甲状腺切除术病史汇报

小白老师说：A case presentation is a formal communication between doctors regarding a patient's clinical information. In a case presentation, a doctor presents the details of a patient's case to colleagues at a clinical meeting in a hospital.

Essential parts of a case presentation 病史汇报的要点▼

How to present a thyroidectomy case 

甲状腺切除术病人病史报告

1) A middle-aged lady, about forty years old, has noticed an enlargement in the front of her neck. She has also noticed that at the same time she was losing weight, she was having night sweats, tremors of the hands, and from time to time noticeable palpitations which could be described as feeling her heartbeat. The duration of her symptoms is about three years and she consulted her doctor about this some six weeks ago. The doctor observed the loss of weight, rapid pulse, the smooth skin and thyroid swelling, and has referred her for consultation.

2) Following some routine blood tests, notably, for haemoglobin levels, white cell counts and for thyroid hormone levels she will almost certainly be advised to have an operation. Drug therapy is advised in toxic nodular goiter. She is also advised that she will need to be hospitalized fairly soon,  in other words, within a matter of three or four weeks, if possible, for the operation to be performed. She is told that the operation removes the enlarged portion of the gland, but will leave her with a sufficient amount of thyroid tissue for normal metabolism.

3) The general physical examination of this lady, which concludes the consultation, reveals that she has a weight of only 59 kg, she has in the past been as heavy as 65 kg. So there has been a significant weight loss. Her blood pressure is somewhat raised elevated in view of her age, just over 40. Her resting blood pressure is 140/90 and she has a constantly rapid pulse in the range of 88 to 96, whereas one would hope for it to be in the range of 72-80.

4) The rest of her history is non-contributory. She is a married woman with two small children aged 8 and 10. She has had no serious previous illnesses and she has not noticed any other symptoms apart from a slight increase in appetite which rather surprised her in spite of her weight loss. There is no family history of thyroid enlargement. She has accepted the advice and will come in for an operation when sent for in about a month's time.

5) She is given an operation for subtotal thyroidectomy in which the exploration of the neck is carried out under general anesthesia. The usual preoperative antithyroid drug is employed to bring the patient into the euthyroid state before operation.

6) The incision of the skin is made transversally in the crease lines of the neck which results in a virtually invisible scar after a period of two to three years.

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