈、心慌，伴刺激咳嗽，自覺全身發(fā)熱 。既往史、個人史無特殊。有吸煙史，飲酒史。家族史無特殊。體格檢查無陽性體征。2

2、012年11月9日廣醫(yī)呼研所胸部CT+肺動脈造影示：1、肺動脈造影未見異常；2、擬左下肺前內(nèi)基底段肺靜脈少量附壁血栓形成；3、左上肺尖后段纖維性肺結(jié)核并含氣不全。4、兩上肺、右下肺背段胸膜下多發(fā)肺大泡形成。纖支鏡檢查：支氣管粘膜充血，未見狹窄及占位病灶。肝膽脾胰腎彩超未見異常。2012年12月23日，血WBC 9.82109/L，中性粒細胞百分比78%，血紅蛋白108/L，血小板正常。CRP12mg/L,ESR20mm/h。ALT35，AST29，GGT42，ALP72。GLU5.6，凝血四項與D-聚體：PT（凝血酶原時間)17.7，PT/R(凝血酶原比值)1.55，PTINR（凝血酶原國際比

3、值）1.52，F(xiàn)bg1.36，TT19.0，D-聚體0.06。腎功UREA2.76，CRE84.1，UA293。痰涂片：未發(fā)現(xiàn)抗酸桿菌，血清肺支原體抗體（-），結(jié)核桿菌抗體（-），急診胸部CT平掃加肺動脈CTA未見異常。經(jīng)抗炎，止血處理2天效果不佳，咯血頻繁，請耳鼻喉會診，給予喉鏡檢查：咽喉炎。行鼻咽喉部MRI掃描未見異常。行胃鏡檢查未見異常。住院第三天再次行CT肺動脈造影并行肺動脈栓塞術(shù)，術(shù)后3小時咯血仍增多，繼續(xù)微泵垂體后葉素等止血對癥處理，住院16天出院。 病例特點病程長，再次發(fā)作，突然加重病情重病情復雜病史不完整轉(zhuǎn)歸不明確一、病例特點1、病程長，再次發(fā)作，突然加重。中青年，男性，反復間

4、斷咯血13年余，再發(fā)5月，加重3天；2、病情重：咯血量較多，約一飯碗，為鮮紅血液。 3、病情復雜：缺乏陽性體征，僅胸部CT檢查及血液檢查陽性，發(fā)病以來缺乏明確診斷。4、病史不完整：缺乏詳細治療史、寄生蟲接觸史等。5、轉(zhuǎn)歸不明確：行CT肺動脈造影并行肺動脈栓塞術(shù)，術(shù)后3小時咯血仍增多，繼續(xù)微泵垂體后葉素等止血對癥處理，住院16天出院。二、診斷本病初步診斷考慮：一、支氣管內(nèi)膜結(jié)核；二、左上肺纖維性肺結(jié)核；三、肺大泡；四、輕度失血性貧血；五、慢性咽喉炎。支持點：1、本病主要臨床表現(xiàn)為咯血伴低熱；2、有陳舊結(jié)核的影像表現(xiàn)；3、CT提示肺部含氣不全，考慮局部支氣管有狹窄或阻塞；4、出血后CT檢查肺部未見

5、異常，考慮出血點位于左上肺含氣不全區(qū)；5、再次肺動脈造影并肺動脈栓塞術(shù)后出血仍增多，考慮為支氣管動脈引起的出血；6、CT示兩上肺、右下肺背段胸膜下多發(fā)肺大泡形成 ；7、患者咯血，血紅蛋白108/L ；8、喉鏡檢查：咽喉炎 。鑒別診斷1、支氣管擴張（咯血常見，CT未提示可排除）2、肺ca （支持點：慢性咯血史、刺激性咳嗽，CT未見明確占位，但細小病變?nèi)缰夤軆?nèi)膜CA未能排除）3、肺大泡破裂（多為胸腔內(nèi)出血，CT未提示）4、血液?。ㄉ僖?，血液及骨髓檢查未完善，暫不支持）5、肺寄生蟲（未作糞便檢查，CT未提示）116、上消化道出血（無消化道病史及體征，胃鏡檢查正常）7、循環(huán)系統(tǒng)病變（無消化系統(tǒng)病史及

6、體征，未完善相關(guān)檢查）8、免疫系統(tǒng)，系統(tǒng)性紅斑狼瘡（缺乏病史及體征，未作相關(guān)檢查）9、先天性疾病，肺AV瘺、肺A瘤（肺A造影不支持）10、慢支肺氣腫（無病史及體征） 三、本病有何經(jīng)驗教訓 1、放寬思維，要把少見病、罕見病考慮進去。2、完善病史及相關(guān)檢查，如循環(huán)系統(tǒng)、支氣管動脈DSA、免疫系統(tǒng)、血液系統(tǒng)等。3、可試行診斷性治療以明確診斷，可使用抗結(jié)核藥物。4、在缺乏陽性體征時，要考慮執(zhí)行相關(guān)輔助檢查。THANKS！Click to edit title styleThemeGallery is a Design Digital Content & Contents mall developed

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