临床带教与英文查房 | 消化科（一）

小白老师说：Bedside teaching is seen as one of the most important modalities in teaching a variety of skills for the medical profession, which greatly improves certain clinical diagnostic skills in medical students and residents.

临床带教和英文查房的内容很受欢迎，很多朋友留言希望能有语音。小白老师特意录了音频，方便大家跟读学习。

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In the Doctor’s Office 在医生办公室

**Chief Resident：**Good morning, everyone. It is time for our routine ward-round made by Chief Physician Professor Smith. Yesterday we received a patient with the problem of recurrent gastrointestinal bleeding. The patient had been admitted for several times in the past few years, but the definite diagnosis of the patient is still not clear. We all expect we can get a conclusion from Chief physician Smith. Let’s begin the meeting with the case introduction presented by Dr. Grey.

**住院总医师：**大家早上好。现在是主任史密斯教授的查房时间。昨天，我们收治了一个反复胃肠道出血病人。这个病人在过去的儿年里反复入院，但是确切的诊断仍未做出，我们都希望能从王主任医师那里得到结论。我们从格蕾医生做病史陈述开始。

Intern: Mr. White, male, 48 years old, was admitted to this hospital for evaluation of recurrent gastrointestinal bleeding. He had been well until 33 months earlier, when he had midepigastric pain and passed black stools that were positive for occult blood. He was found to be anemic and was admitted to the hospital for evaluation. He had been taking low doses of ibuprofen daily for the treatment of chronic shoulder pain. On examination, the abdomen was soft and non-tender. Laboratory data are shown in Table 1.

The results of evaluation by esophagogastroduodenoscopy and colonoscopy, including examination of the terminal ileum, were normal. No source of bleeding was identified. Two units of packed red cells were transfused, and the patient was discharged home with instructions to avoid further use of nonsteroidal anti-inflammatory drugs. On a follow-up visit two months later, the patient reported fatigue. A stool specimen was negative for occult blood. The hematocrit was 26.3 percent. Ferrous sulfate (325 mg three times per day) was prescribed.

One month later, the hematocrit had risen to 38 percent. Air-contrast barium studies of the upper gastrointestinal tract with small-bowel follow-through were performed two months and eight months later, the results were normal.

Two years before admission, the patient again had midepigastric pain and came to the emergency department. The physical examination and an abdominal ultrasonographic evaluation revealed no abnormalities. A stool specimen was positive for occult blood. Laboratory data are shown in Table 2. Ranitidine was administered, and the patient was discharged home with prescription for 20 mg of omeprazole per day. Subsequently, a serologic test for antibody to Helicobacter pylori was positive. A 10-day course of metronidazole, tetracycline, and pantoprazole was prescribed.

One year before the current admission, midepigastric pain recurred. A computed tomographic (CT) scan of the abdomen and pelvis showed a normal bowel without obstruction or inflammation. There were no masses. The pain resolved without treatment.

Two and a half months before admission, the patient traveled to Mexico, where he had a 2-day episode of abdominal pain associated with the frequent passage of black stools.

The symptoms resolved without treatment, but during the next two weeks, recurrent stools. Increasing fatigue and light-headedness developed. When the knife-like epigastric pain occurred, again in association with the passage of black returned home, he saw his primary care physician, who prescribed omeprazole. Laboratory data are shown in Table 3.

During the next two weeks, the pain and passage of black stools continued, ranitidine was prescribed. Later he was admitted to this hospital.

**实习医师：**怀特先生，男性，48 岁，因反复胃肠道出血入院。33 个月前该病人出现中上腹痛与黑便，隐血阳性。以贫血入院观察。病人每日服小剂量布洛芬以治疗慢性肩关节痛。查体腹软，无触痛。实验室检查见表1。食管胃十二指肠镜，包括回肠末端的结肠镜检查均正常。未发现出血部位。输注 2U 浓缩红细胞并指导病人避免继续服用非甾休抗炎药后出院。2 个月后随访，病人诉疲劳。粪便隐血试验阴性。血细胞比容为 26.3%。给予硫酸亚铁（325 mg，3 次/日）。一个月后，血细胞比容升至 38.0%。2 个月与 8 个月后分别做胃肠上段气钡双重造影与小肠钡剂追踪检查，皆无异常。入院 2 年前，病人再次因中上腹部疼痛急诊。体检与腹部超声检查未见异常。粪便隐血试验阳性。实验室检查见表 2。给予雷尼替丁治疗，病人 时予奥美拉唑 20 mg/d。此后，抗幽门螺杆菌抗体结合试验阳性。给予 10 日量的甲硝唑、四环素与泮托拉唑治疗。本次住院前一年，病人中上腹部疼痛复发。做腹部及盆腔 CT 扫描检查提示肠道正常，无梗阻或炎症，无肿块。未经治疗疼痛缓解。本次入院前两个半月，病人赴墨西哥旅游时，腹痛 2 日伴黑便多次，症状未经治疗而自行缓解；但接下来 2 周内，再次出现上腹部刀样绞痛伴黑便。疲劳加重，出现头晕。返家后，病人就诊于保健医师，予以奥美拉唑治疗。实验室检査见表 3。接下来的 2 周内，腹痛与黑便持续存在，给予雷尼古丁治疗。2 日后入本院。

Chief physician: Your description of the case is in great detail. I am quite interested in the history of the patient. Have you got it?

**主任医师：**你对这个病例的介绍很详尽，我对病人的过去史很感兴趣，你能说一下吗？

Intern: Yes. The patient had been born and raised in Argentina and had emigrated to the United States seven years before admission. He worked as an automobile mechanic. He drank one glass of wine daily.

**实习医师：**好的，病人出生并成长于阿根廷，入院前已移居美国 7 年。职业是汽车机械工。饮葡萄酒每日 1 杯。

Chief physician: What about the vital sign and laboratory data on admission?

主任医师：病人入院时的生命体征和实验室数据如何？

Intern: The blood pressure was 120/80 mmHg while he was standing and 138/89 mmHg while he was supine, and the pulse was 89 and 85 beats per minute (bpm), respectively. Physical examination revealed no abnormalities. The levels of serum electrolytes, amylase, and lipase were normal, as were the results of urinalysis and liver-function studies. A stool specimen was black but no tarry and was positive for occult blood. Stool cultures were negative for enteric pathogen, protozoa, and helminth.

**实习医师：**直立位血压 120/80 mmHg，仰卧位血压 138/89 mmHg，脉搏 89次/分，心率 85 次/分。体检未见异常。血清电解质、淀粉酶、脂酶及尿检和肝功能均皆正常。粪便标本色黑，无柏油样便，隐血试验阳性。粪便培养查肠道菌、原虫与寄生虫均阴性。

Chief physician: All right. It seems to be important to find the site of bleeding. Dr. Grey, have you taken further examination?

**主任医师：**好的。看起来找到出血点十分重要。格蕾医生，你们为病人做进一步检查了吗？

Intern: Yes, we have the endoscopy and CT.

**实习医师：**是的，我们进行了内镜和 CT 检查。

Chief physician: What findings have you got?

**主任医师：**有什么发现吗？

Intern: Upper-gastrointestinal endoscopy showed a normal esophagus, striped erythematous mucosa in the cardia, a normal duodenum, and a normal jejunum to 160 cm. colonoscopy showed no abnormalities. CT scanning of the abdomen and pelvis with the use of intravenous contrast material showed a soft-tissue lesion, 2 cm in diameter, within the distal small bowel ; its central area had the density of fat and was surrounded by a wall with the density of soft tissue. Mesenteric angiography showed no abnormalities.

**实习医师：**上消化道内镜显示食管正常，贲门黏膜有条状红斑，十二指肠至空肠 160 cm处正常。结肠镜未见异常。静脉注射造影剂行腹部与盆腔 CT 扫描见软组织病变，直径 2 cm，位于小肠末端其中央区域为脂肪密度，周围被软组织密度的壁包被。肠系膜血管造影术未见异常。

Chief Physician: All right. We have known about the most data for this case. Now it’s high time for us to visit the patient and then we can make differentiation.

**主任医师：**可以了。我们已经知道该病例的大部分资料。现在该去看一下病人，然后再做鉴别诊断。

未完待续。。。

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