"Above or below?".
"Above or below?".
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DOI：
10.1002/jhm.2
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发表时间：
2006
影响因子：
2.6
通讯作者：
Gregory M. Bump;Vikas I. Parekh;S. Saint
中科院分区：
文献类型：
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作者：
Gregory M. Bump;Vikas I. Parekh;S. Saint
患者男，49岁，因寒战、发热、食欲不振、咳嗽和呼吸困难加重就诊2天。患者有慢性阻塞性肺疾病（COPD）病史，并注意到其咳嗽和呼吸困难数天高于正常水平。他现在呼吸困难，活动很少，由于呼吸困难，在评估前一天晚上睡在45度的斜坡上。他注意到使用定量吸入器后的改善比平时少。他咳嗽时偶尔有少量白色痰.他吐了一次。在一次咳嗽发作期间，患者突然出现右上腹剧烈疼痛，并随着咳嗽和突然体位改变而加重。患者否认既往腹痛或手术史。患者最后一次排便是在入院前2天。他否认黑便或直肠鲜红色血。我对这位病人呼吸困难和咳嗽的初步鉴别诊断是肺炎、慢性阻塞性肺病急性加重或充血性心力衰竭。发热和厌食症的出现增加了感染性病因的可能性，而端坐呼吸的出现则提示充血性心力衰竭。非心源性疾病如大量胸腔积液或肺尖部疾病也可引起端坐呼吸。他的腹痛可能是肺炎单独引起的（可能是右下叶的炎症），但我也在考虑肺炎的并发症，如脓胸。虽然他的腹痛、呼吸困难和咳嗽也可能是肝胆疾病、内脏穿孔或胰腺炎的结果，但我们目前几乎没有理由怀疑直接的腹部病因。我的首要诊断是社区获得性肺炎，可能伴有胸腔积液。
A49-year-old man presented with 2 days of chills, fever, an-orexia, and increased cough and dyspnea. The patient had a history of chronic obstructive pulmonary disease (COPD) and noted that his cough and dyspnea had increased above normal for several days. He was now dyspneic with minimal activity and had slept at a 45-degree incline the night prior to evaluation due to dyspnea. He noted less improvement than usual with the use of his metered dose inhaler. His cough was occasionally productive of small amounts of white phlegm. He had vomited once. During a coughing episode the patient experienced a sudden onset of sharp right upper quadrant abdominal pain that worsened with coughing and sudden position changes. The patient denied a prior history of abdominal pain or surgery. The patient’s last bowel movement was 2 days prior to admission. He denied melena or bright red blood per rectum.My initial differential diagnosis for this patient’s dyspnea and cough is pneumonia, acute exacerbation of COPD, or congestive heart failure. The presence of fever and anorexia increases the likelihood of infectious etiologies, whereas the presence of orthopnea points toward congestive heart failure. Noncardiac processes—such as a large pleural effusion or apical lung disease—could also cause orthopnea. His abdominal pain could be a result of pneumonia alone (perhaps in the right lower lobe with diaphragmatic irritation), but I am also considering complications of pneumonia such as empyema. Although his abdominal pain, dyspnea, and cough could also be a result of hepatobiliary disease, a perforated viscus, or pancreatitis, we currently have little reason to suspect a direct abdominal etiology. My top diagnosis is community-acquired pneumonia, perhaps accompanied by pleural effusion.