病例報(bào)告病例報(bào)告1目錄CONTENTSCASA01患者信息02診療過程03分析討論目錄201患者信息013患者基本信息姓名:陳X年嶺:26歲職業(yè):醫(yī)生出生地:浙江入院時(shí)間:2018年6月9日1003主誆:停經(jīng)39+1周,下腹陣痛2小時(shí)余。)A院診斷:孕1產(chǎn)0394周O待產(chǎn)患者基本信息4患者基本信息現(xiàn)病史●患者平素月經(jīng)規(guī)則,末次月經(jīng):2017年9月8日?！裨衅诙ㄆ诋a(chǎn)檢未見異常。患者32周時(shí)肝功能正病史」常,近期未查,患者近1周反復(fù)低熱,最高體溫380℃,因血常規(guī)“正?！?未予特殊處理?，F(xiàn)孕39+1周,2小時(shí)余前出下腹脹痛,陣發(fā)性,間隔時(shí)間不定,持續(xù)時(shí)間短,無陰道流液及陰道出血,自覺胎動(dòng)如常?；颊呋拘畔?入院查體情況一般體檢:T369℃、P85次/分、R19次/分、BP12286mmHg神志清,精神好,皮膚、鞏膜無黃染,心率85次/分,律齊,未聞及病理性雜音,雙肺呼吸音清,未聞及干濕羅音,腹膨隆,肝、脾肋下觸診不滿意,雙腎區(qū)叩擊痛(-),脊柱、四肢無畸形,雙下肢浮腫?？茩z查產(chǎn)檢:宮底高31cm,腹圍90cm,胎位LOA,胎心率137次/分,不規(guī)則宮縮,陰道檢查:宮頸部分消退宮口容1指,先露-2cm,未破膜,宮頸評(píng)分6分,胎心監(jiān)護(hù)反應(yīng)型。入院查體情況602診療過程027診療過程入院后宮縮漸加強(qiáng),于11:30即出現(xiàn)規(guī)律宮縮,13:20予分娩鎮(zhèn)痛。當(dāng)日下午15:20查看返回報(bào)告:肝腎功能(肝功能損害):空腹血糖:3.03mmol:總膽汁酸:79umol/:甘膽酸:2497ug/m:白蛋白:295g/:總膽紅素:90.3umo:肌酐(酶法):90.5μumo/;谷丙轉(zhuǎn)氨酶:147.7U/:谷草轉(zhuǎn)氨酶:179UPT+APT(凝血功能障礙):纖維蛋白元:1.01g/;PTNR:1.48R:PT正常對(duì)照:115S:凝血酶原時(shí)間:1715;部分凝血活酶時(shí)間:394S:D-二聚體(急診):7450ng/ml診療過程8診療過程血常規(guī)+超敏CRP(急診):白細(xì)胞計(jì)數(shù)WBC:67810E9/嗜中性3410E9/;嗜中性粒細(xì)胞百分比3:149g/;血小板計(jì)數(shù)PL:93決速):15mg/立即復(fù)查!診療過程9診療過程復(fù)查后報(bào)告:PT+APT(急診):纖維蛋白元:0.89g/;PTNR:167R:P正常對(duì)照115:凝血酶原時(shí)間:19.35:部分凝血活酶時(shí)間:41.3S:D-二聚體(急診):7130ng/ml急診生化常規(guī):血糖(急診:654mmo/;總膽紅素(急診:782umol/:間接膽紅素(急診):285umol/:直接膽紅素(急診):49,7umo/:白蛋白(急診):25.4g/:總膽汁酸(急診):345μmo:谷丙轉(zhuǎn)氨酶(急診):1083U/:肌酐(急診):934umoM診療過程10產(chǎn)科重癥感染病例匯報(bào)課件11產(chǎn)科重癥感染病例匯報(bào)課件12產(chǎn)科重癥感染病例匯報(bào)課件13產(chǎn)科重癥感染病例匯報(bào)課件14產(chǎn)科重癥感染病例匯報(bào)課件15產(chǎn)科重癥感染病例匯報(bào)課件16產(chǎn)科重癥感染病例匯報(bào)課件17產(chǎn)科重癥感染病例匯報(bào)課件18產(chǎn)科重癥感染病例匯報(bào)課件19產(chǎn)科重癥感染病例匯報(bào)課件20產(chǎn)科重癥感染病例匯報(bào)課件21產(chǎn)科重癥感染病例匯報(bào)課件22產(chǎn)科重癥感染病例匯報(bào)課件23產(chǎn)科重癥感染病例匯報(bào)課件24產(chǎn)科重癥感染病例匯報(bào)課件25產(chǎn)科重癥感染病例匯報(bào)課件26產(chǎn)科重癥感染病例匯報(bào)課件27產(chǎn)科重癥感染病例匯報(bào)課件28產(chǎn)科重癥感染病例匯報(bào)課件29產(chǎn)科重癥感染病例匯報(bào)課件30產(chǎn)科重癥感染病例匯報(bào)課件31產(chǎn)科重癥感染病例匯報(bào)課件32產(chǎn)科重癥感染病例匯報(bào)課件33產(chǎn)科重癥感染病例匯報(bào)課件34產(chǎn)科重癥感染病例匯報(bào)課件35產(chǎn)科重癥感染病例匯報(bào)課件36產(chǎn)科重癥感染病例匯報(bào)課件37產(chǎn)科重癥感染病例匯報(bào)課件38產(chǎn)科重癥感染病例匯報(bào)課件39產(chǎn)科重癥感染病例匯報(bào)課件40產(chǎn)科重癥感染病例匯報(bào)課件41產(chǎn)科重癥感染病例匯報(bào)課件42產(chǎn)科重癥感染病例匯報(bào)課件43病例報(bào)告病例報(bào)告44目錄CONTENTSCASA01患者信息02診療過程03分析討論目錄4501患者信息0146患者基本信息姓名:陳X年嶺:26歲職業(yè):醫(yī)生出生地:浙江入院時(shí)間:2018年6月9日1003主誆:停經(jīng)39+1周,下腹陣痛2小時(shí)余。)A院診斷:孕1產(chǎn)0394周O待產(chǎn)患者基本信息47患者基本信息現(xiàn)病史●患者平素月經(jīng)規(guī)則,末次月經(jīng):2017年9月8日。●孕期定期產(chǎn)檢未見異常?；颊?2周時(shí)肝功能正病史」常,近期未查,患者近1周反復(fù)低熱,最高體溫380℃,因血常規(guī)“正常”,未予特殊處理?，F(xiàn)孕39+1周,2小時(shí)余前出下腹脹痛,陣發(fā)性,間隔時(shí)間不定,持續(xù)時(shí)間短,無陰道流液及陰道出血,自覺胎動(dòng)如常?；颊呋拘畔?8入院查體情況一般體檢:T369℃、P85次/分、R19次/分、BP12286mmHg神志清,精神好,皮膚、鞏膜無黃染,心率85次/分,律齊,未聞及病理性雜音,雙肺呼吸音清,未聞及干濕羅音,腹膨隆,肝、脾肋下觸診不滿意,雙腎區(qū)叩擊痛(-),脊柱、四肢無畸形,雙下肢浮腫?？茩z查產(chǎn)檢:宮底高31cm,腹圍90cm,胎位LOA,胎心率137次/分,不規(guī)則宮縮,陰道檢查:宮頸部分消退宮口容1指,先露-2cm,未破膜,宮頸評(píng)分6分,胎心監(jiān)護(hù)反應(yīng)型。入院查體情況4902診療過程0250診療過程入院后宮縮漸加強(qiáng),于11:30即出現(xiàn)規(guī)律宮縮,13:20予分娩鎮(zhèn)痛。當(dāng)日下午15:20查看返回報(bào)告:肝腎功能(肝功能損害):空腹血糖:3.03mmol:總膽汁酸:79umol/:甘膽酸:2497ug/m:白蛋白:295g/:總膽紅素:90.3umo:肌酐(酶法):90.5μumo/;谷丙轉(zhuǎn)氨酶:147.7U/:谷草轉(zhuǎn)氨酶:179UPT+APT(凝血功能障礙):纖維蛋白元:1.01g/;PTNR:1.48R:PT正常對(duì)照:115S:凝血酶原時(shí)間:1715;部分凝血活酶時(shí)間:394S:D-二聚體(急診):7450ng/ml診療過程51診療過程血常規(guī)+超敏CRP(急診):白細(xì)胞計(jì)數(shù)WBC:67810E9/嗜中性3410E9/;嗜中性粒細(xì)胞百分比3:149g/;血小板計(jì)數(shù)PL:93決速):15mg/立即復(fù)查!診療過程52診療過程復(fù)查后報(bào)告:PT+APT(急診):纖維蛋白元:0.89g/;PTNR:167R:P正常對(duì)照115:凝血酶原時(shí)間:19.35:部分凝血活酶時(shí)間:41.3S:D-二聚體(急診):7130ng/ml急診生化常規(guī):血糖(急診:654mmo/;總膽紅素(急診:782umol/:間接膽紅素(急診):285umol/:直接膽紅素(急診):49,7umo/:白蛋白(急診):25.4g/:總膽汁酸(急診):345μmo:谷丙轉(zhuǎn)氨酶(急診):1083U/:肌酐(急診):934umoM診療過程53產(chǎn)科重癥感染病例匯報(bào)課件54產(chǎn)科重癥感染病例匯報(bào)課件55產(chǎn)科重癥感染病例匯報(bào)課件56產(chǎn)科重癥感染病例匯報(bào)課件57產(chǎn)科重癥感染病例匯報(bào)課件58產(chǎn)科重癥感染病例匯報(bào)課件59產(chǎn)科重癥感染病例匯報(bào)課件60產(chǎn)科重癥感染病例匯報(bào)課件61產(chǎn)科重癥感染病例匯報(bào)課件62產(chǎn)科重癥感染病例匯報(bào)課件63產(chǎn)科重癥感染病例匯報(bào)課件64產(chǎn)科重癥感染病例匯報(bào)課件65產(chǎn)科重癥感染病例匯報(bào)課件66產(chǎn)科重癥感染病例匯報(bào)課件67產(chǎn)科重癥感染病例匯報(bào)課件68產(chǎn)科重癥感染病例匯報(bào)課件69產(chǎn)科重癥感染病例匯報(bào)課件70產(chǎn)科重癥感染病例匯報(bào)課件71產(chǎn)科重癥感染病例匯報(bào)課件72產(chǎn)科重癥感染病例匯報(bào)課件73產(chǎn)科重癥感染病例匯報(bào)課件74產(chǎn)科重癥感染病例匯報(bào)課件75