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病例7-2017:一名意识错乱和鼻出血反复发作的73岁男性
Case 7-2017 — A 73-Year-Old Man with Confusion and Recurrent Epistaxis


Robert L. Fogerty ... 其他 • 2017.03.09

一个疑难病例诊治给我们的启示

 

王济平†‡

† NEJM医学前沿;‡ Division of Surgical Oncology at Brigham and Women’s Hospital, Harvard Medical School

 

本期NEJM发表了2017年的第7个疑难病例讨论——“一名意识错乱和鼻出血反复发作的73岁男性”。该患者以神志不清和易激惹2日而急诊入院。其既往病史包括高脂血症、全血细胞减少、阻塞性睡眠呼吸暂停、胃食管反流、头痛、糖尿病、心房颤动、冠心病、舒张性心力衰竭和肺动脉高压。右心衰竭原因不明。患者还患有未被证实的脑动静脉畸形。患者一个月前曾以相似主诉入院,超声检查发现门体静脉瘘,所以诊断为肝性脑病,给予乳果糖和利福昔明后症状得以好转。该病例通过内科、外科、放射科和病理科的协同努力,医师们剥茧抽丝,逐渐做出正确的诊断和治疗1

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病历陈述


Jeffrey L.Greenwald医师:一名患多种内科慢性疾病的73岁男性患者因意识错乱和易受激惹而入院。

在此次入院前2日,患者越来越虚弱,出现嗜睡、寒战以及腹泻等症状。该患者对其家属反应迟钝,较容易发怒,并且出现意识错乱。他停止服用自己的药物。在入院当日,他喝了500 mL液体。家属报告说,他处于“几近强直”的状态;他无法起床,鼻出血反复发作,并报告他的胸部与左上肢疼痛。他被送至本院的急诊科。

该患者的健康状况不佳,近期患非典型肺炎,并接受左氧氟沙星治疗。他的既往病史包括糖尿病、心房颤动、冠状动脉疾病、舒张性心力衰竭以及肺动脉高压。在过去十年进行的心脏评估显示,患者有心包渗出性积液,但已自行消退;患者同时并发右心为主的心力衰竭(左心室射血分数69%,肺动脉收缩压61 mmHg)。右侧心脏活检未能明确心力衰竭的病因。该患者自儿童期便反复发作鼻出血,而且近期加重。其他病史包括高脂血症、全血细胞减少、阻塞性睡眠呼吸暂停、胃食管反流与头痛;他可能有脑部动静脉畸形的病史,该疾患在20年前的影像学检查中发现;但在此次入院前7年,患者于本院接受磁共振成像(MRI)检查,未能证实该疾患。他曾接受过基底细胞癌切除术和阑尾切除术。





作者信息

Robert L. Fogerty, M.D., M.P.H., Jeffrey L. Greenwald, M.D., Shaunagh McDermott, M.D., Angela E. Lin, M.D., and James R. Stone, M.D., Ph.D.
From the Department of Internal Medicine, Yale School of Medicine, New Haven, CT (R.L.F.); and the Departments of Medicine (J.L.G.), Radiology (S.M.), Pediatrics (A.E.L.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Medicine (J.L.G.), Radiology (S.M.), Pediatrics (A.E.L.), and Pathology (J.R.S.), Harvard Medical School — both in Boston.

 

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