SunNEJMCase6

白癜风初期的图片 http://pf.39.net/bdfyy/bdfrczy/190210/6858103.html

Case6---A16-Year-OldBoywithCoughingSpells

16岁男孩阵咳一例

Dr.MarkA.Goldstein(Pediatrics):A16-year-oldboywasseenintheadolescentmedicineoutpatientclinicofthishospitalinlatespringbecauseofcoughingspells.

MarkA.Goldstein医生（儿科）：16岁的男孩因医院的青少年医学院门诊部就诊。

Thepatienthadbeenwelluntilapproximately3weeksbeforethecurrentpresentation,whencoughandnasalcongestiondevelopedandpersisted,withoutfeverorchills.Hetookfexofenadinehydrochloride,withoutimprovement.Threedaysbeforethecurrentpresentation,heawokeatnightwithaseverecoughingspell,withassociatedpost-tussiveemesisandtroublebreathing.Hisparentstookhimtotheemergencydepartmentofanotherhospital.Onexamination,heappearedtobeinnodistress;thetemperaturewas37.0°C,thebloodpressure/87mmHg,thepulsebeatsperminute,therespiratoryrate18breathsperminute,andtheoxygensaturation%whilehewasbreathingambientair.Themucosaoftheposteriororopharynxhadacobblestoneappearanceandtheuvulawasmidline;therewasnotonsillaredemaorexudate.Nasalcongestion,boggynasalmucosa,andserouseffusionsbehindbothtympanicmembraneswereevident.Thelungswereclearonauscultation,andtheremainderoftheexaminationwasnormal.Adiagnosisofallergicrhinitiswiththeupper-airwaycoughsyndrome(postnasaldrip)wasmade,andfluticasonepropionatenasalsprayandbenzonatate(mgthreetimesdaily)wererescribed.

近3周来，患者状态良好，这天出现持续进展的咳嗽和鼻塞，没有发热或发冷。他服用了盐酸非索非那定，没有好转。在目前报告的三天前，他夜间醒来时伴有严重咳嗽，并伴有咳嗽后呕吐和呼吸困难。他的父医院的急诊科。检查时，患者没有不适。体温37.0℃，血压/87mmHg，脉搏每分钟次，呼吸每分钟18次，呼吸周围空气时，氧饱和度为%。后方口咽黏膜呈鹅卵石状，悬雍垂居中，无扁桃体水肿或渗出物。鼻塞、鼻粘膜水肿、鼓膜后浆液性渗出明显。肺部听诊清晰，其余检查正常。诊断为过敏性鼻炎伴上呼吸道咳嗽综合征（鼻后滴流），开了处方丙酸氟替卡松鼻喷雾剂和苯甲酸盐（mg，每日三次）。

Thenextday,thepatientcontinuedtocoughbutwasabletoattendschool.Thatnight,heawokefromsleepwithanepisodeofseverecoughingthatlastedapproximately10minutesandwasassociatedwithtwoepisodesofvomiting.Hereturnedtotheemergencydepartmentoftheotherhospital.Hereportednochestpain,fevers,nightsweats,orweightloss.Onexamination,heappearedtobewellandwasnotcoughing;thetemperaturewas36.8°C,thebloodpressure/87mmHg,thepulse93beatsperminute,therespiratoryrate18breathsperminute,andtheoxygensaturation97%whilehewasbreathingambientair.Mildnasalcongestionanderythemaoftheposteriorpharynxwerepresent,andtheremainderoftheexaminationwasnormal.Achestradiographwasreportedlynormal.Apresumptivediagnosisofbronchospasmwasmade.Adoseofdexamethasonewasadministeredfortreatmentofpossiblecroup,andanalbuterolinhalerwasprescribed.Thepatientwasadvisedtofollowupwithhispediatrician.

第二天，患者继续咳嗽，但可以上学。晚上，他从睡梦中醒来，出现了持续约10分钟的严重咳嗽，并伴有两次呕吐。医院的急诊科。自诉无胸痛，发烧，盗汗，或体重减轻。经检查，患者看上去状态良好，无正在发作的咳嗽。体温36.8℃，血压/87mmHg，脉搏每分钟93次，呼吸每分钟18次，呼吸周围空气时血氧饱和度为97%。有轻度鼻塞和咽后红斑，其余检查正常。胸片报道正常。可能的诊断为支气管痉挛。给一定剂量的地塞米松治疗可能的哮喘，并开了沙丁胺醇吸入剂。建议去看儿科医生。

Duringthenext2days(aweekend),thecoughpersisted,withoutparoxysms;thenightbeforethecurrentpresentation,thepatienthadtwoepisodesofseverecoughing,followedbyinspirationswithchokingsounds.Onthedayofthecurrentpresentation,heattendedschool.Hisparentsscheduledanappointmentwithhispediatricianatanoutpatientclinicofthishospitalforlaterthatday.

在接下来的两天（一个周末），咳嗽持续，没有严重发作。在出现症状的前一天晚上，患者有两次严重咳嗽，随后出现呛咳声。在本次报告的当天，患者上学了。他的父母安排了当医院的门诊部和儿科医生预约。

Thepatientreportedepistaxisduringhiscoughingepisodes;hisparentsreportedthattheythoughthewaschokingduringtheepisodes.Hedidnothaveheadaches,hearingproblems,chestpain,shortnessofbreathotherthanwithcoughing,abdominalpain,diarrhea,orconstipation.Hehadahistoryofelevatedsystolicbloodpressureandabody-massindexinthe94thpercentile.Hetooknoregularmedications.Hewasfullyimmunizedwithchildhoodvaccines,includingfivedosesofdiphtheria–tetanus–acellularpertussis(DTaP)vaccine,fourdosesofHaemophilusinfluenzaetypeBvaccine,threedosesofhepatitisBvaccine,andtwodosesofmeasles–mumps–rubellavaccine(ininfancyandearlychildhood),aswellastwodosesofmeningococcalvaccine(at11and16yearsofage),onedoseoftetanustoxoid–reduceddiphtheriatoxoid–acellularpertussis,adsorbed(Tdap)vaccine(at11yearsofage),andonedoseofhumanpapillomavirusvaccine(at16yearsofage);therewasnodocumentationofpneumococcalorinfluenzavaccinations.Hehadnoknownallergiestomedications.Helivedwithhisparentsandoneyoungersiblingandattendedhighschool.Heoccasionallydrankalcoholandsmokedcigarettesandwasnotsexuallyactive.Hisfatherhadhypertension;hismother,whowasreceivingchemotherapyforcancer,hadadry,nonproductivecoughofapproximately4weeks’duration,whichhadbegunbeforetheonsetofthepatient’ssymptoms.

患者自诉咳嗽时有鼻出血，他的父母说他在这期间有窒息感。除了咳嗽、腹痛、腹泻或便秘外，没有头痛、听力问题、胸痛、气短等症状。有收缩压升高的病史，体重指数在第94百分位数。没有常规服用药物。完整接种儿童疫苗，包括包括5剂白喉-破伤风-无细胞百日咳（DTaP）疫苗，4剂B型流感嗜血杆菌疫苗，3剂乙肝疫苗和2剂麻疹-腮腺炎-风疹疫苗（婴儿期和幼儿期）以及2剂脑膜炎球菌疫苗（11岁和16岁），1剂破伤风类毒素-白喉类毒素-无细胞百日咳，吸附（Tdap）疫苗（11岁）和1剂人乳头瘤病毒疫苗（16岁），没有肺炎球菌疫苗或流感疫苗的接种史。无药物过敏史。跟父母和一个弟弟妹妹住在一起，在上高中。偶尔喝酒抽烟，性生活不频繁。父亲患有高血压，母亲正在接受癌症化疗。患者症状出现前，有持续约4周的干咳。

Onexamination,thepatientappearedtobewell.Thebloodpressurewas/79mmHgintherightarmand/72mmHgintheleftarm,thepulse83beatsperminute,thetemperature36.5°C,andtheoxygensaturation99%whilehewasbreathingambientair.Examinationofthechestrevealeddecreasedbreathsoundsontherightside,andtheremainderoftheexaminationwasnormal.Nocoughingwasobservedduringa40-minuteperiod.Thewhite-cellcountwas8percubicmillimeter(referencerange,to13,),with46.1%neutrophils(referencerange,40to62),42.6%lymphocytes(referencerange,27to40),8.9%monocytes(referencerange,4to11),1.6%eosinophils(referencerange,0to8),and0.6%basophils(referencerange,0to3);thehematocrit,hemoglobinlevel,andplateletcountwerenormal,aswasachestradiograph.

查体：患者状态良好。右臂的血压为/79mmHg，左臂为/72mmHg，脉搏每分钟83次，体温36.5℃，呼吸周围空气血氧饱和度99%。胸部查体右侧呼吸音减弱，其余检查正常。40分钟内没有观察到咳嗽。白细胞计数为8每立方毫米（参考范围至13），中性粒细胞46.1%（参考范围40至62），淋巴细胞42.6%（参考范围27至40），单核细胞8.9%（参考范围4至11），嗜酸性粒细胞1.6%（参考范围0至8）和嗜碱性粒细胞0.6%（参考范围0至3），红细胞压积，血红蛋白和血小板计数正常，胸片也正常。

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