英文版病理讨论.ppt

Case discussion Patient ChengGe , male, 43 years old In October 24, 2015 he went to Taihe hospital emergency department Chief complaint：The patient had begma expectoration before 5 days at midnight. The sputum was white phlegm. The amount of sputamentum was moderately. The expectoration was facility. There was chest pain while cough.Pain was in the both lung bases,pain intensified when he ough and breathing. During the course , there is no chest complaint , no fever, no nausea and emesia.Initialy,He had no treatment. Above-mentioned symptom increased before1 das.He came to be treated in his local hospital with no effec. Ambulance delivered to our emergency room.He was he was given flueds intraveno and admitted in our department for further therapy. She was clearly minded, anepithymia ， with normal urine and sedes since it aggaravated. Past medical history: He was healthy before,had no specific history disease befer,no hypertension, cardiac disease,diabetes, alcoholism. Personal history: He had hobbys of alcohol (500 grams liquor every day)and cigarette(20 cigarettes every day). Physical examination:T37.5℃ BP 87/60mmHg，Pallescence in lips. Pharyngeal portion has not congestion. Surplus with jugular veins. We could see carotid pulse,especially the right side. No thoracic deformity.His lung sounds were a bit quieter than normal, especially right lung bottom.There are scatter moist rale sound in both lung, rhonchi and crackles in both basis pulmonis.HR90bpm,regular rthythm,normal cardiac sound.Without any murmurwere heard. Peculiarity was rough hard sphere . No edema in both lower extremities. Auxiliary examination:(2015-10-24 Shiyan Railway Hospital) three-dimensional reconstruction of chest + rib reinforced CT: double lung leakage lesions, infection may be, contusion? Bilateral pleural effusion (right amount, a small amount of left); (2015-10-24 Shiyan City railway hospital) liver function tests: ALT210 IU / L, AST 185IU/L, r-GT 64IU/L, TP53.8 / L, ALB 37.5g/l, TBI