呼吸系统病案（Respiratory system medical record）.docVIP

呼吸系统病案（Respiratory system medical record） Respiratory system, medical record, analysis Case 1: patients, male, 32 years old, workers. To sudden chills, high fever, accompanied by headache and fatigue, aching all over the body, loss of appetite, 1 hours emergency admission. Medical history, patients usually fit, yesterday rain, there was no special discomfort. Physical examination: T400C, P115 / min, R34 / min, BPl5 / 10kPa, acute tolerance, facial flushing, shortness of breath, nose flap, cyanosis. The right lung dullness to percussion, audible and bronchial breath sounds and fine rales. The heart rate is 115 times / minute, the rhythm of the heart is regular, the apex can be heard and the second systolic murmur is softer. Abdominal, limb and no abnormalities. X-ray: large shadow of higher density in lungs. Problem: 1. diagnosis. 2. diagnostic criteria. 3. differential diagnosis. Answer: 1. diagnosis: pneumococcal pneumonia. 2. diagnostic criteria: 1. Cold symptoms of upper respiratory tract infections; the typical symptoms of fever chills; the typical symptoms: respiratory distress, cyanosis, nasal flap, right upper lung percussion dullness, audible and bronchial breathing and rales; 4 with gastrointestinal symptoms: loss of appetite; the X-ray features. 3. 、 differential diagnosis: caseous pneumonia. Pneumonia caused by other bacteria. Acute lung abscess. Lung cancer. Acute exudative pleurisy. Case two: female, 10 years old, student. V. fatigue, sore throat, muscle soreness and irritation cough for 3 weeks. Physical examination: the body temperature was 38 BP, L2 / 9KPa, the pulse rate was 85 / min, and the respiratory sounds increased. Chest radiograph: the lower right lung shows patchy infiltrates. Laboratory examination, WBC, l0 * 109 / L, neutrophil 0.8. Problem: 1. diagnosis. 2. diagnostic criteria. 3. principles of treatment. Answer: 1. diagnosis: Mycoplasma pneumonia. 2. diagnosis: children; the fatigue, sore throat, muscle soreness and irritation cough as