casereportofXXX(英文病例汇报).ppt

Case report,The Third Ward of The Department of Gastroenterology,The Third Section of The Department of Gastroenterology,Medical Records for Admisson Medical Number:Y1571532 General information,Name: XXX Age: Twenty One Sex: Male Race: Han Nationality: China Address: XinYang,Henan. Occupation: Excavator driver,Marital status: Unmarried Date of admission: Nov 11th, 2015 Date of record: 8Pm, Nov 11th, 2015 Complainer of history: patients father and himself Reliability: Reliable,Chief complaint: Reduplicated nausea and vomit for six and a half months.,The Third Section of The Department of Gastroenterology,Present illness:,The patient felt sudden nausea and vomited the food he took in with no recognizable cause about six and a half months ago. He didnt pay attention to it and thought he had ate something wrong.,The Third Section of The Department of Gastroenterology,Present illness:,About two weeks later, the nauseous and vomitory symptom appeared again and he felt sour regurgitation and heartburn at the same time.So he went to the first affiliated hospital of SuZhou University.,The Third Section of The Department of Gastroenterology,Present illness:,The endoscopic examination showed he had duodenal ulcers and reflux esophagitis.And the pathological report of the ulcers was chronic inflammation with proliferation of lymphocytes.Then the Rabeprazole which had show a curative effect was given to him.,The Third Section of The Department of Gastroenterology,Present illness:,But two months later after the treatment,the above-mentioned symptom appeared again and became more serious so he went to the first affiliated hospital of SuZhou University again for further threatment.,The Third Section of The Department of Gastroenterology,Present illness:,The abdominal CT,MRI and MRCP all showed the dilatation of the bile ducts（both the intra- hepatic and extrahepatic bile d-ucts）and the pancreatic ducts. Besides,the abdominal CT sho-wed the enlargement of pancre-as with the probability of pancr-eatic divisum.Then he was diag-nosed as pancreatitis and the symptomatic treatment was applied but the effect was not comfor-table.,The Third Section of The Department of Gastroenterology,Present illness:,So he went to the first affiliated hospital of Zheng Zhou University. The abdominal CT showed there were so-me enlarged lymph nodes in the abdominal cavity and the duodenal wall had became thickened.The pathological ex-amination report of the duodenal wall showed he was dia-gnosed T lymphoma.,The Third Section of The Department of Gastroenterology,Present illness:,For accurate diagnosis,his family sent the pathological slide to three top hospitals of China in Beijing.Nether the pathology department of our hospital nor the Youyi hospital could exclude the diagnosis of the T lymphoma,but the pathology department of the hospital of the Beijing Univ-ersity had diagnosed that he was not a patient with T ly-mphoma.,The Third Section of The Department of Gastroenterology,Present illness:,One month ago he went to the emergency department of our hospital for treatment.The pathological examination of the duodenal wall showed th-ere was severe acute inflame-mation with the infiltration of many eosnophils. The intesti-nal feeding tube was applied but filled.,The Third Section of The Department of Gastroenterology,Present illness:,Eight days ago,the patient was accepted because of “reduplicated nausea and vomit for six and a half months”.Since the disease coming on, the patient had losed 18kg weights.,The Third Section of The Department of Gastroenterology,Past history:,The patient is healthy before. No history of infective diseases. No allergy history of food or drugs.,The Third Section of The Department of Gastroenterology,Impression:,Unexplained stenosis of the duodenum : Crohn Disease of the duodenum? T lymphoma of the duodenum? Tuberculosis of the duodenum? Behcet disease？ Nonspecific inflammation？ Malignant tumor?,The Third Section of The Department of Gastroenterology,Past history:,Operative history: Never undergoing any operation. Infectious history: No history of severe infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease. Circulatory system: No history of precordial pain. Alimentary system: No history of regurgitation. Genitourinary system: No history of genitourinary disease. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural system: No history of headache or dizziness.,The Third Section of The Department of Gastroenterology,