1、*Error! Picture switch must be first formatting switch. 2013-06-06 11:03Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.住院首次病程录 Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.【病
2、历特点】 Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.1.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch. 陈博雅 Error! Picture sw
3、itch must be first formatting switch.， Error! Picture switch must be first formatting switch.女 Error! Picture switch must be first formatting switch.， Error! Picture switch must be first formatting switch.1岁4个月 Error! Picture switch must be first formatting switch.Error! Picture switch must be first
4、 formatting switch.Error! Picture switch must be first formatting switch.2.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.主诉： Error! Picture switch must be first formatting switch.Error
5、! Picture switch must be first formatting switch.发现心脏杂音20余天。 Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.3. 体格检查： Error! Picture switch must be first formatting switch.Error! Pictur
6、e switch must be first formatting switch.Error! Picture switch must be first formatting switch.体温：腋温脉搏：次/分呼吸：次/分血压：80/44mmHg身长/高：cm体重：kg Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.神志清，精神反应可，发育正常，面色正常，血氧饱和度：营养：良好。 Error! Picture switch
7、must be first formatting switch.Error! Picture switch must be first formatting switch.浅表淋巴结未及。 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.口唇无明显干燥，无义齿，咽不红，扁桃体不大，口腔黏膜完整。 Error! Picture switch must be first formatting switch.心： Error! Pic
8、ture switch must be first formatting switch.听诊：心率次/分，心律齐，心音有力，可及。 Error! Picture switch must be first formatting switch.肺： Error! Picture switch must be first formatting switch.听诊：双侧呼吸音粗，有罗音。 Error! Picture switch must be first formatting switch.腹部：Error! Picture switch must be first formatting swit
9、ch.望诊：平坦，未见明显肠型。腹壁静脉未见明显曲张。触诊：全腹软，未及包块。无明显压痛，无反跳痛。肝脏：肋下cm，剑突下cm，质软，无触痛。脾脏：肋下未触及，质软，无触痛。叩诊：鼓音，无移动性浊音。听诊：肠鸣音-次/分。 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.颈软，脑膜刺激症：布氏征阴性，克氏症阴性，生理反射：膝反射正常，踺反射正常。病理反射：巴氏征阴性。 Error! Picture switch must be
10、first formatting switch.Error! Picture switch must be first formatting switch.专科检查： Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.心界扩大，心率次分，心律齐，-可及 Error! Picture switch must be first formatting switch.Error! Picture switch must be first
11、formatting switch.Error! Picture switch must be first formatting switch.4.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.辅助检查： Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch. Err
12、or! Picture switch must be first formatting switch.我院心脏彩超（.）：房间隔缺损，左上腔静脉残存，肺动脉高压，心包积液。我院胸片（.）：心影大，两肺少许感染。Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.Error! Picture switch must be f
13、irst formatting switch.*Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.【初步诊断】 Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting swit
14、ch.房间隔缺损、左上腔静脉残存、肺动脉高压、心包积液.肺部感染 Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting s
15、witch.【诊断依据】 Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.患儿岁个月，发现心脏杂音余天。体查：心界增大，心率次分，心律齐，心音有力。-可及级。心脏彩超可诊断。可进一步行心导管检查明确。.有先心病的基础疾病，天来反复咳嗽，余外院及我院多次查胸片诊断肺部感染，故诊断成立。可复查胸片。 Error! Picture switch must be first formatting switch. Error! Pict
16、ure switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.【鉴别诊断】 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be firs
17、t formatting switch.Error! Picture switch must be first formatting switch.室间隔缺损：为左向右分流先心病。分流量较大时有典型的充血性心力衰竭症状，包括反复上呼吸道感染、喂养困难、体重不增、喂养时出汗。听诊L3-4 iii/vi SM ,P2可有亢进。CXR提示肺血增多。该患儿根据临床表现、体征和影像学检查，可排除诊断VSD。 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formattin
18、g switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.动脉导管未闭：为左向右分流先心病。分流量大时有明显充血性心力衰竭症状，可有反复呼吸道感染和喂养困难。听诊时于L2-3可闻及典型的机器样、连续性杂音，并向左锁骨上窝传导，局部常可触及震颤，P2亢进。该患儿根据临床表现、体征和影像学检查，可排除诊断PDA。 Er
19、ror! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.【诊疗计划】 Error! Picture switch mu
20、st be first formatting switch.Error! Picture switch must be first formatting switch.予抗感染、雾化、止咳化痰治疗。 Error! Picture switch must be first formatting switch.择期行心导管检查明确病变情况后再拟定下一步治疗方案。 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Pict
21、ure switch must be first formatting switch.【出院计划】 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.待感染控制、心导管检查明确病变情况后再拟定出院计划。 Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.Error!
22、 Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.记录医师： Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.盛瑾 Error! Picture switch must be first formatting switch. Error! Picture switch mus
23、t be first formatting switch.签名： Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.主治医师签 名： Error! Picture switch must be first form
24、atting switch.*Error! Picture switch must be first formatting switch.日期： Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.年 Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.月 Error
25、! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.日 Error! Picture switch must be first formatting switch. *Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.2013-06-07 10:16Error! Pictur
26、e switch must be first formatting switch. Error! Picture switch must be first formatting switch.刘廷亮 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.主治医师查房 Error! Picture switch must be first formatting switch.*Error! Picture switch must be
27、first formatting switch.【病史和体征】 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.1.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting swi
28、tch.Error! Picture switch must be first formatting switch. 陈博雅 Error! Picture switch must be first formatting switch.， Error! Picture switch must be first formatting switch.女 Error! Picture switch must be first formatting switch.， Error! Picture switch must be first formatting switch.1岁4个月 Error! Pi
29、cture switch must be first formatting switch.Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.2.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first
30、formatting switch.主诉： Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.发现心脏杂音20余天。 Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting sw
31、itch.3.体格检查： Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.体温：腋温脉搏：次/分呼吸：次/分血压：80/44mmHg身长/高：cm体重：kg神志清，精神反应可，发育正常，面色正常，血氧饱和度：营养：良好。浅表淋巴结未及。口唇无明显干燥，无义齿，咽不红，扁桃体不大，口腔黏膜完整。心：听诊：心率次/分，心律齐
32、，心音有力，可及。肺：听诊：双侧呼吸音粗，有罗音。腹部：望诊：平坦，未见明显肠型。腹壁静脉未见明显曲张。触诊：全腹软，未及包块。无明显压痛，无反跳痛。肝脏：肋下cm，剑突下cm，质软，无触痛。脾脏：肋下未触及，质软，无触痛。叩诊：鼓音，无移动性浊音。听诊：肠鸣音-次/分。颈软，脑膜刺激症：布氏征阴性，克氏症阴性，生理反射：膝反射正常，踺反射正常。病理反射：巴氏征阴性。专科检查：心界扩大，心率次分，心律齐，-可及 Error! Picture switch must be first formatting switch. Error! Picture switch must be first f
33、ormatting switch.Error! Picture switch must be first formatting switch.4.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.辅助检查： Error! Picture switch must be first formatting switch. Erro
34、r! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.我院心脏彩超（.）：房间隔缺损，左上腔静脉残存，肺动脉高压，心包积液。我院胸片（.）：心影大，两肺少许感染。 Error! Picture switch must be first formatting switch. Error! Picture switch must be f
35、irst formatting switch.Error! Picture switch must be first formatting switch.5.补充病史、体征、辅助检查：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.ABO血型和Rh血型鉴定(2013-06-06): ABO血型鉴定 A型，RH血型鉴定 阳性。肾功能3项+肝功能+电解质7项(2013-06-06): Mg 0.88mmol/L，Ca 2.45mmo
36、l/L，NA+ 144.1mmol/L，K+ 4.69mmol/L，CL- 107mmol/L，ECO2 21.0mmol/L，以上项目方法学: ，P 1.62mmol/L。PT+APTT(2013-06-06): APTT 43.2秒，INR 1.03，PT 14.3秒。血常规5分类+CRP(2013-06-06): 红细胞体积分布-W 14.0%，白细胞计数 11.3109/L，红细胞比容测定 36.4%，血红蛋白测定 118.0g/L，平均红细胞Hb含量 26.9pg，平均血小板体积 9.3fl，淋巴细胞# 8.210 9/L，淋巴细胞% 72.8%，平均红细胞Hb浓度 324g/L，平
37、均红细胞体积 82.9fl，单核细胞# 0.610 9/L，中性粒细胞# 2.3109/L，血小板计数 39810 9/L，红细胞计数 4.3910 12/L，BASO# 0.0110 9/L，以下项目方法学: ，嗜碱性粒细胞% 0.1%，EOS# 0.10010 9/L，嗜酸性粒细胞% 0.9%，单核细胞% 5.7%，中性粒细胞% 20.5%，报警信息1 淋巴细胞增加，报警信息2 异型淋巴细胞？，C-反应蛋白 7mg/L。NT-ProBNP(2013-06-06): NT-proBNP 219pg/ml。心脏US(2013-06-03) 房间隔缺损()肺动脉高压左上腔静脉残存心包积液建议进一
38、步检查！。心电图(2013-06-06) PR间期正常高限T波变化右室肥大可能。数字化摄影(2013-06-06) 心影增大，两肺纹多模糊。 Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.*Error! Pict
39、ure switch must be first formatting switch.【 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.刘廷亮 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.主治医师分析】 Error! Picture switch must
40、be first formatting switch.*Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.1.诊断： Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.1）.房间隔缺损、左上腔静脉残存、肺动脉高压、心包积液 2）.肺部感染 Error! Picture
41、 switch must be first formatting switch.Error! Picture switch must be first formatting switch.2.诊断依据： Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.*1）、患儿发现心脏杂音20余天。心脏听诊：心率116次/分，心律齐，心音有力，L2-3可及II/VI SM,结合心脏彩超：心脏US(2013-06-03) 房间隔缺损()肺动脉高
42、压左上腔静脉残存心包积液。支持诊断。*2）、患儿有先心病的基础疾病，近20天反复咳嗽、咳痰。肺部体查：双肺呼吸音粗，有罗音。辅助检查：胸部正位（DR）(2013-06-01) 心影大，两肺少许感染。数字化摄影(2013-06-06) 心影增大，两肺纹多模糊。故明确诊断。 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.3.鉴别诊断： Error! Picture switch must be first formatting s
43、witch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.室间隔缺损：为左向右分流先心病。分流量较大时有典型的充血性心力衰竭症状，包括反复上呼吸道感染、喂养困难、体重不增、喂养时出汗。听诊L3-4 iii/vi SM ,P2可有亢进。CXR提示肺血增多。该患儿根据临床表现、体征和影像学检查，可排除诊断VSD。 Error
44、! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.动脉导管未闭：为左向右分流先心病。分流量大时有明显充血性心力衰竭症状，可有反复呼吸道感染和喂养困难。听诊时于L2-3可闻及典型的机器样、连续性杂音，并向左锁骨上窝传导，局部常可触
45、及震颤，P2亢进。该患儿根据临床表现、体征和影像学检查，可排除诊断PDA。 Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.4.诊疗计划： Error! Picture switch must be first fo
46、rmatting switch. Error! Picture switch must be first formatting switch.*1）.待患儿肺部感染控制后复查心脏彩超；2）.进一步行心脏MRI检查明确心脏病变情况；*3）. Error! Picture switch must be first formatting switch.择期行心导管检查+ASD介入封堵术；4）.继续予抗感染、止咳、化痰等一系列对症支持治疗。 Error! Picture switch must be first formatting switch.Error! Picture switch must
47、be first formatting switch.*Error! Picture switch must be first formatting switch.记录医师： Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch. Error! Picture switch must be first formatting sw
48、itch.签名： Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.主治医 师签名：Error! Picture switch must be first formatting switch.Error! Picture switch must be first formatting switch.刘廷亮 Error! Picture switch must be first formatting switch.*Error! Picture switch must be first formatting switch.日期： Error! P
