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自发性气胸住院病历模板范文英文回答：Spontaneous pneumothorax is a condition where air accumulates in the space between the lungs and the chest wall, causing the lung to collapse. I recently had a personal experience with spontaneous pneumothorax and was admitted to the hospital for treatment. Here is a template of my hospital record for spontaneous pneumothorax:Patient Name: [Your Name]Age: [Your Age]Gender: [Your Gender]Date of Admission: [Admission Date]Chief Complaint: Sudden sharp chest pain on the left side, difficulty breathing.History of Present Illness: I was at home when I suddenly felt a sharp pain in my left chest. It wasdifficult for me to take a deep breath and I felt short of breath. The pain worsened with movement and I decided to seek medical attention.Past Medical History: No history of lung diseases or previous episodes of pneumothorax. No known allergies.Physical Examination Findings: Upon examination, I had decreased breath sounds on the left side of my chest. There was also decreased chest expansion on the left side. The rest of the physical examination was unremarkable.Diagnostic Tests:1. Chest X-ray: A chest X-ray was performed, which showed a collapsed lung on the left side.2. Arterial Blood Gas (ABG) analysis: ABG analysis revealed decreased oxygen levels and increased carbondioxide levels, indicating respiratory distress.Treatment:1. Thoracostomy: A chest tube was inserted into theleft side of my chest to remove the accumulated air and re-inflate the collapsed lung.2. Oxygen therapy: I was given supplemental oxygen to improve oxygenation and alleviate respiratory distress.3. Pain management: Analgesics were administered to relieve the sharp chest pain.Progress Notes:The chest tube was connected to a water-seal drainage system to monitor the amount of air being removed from the chest cavity.Regular chest X-rays were performed to monitor the lung re-expansion.The chest tube was removed once the lung was fully re-inflated and there was no evidence of air leakage.Discharge Instructions:I was advised to avoid activities that may increase the risk of another pneumothorax, such as smoking or scuba diving.I was given a prescription for pain medication to manage any residual discomfort.Follow-up appointment with a pulmonologist was scheduled for further evaluation and to discuss preventive measures.中文回答：自发性气胸是一种空气在肺与胸壁之间积聚的情况，导致肺部塌陷。
青少年自发性气胸案例一、案例：王某，男，16岁，高二学生，身体偏瘦高型，平时喜欢运动，某日，上体育课时，突觉左胸憋闷，有压迫感，呼吸时自觉左胸疼痛，同学搀扶到医务室，观其面色略显苍白，不敢大口呼吸，问其病史，无心脏、肺部疾患，测血压心率正常，结合症状，初步考虑自发性气胸，嘱其斜坡卧位，保持安静，立即与班主任、家长联系，去医院诊治，确诊为“自发性气胸”，收住入院，择日行引流手术，数日后痊愈出院。
因在学校初步诊断气胸，静卧勿动，送治及时，没有出现不良后果。
一、分析：1、青少年自发性气胸，是胸外科的常见病，近年来，初高中生的发病率呈上升趋势。
这是由于现在的学生平时缺乏锻炼，体质较差，运动前的准备也不充分，当突然进行强烈的运动，就会导致疾病的发生。
据临床观察发现，个子偏高、体型较瘦的和以往患过肺炎的孩子是高发人群，因此要尤为注意。
2、自发性气胸是由于胸膜破裂，胸膜腔与大气相通，空气进入胸膜腔所致，当胸膜腔积聚了大量气体，从而使肺被空气压缩而萎缩，临床表现常有咳嗽、提重物、剧烈运动等诱因，急聚发病，典型症状为患侧胸痛、锐痛，可放射至肩部、背部、腋侧，咳嗽或深吸气疼痛加重，呼吸困难，刺激性干咳，病情严重者可引起紫绀、休克，危及生命。
3、要想避免青少年自发性气胸的发生，就要在日常生活中养成锻炼的好习惯;在进行幅度大的运动前，做好充分的准备活动;当运动后出现不适症状时，千万不可忽视，避免做剧烈运动和搬运，应尽早检查，以免耽误治疗。
二、启示：学校医务室的主要功能是卫生保健工作，诊治条件有限，但我们应根据临床症状，考虑到可能出现的急发病，做好院前的初步诊断和正确护理，并立即与家长联系及时治疗，病情危及时拨打120，以免耽误病情，因青少年自发性气胸，初步症状不是很典型，但会因忽略病情或护理不当，尤其不注意运动的限制和就治不及时，很容易使病情加重危及生命，现就青少年气胸一例，特与大家分享共勉。
投稿人：孙福梅单位：北京市外事学校。
双侧胸腔自发性气胸个案报道1.1、患者，男性，56岁，因“胸闷、气促、喘息2天，呼吸困难1天余”于2011年3月19日18时入院。
患者2011年3月17日因饭后偶感上腹胀痛，在当地诊所服药治疗，病情好转（具体用药不详），18日活动后偶感胸闷、气促、喘息，立即到禄劝县当地医院行胸部正位片检查示：见图1，并住院治疗，住院过程中患者胸闷、气促、喘息，呈进行性加重，并渐感呼吸困难，难以平卧。
无恶心、呕吐，无昏迷，无心悸、无腹胀、腹痛等伴随症状。
要求120接入我院治疗。
3、既往史：体健，无手术、外伤史。
否认有肝炎、结核、伤寒等传染病及传染病接触史，否认药物过敏史，无输血史，预防接种史不详。
入院查体：体温：37.4℃脉搏：120次/分呼吸：34次/分血压：115/80mmHg。
发育正常，营养中等，神志清楚，急性痛苦病容，颜面部及口唇青紫，双瞳等圆等大，约2.5mm，对光反射灵敏。
胸廓无明显畸形，无皮下气肿，双侧胸部呼吸无能无力与触觉语颤减弱。
双肺叩诊呈过清音。
听诊未闻及双肺呼，腹部无压痛，肛周、外生殖器未见异常。
畸形，活动自如。
生理反射存在，病理反射未引出。
1.2、辅助检查：血钾：6.39mmol/L，血钠：135.2 mmol/L。
CRP：4.2mg/L。
血气分析：PH：PCo2：47 mmol/L，P：35 mmol/L，HCT：65%。
-HCO329.8 mmol/L，SO2C：68%。
肝肾功能正常。
急诊双肺CT示：双侧液气胸并左肺上叶及右中叶肺不张，右肺下叶斑片状密度增高影，右侧叶间胸膜增厚并粘连。
初步诊断：双侧自发性气胸，并胸膜粘连，呼吸衰竭。
影像见图2。
1.3、治疗计划：1、急诊科护理常规特级护理，心电监护，呼吸机无创辅助呼吸；2、急诊行双侧胸腔闭式引流；3、术后给予抗炎、止血、镇痛、对症支持治疗；双侧胸腔闭式引流术后双肺CT示：双侧液气胸较前明显吸收好转，以右侧明显，余变化不大。
影像见图3，2011年3月25日08时再次复查双肺CT：双侧气胸基本吸收，双下叶见条片状密度增高影。
自发性气胸【一般资料】男性,77岁,【主诉】突发胸痛伴气促端坐呼吸一天【现病史】患者入院当天早晨因起床后咳嗽，突发胸痛不适，当时即感胸闷不适伴有心慌喘息，不能平卧休息。
因患者既往有肺结核及长期咳喘病史，未行特殊检查治疗，自行家中休息无好转。
后患者上述病情渐渐加重，明显呼吸困难伴少量出汗，被其家人送入当地卫生院检查治疗，行胸部X检查提示右侧气胸，未能进一步治疗，要求转入我院检查治疗。
病程中患者心慌喘息，无明显咳痰咳血，无明显心前区疼痛，无意识丧失，大便未解，小便少。
来院后，门诊行胸部CT及胸部X检查后，以肺气肿并自发气胸肺结核收住院。
发病来，患者精神差，大便未解，小便少，少量进食流质饮食，体力有下降。
【既往史】有结核病史十余年，现口服抗结核药物治疗，病情控制差。
发现脑膜瘤病史两年。
否认肝炎高血压糖尿病病史，无家族遗传病史。
【查体】T:36.5℃,P:98次/分,R:20次/分,BP:123/57/mmhg。
体温：36.5℃；脉搏：98次/分；呼吸：次/分；血压：123/57mmHg。
神志清，精神差，呈端坐呼吸，发育正常，营养不良，平车推入病室，自动体位，查体合作，对答切题。
全身皮肤、粘膜未见黄染及出血点，全身浅表淋巴结未触及肿大。
头颅无畸形，眼球活动自如，双侧瞳孔等大等圆，对光反射灵敏，双侧额纹、鼻唇沟对称，口唇无紫绀，伸舌居中，咽部不红，双侧扁桃体未见肿大。
颈软，无抵抗，双侧颈静脉怒张，气管居中，双侧甲状腺未触及肿大。
胸廓不对称，锁骨上窝凹陷，右胸明显隆起，肋间隙增宽，叩诊鼓音，呼吸音消失，心尖波动位置左移。
左肺呼吸音粗，可及啸鸣音，闻及干湿性啰音。
心率98次/分，律齐，各瓣膜听诊区未闻及病理性杂音。
腹软，未见胃肠型及胃肠蠕动波，未扪及包块，肝脾肋下未触及，肝区无叩击痛，上腹压痛未及反跳痛，murphy（-）。
移动性浊音阴性，肠鸣音3-4次/分。
肾区无叩击痛，肛门及外生殖器未见异常。
脊柱及四肢无畸形功能障碍。
自发性气胸住院病历模板范文英文回答：Spontaneous pneumothorax is a condition where air accumulates in the space between the lung and the chest wall, causing the lung to collapse. I experienced this condition recently and was hospitalized for treatment. Here is a template of my medical record during my hospitalization:Patient Name: [Your Name]Age: [Your Age]Gender: [Your Gender]Date of Admission: [Admission Date]Date of Discharge: [Discharge Date]Chief Complaint:I presented to the emergency department with sudden onset of sharp chest pain on the right side, which worsened with deep breaths. I also had difficulty breathing and felt lightheaded.History of Present Illness:I was at home when I suddenly felt a sharp pain in my right chest. The pain was so severe that it made itdifficult for me to take deep breaths. I also noticed that my breathing became more rapid and shallow. I felt lightheaded and had to sit down to catch my breath. The pain persisted for several hours, so I decided to go to the hospital.Past Medical History:I have never experienced any significant medical problems in the past. I do not have any history of lung diseases or previous episodes of pneumothorax.Physical Examination:Upon examination, I was found to have decreased breath sounds on the right side of my chest. My chest was slightly asymmetrical, with decreased movement on the right side. A chest X-ray confirmed the diagnosis of a spontaneous pneumothorax.Treatment:I was admitted to the hospital for further management.A chest tube was inserted into my right chest to remove the accumulated air and re-expand the lung. I was also given supplemental oxygen to help with my breathing. Pain medication was administered to alleviate my chest pain.Progress:Over the course of my hospitalization, my symptoms gradually improved. The chest tube was removed after a few days when the lung was fully re-expanded. I was able tobreathe comfortably and my chest pain resolved. I was discharged with instructions to follow up with my primary care physician for further evaluation and to discuss the possibility of preventive measures to reduce the risk of recurrence.中文回答：自发性气胸是一种空气在肺与胸壁之间积聚，导致肺部塌陷的状况。
