胸外科病例讨论英文版.ppt

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2024-03-16 发布于四川
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胸外科病例讨论英文版.ppt

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Casereport097617魏迎亮

ChiefComplaint:hardobjectstostriketheleftchestpainwithbreathingdifficultiesoneday.Historyofpresentillness:Patients1dayagoridingamotorcycleaccidentallyhitontherightchest,feltthepain,toendure,noshortnessofbreath,chesttightness,nohemoptysissputumsilk,withoutanyspecialtreatment.Aftertheperceivedpaingraduallyincreased,withdyspnea,cough,sputum,sputumwithbloodshoteyes,nocardiacpain,noheadache,dizziness,nobloatingdiarrhea.

Pastmedicalhistory:previouslyhealthy,nohistoryoftuberculosisandnohistoryofchronicbronchitis,nofood,drugallergies,nohistoryoftrauma,surgeryPersonalhistory:deniedrecenthistoryofcontactwithepidemicofwater,notsmoking,notdrinking.Obstetricalhistory:married,notsterile.?Familyhistory:familyhealth,nohepatitis,tuberculosispatientswithouthypertension,diabetes,non-hereditarydisease.

PhysicalexaminationT36.8℃,P80beats/min,R20beats/min,BP110/60mmHgNormaldevelopment,goodnutrition,conscious,walkinghospital,automaticposition,examinationcooperation.Bodyskin,sclerawithoutjaundice,liverpalms,spiderveins,superficiallymphnodeenlargement.Skullnodeformity,handsome,andothermajorbilateralandroundpupil,lightreflexsensitivity,regulatingreflex.Auricularnodeformity,bilateralearcanal,noabnormalnasalandoralsecretions.Normalhearing.Paranasalsinusesnotenderness,nolipscyanosis,tonguecentering,gingivalbleeding,swelling,bilateraltonsilenlargement,pharynx,nocongestion,cleararticulation,

necksoft,noresistance,nojugularveinengorgement,trachea,bilateralthyroidenlargement.BilateralbreastisnormalPrecordialbulgeapexbeatpointislocatedontheleftfifthintercostalspaceatthemidclavicularlinewithin1.0cmdiameterofabout2.0cm,untouchedtremor,lackofheart,heartneatly,HR80beats/min,valveareais