哮喘临床见习记录1
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今天带大家一起到
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病房看一个哮喘患儿
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上一次课呢
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正好给大家讲哮喘这一个病
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我们病房里现在也正好有这个哮喘
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典型发作的小孩
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但是进入病房以后呢
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希望大家就是保持安静
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然后查题的时候呢
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要注意小孩不要受凉啊
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一个一个的来还要取得小孩的配合
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如果这个小孩不愿意给我们听呢
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那我们换其他小孩你就不要硬给他听
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就这些那我们去看电影吧嗯
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美龙
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吴新宇你好
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小朋友好啊
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奶奶好
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怎么样啊
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现在咳嗽咳得怎么样了
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啊奶奶说说咳嗽咳的好一些了吗
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好一点好一点
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好一点了啊
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我们现在去
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给大家汇报一下他的这个病情啊
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呃顾新雨男3岁
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因咳喘一天有门诊收入入院
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呃患儿一天前无明显又因出现咳喘
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呃
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无鼻塞流涕无物盘发热
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呃家长呃睡痔门诊就诊
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时差选项白细胞24.6乘以10的90方每升
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增强率86.4%
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呃CRP 5毫克每升
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呃患儿入院时为求
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现为求进一步系统治疗
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由门诊收入入院
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患儿入院时
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咳嗽咳嗽食坐
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气息气促啊
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无鼻塞流涕无宫寒发热
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嗯呼吸向延长
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呃无腹痛腹泻无恶心呕吐啊
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那时可二便正常
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呃治疗上在于
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呃头孢瘤
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头孢曲中心经济抗感染
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嗯痰热清
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痰热清清热
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化痰
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甲强龙
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金鸡抗炎平喘安茶碱减轻平喘
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口服的有平效合剂维腐清
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助检查张卫辉
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这个小孩啊
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他的会发的病毒
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所以咳喘了还可以进来的
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呃
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我刚才听了一下
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肺里面那两肺是满腹向筋的所
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以一会来大家也可以听一听
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听一听
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肺部的体征
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另外呢就是还有很多需要问的病史
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你们还可以问
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包括他的这一种
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他的全身情况啊吃饭饮食等等啊
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因为这个给辩证有关的
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给这个疾病的诊断有关的问题
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大家可以问
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哎奶奶那个我想问一下
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像新宇
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他以前还有发生过这样哮喘的经历吗
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有呃
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你一共有过几次啊
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今年就是连续一次大概两次住院
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今年算这次两次
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那去年呢
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7月份8月份也犯过两次
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7月份8月
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那他以前还有过就是呃像鼻炎啊
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或者呃共同咳嗽
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例如像早上起来遇到冷空气啊
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运动后咳嗽加重之类的
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咳嗽平台也有偶尔也会咳嗽
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啊
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新宇以前有没有得过那个效那个呃
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湿疹
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湿疹有
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湿疹有得过
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哎
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心雨有没有对什么那个食物食品啊
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像吃过什么之后身上会起刺疹会过敏
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吃饱了好像还没太怎么
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发现不了
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就目前还没有就是因为食物之类
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的还没有
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心雨每次那个他喘之前都有过
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像例如有先咳嗽再喘还是先感
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有一些那个先感冒还是再喘
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就像感冒感冒然后就会咳嗽
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一咳嗽马上就发出来
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基本上每次都是先感冒然后咳嗽再喘
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对
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就是这样哎呦
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哎运动之后会不会有的时候也会喘
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运动之后还好
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就是说运动之后呢
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等于他汗可能也许是汗成了一些
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然后就是像感冒一样的
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马上就就说发就发出来
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就会突然的发作说话难发作
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你也记得清楚
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到目前为止发过多少次啊
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就是他这个船
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今年啊
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不是今年
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他不是一共才两岁多吗
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这个就是两次
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两次去年8月份
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去年7月份
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8月份去年好像也是
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今年是去年有8月份去年
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去年也有去年是
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可能都记不清了至少有4次5次以上了
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吧那
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每次你们能听到这一种吼的声音吗
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像明都能听到
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那个我想问一下
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他每次这样齁都住院吗
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还是这是第一次住
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院
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哦
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每次都每次齁的时候都来医院看是
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不是就是感觉药有没有药物治疗
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都有哪些药物治疗
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反正就是吃的这些
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吐泡啊还有一个盐酸
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那有没有吃过中药啊
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中药他不吃
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哦
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因为小孩的父母
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小的时候还曾经喘过呀
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父母呢等于他家他爸妈等于我家
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儿子小的时候也有过气管炎
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也喘过
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也喘过
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你那个时候好像住过一次医院
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嗯
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但现在后来好了
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大了以后就好了
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现在好了
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小孩喘的时候夜间还明显
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这个好像还好
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嗯他就反正他这个一穿的就是发烧
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他的还好发烧不发烧
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就是一感冒的时候就会又发
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哎一感冒就是咳咳咳就
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白天多还是晚上多嘞
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晚上睡下脸的好像稍微好像那个
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这个晚上他会
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会会不会憋醒啊
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会憋醒是吧
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咳醒也不会咳醒也咳醒是吧
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像他这个这个痰的话有没有痰痰痰
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吐不出来
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吐不出来是吧
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有有呢
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感觉难受啊
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来坐下来坐下来给给他们听听好不好
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嗯表现不错啊今天还比较配合
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其实我们一进到诊室
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不用听诊器
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可能大家都感觉到这小孩在喘是吧
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就能听到他还不算
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最严重的这个更严重的喘的声音更大
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根本不需要听诊器
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所以有时候家长啊他不要听诊器
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就是有的人是拿耳朵贴在这
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发作
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能听到有的不需要
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这个家长自己就感觉出小孩穿起来了
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还是很典型的发作
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大家都听到了没有
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有没有听到
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听到那你们来说说
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这个校名有一些什么样的特点
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小明他主要是
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缓解期的时候
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可以表现的不明显
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或浓或深的可能听不到
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这下面是在呼气向还是在吸气向明显
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呼气向
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呼气向明显啊
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为什么他在呼气向明显啊
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因为他这个气道狭窄嘛对吧
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然后他这个哨门音的话
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他主要是因为就说气道狭窄
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气流通过这个狭窄气道产生的一
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种高调音
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嗯然后
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你呼吸的时候气道狭窄就会产生一下
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他搭的不错啊
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确实是因为这表明这个病变是在哪里
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在气管
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气到
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痉挛收缩的时候发展
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所以产生的这样的一个高调的声音
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还有的家长他不知道什么是橡皮
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可能你问一下踩过没有
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很多家长都说不知道什么叫踩没踩过
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如果不是有这么典型的风
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但是你告诉他
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你晚上有没有听到过
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像吹哨子一样的声音呢
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就是喉咙里面有声音啊
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哦有个这样的说
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那倒是听到过的
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这
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下面这下面音
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那这个下面音呢呃
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和这个湿罗音有什么区别啊
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我们经常要记住啊
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就是觉得听起来不好
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那究竟是施罗音还是下面音
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失落音它主要是在那个吸气腔的时候
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尤其在吸气末的时候
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失落音它
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是在吸气的时候是最明显的
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而且失落音它主要是发生在肺套部部
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而项目音它主要是发生在气管
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所以存在听诊的部位上有一些差别
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而且在听诊的时间上
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两个产生声音产生的时间像不太一样
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啊
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一个是在吸气下凝结特别是吸气末
237
00:08:36,866 --> 00:08:38,500
有的小孩不老是哭吗
238
00:08:38,500 --> 00:08:40,366
他在哭的时候抽气的时候
239
00:08:40,366 --> 00:08:41,366
你可能能听到
240
00:08:42,000 --> 00:08:44,666
那个湿落音主要是一个水泡的声音
241
00:08:45,333 --> 00:08:47,166
我们说你比如说有人不知道
242
00:08:47,166 --> 00:08:48,700
还是不知道水泡音是什么
243
00:08:48,700 --> 00:08:50,366
我说你可能煮过稀饭
244
00:08:50,566 --> 00:08:52,500
煮稀饭的水快干了的时候
245
00:08:52,500 --> 00:08:53,733
就噗噗噗的声音
246
00:08:53,866 --> 00:08:56,500
这种小的水泡音还有一个特点
247
00:08:56,766 --> 00:08:59,500
施罗音呢位置相对比较固定
248
00:09:00,166 --> 00:09:02,566
哎他不会说因为这个小孩翻了身
249
00:09:02,566 --> 00:09:03,800
或者你给他拍拍背
250
00:09:03,800 --> 00:09:06,333
他吐一吐痰这个声音就消失了啊
251
00:09:06,566 --> 00:09:07,366
那下面呢
252
00:09:07,366 --> 00:09:10,166
我们说哎他也不会说一直持续的
253
00:09:10,166 --> 00:09:12,500
这个小孩比如说他夜间清晨有症状
254
00:09:12,500 --> 00:09:13,366
可能在家里
255
00:09:13,400 --> 00:09:15,133
到了医院里来他就不咳了
256
00:09:15,133 --> 00:09:16,566
那这个小孩呢正好
257
00:09:16,566 --> 00:09:18,100
为什么带你们看这个小孩
258
00:09:18,500 --> 00:09:21,300
他现在正好就是喘很明显像明白的
259
00:09:22,500 --> 00:09:23,600
应该都能记得
260
00:09:24,066 --> 00:09:25,066
那这个小孩呢
261
00:09:25,066 --> 00:09:25,800
因为我们看
262
00:09:25,800 --> 00:09:27,666
刚才听到这个馆房的同学啊
263
00:09:27,666 --> 00:09:29,300
汇报了他的一个病史
264
00:09:29,533 --> 00:09:31,066
讲到多少了一天
265
00:09:31,200 --> 00:09:32,000
然后就
266
00:09:32,366 --> 00:09:35,200
呃他也讲了他一系列的病史的过程
267
00:09:35,500 --> 00:09:36,700
包括他的诊断
268
00:09:36,866 --> 00:09:38,933
那你们来说说他这个小孩
269
00:09:38,933 --> 00:09:41,000
根据你们的补充询问的病词
270
00:09:41,000 --> 00:09:43,100
和刚才他汇报的这一个病情
271
00:09:43,166 --> 00:09:45,300
觉得这个小孩终于等到哮喘
272
00:09:45,300 --> 00:09:46,366
能不能成立啊
273
00:09:48,333 --> 00:09:51,166
因为首先他有一个很明显的过敏齿
274
00:09:51,166 --> 00:09:52,566
小孩以前有湿疹
275
00:09:52,766 --> 00:09:54,666
然后而且他有家长时
276
00:09:54,666 --> 00:09:55,966
他的病也小的时候
277
00:09:55,966 --> 00:09:58,533
也是有过气管炎喘之类的症状
278
00:09:58,866 --> 00:10:00,700
然后其实他已经反反复复
279
00:10:00,700 --> 00:10:01,966
至少发作了两年
280
00:10:01,966 --> 00:10:03,066
然后四次以上
281
00:10:03,200 --> 00:10:04,000
嗯
282
00:10:04,700 --> 00:10:06,766
呃主要症状是以咳喘
283
00:10:07,200 --> 00:10:08,466
然后而且
284
00:10:08,933 --> 00:10:11,800
肺部我们也能听到那个很明显的嗅鸣
285
00:10:12,133 --> 00:10:13,266
然后这些症状
286
00:10:14,500 --> 00:10:16,566
所以我们基本上可以给他拉维秀
287
00:10:16,866 --> 00:10:18,000
免单哮喘啊
288
00:10:18,000 --> 00:10:18,566
我说
289
00:10:18,566 --> 00:10:21,333
因为你们就正好是刚刚上了这个课
290
00:10:21,333 --> 00:10:21,700
哮喘
291
00:10:21,700 --> 00:10:22,500
这个课
292
00:10:22,533 --> 00:10:24,400
讲到中医讲哮喘的诊断
293
00:10:24,466 --> 00:10:26,166
一个病死特点很重要
294
00:10:26,533 --> 00:10:28,200
病史课题有个反复发作
295
00:10:28,266 --> 00:10:31,100
我说这个反复发作你至少3次以上
296
00:10:31,100 --> 00:10:32,300
你才好讲他反复
297
00:10:32,333 --> 00:10:34,200
刚才我们大家一起来问的这个病史
298
00:10:34,200 --> 00:10:35,100
是不是3次
299
00:10:35,100 --> 00:10:37,500
对吧而且他这个每一次发作
300
00:10:37,500 --> 00:10:39,000
可能因为感冒诱发
301
00:10:39,066 --> 00:10:40,666
奶奶也感到有时候是的
302
00:10:40,666 --> 00:10:42,333
实际上是说说发就发
303
00:10:42,400 --> 00:10:43,400
突然就发作
304
00:10:43,800 --> 00:10:45,666
很符合哮喘一个发作的
305
00:10:45,666 --> 00:10:46,966
这样的一个特点啊
306
00:10:47,066 --> 00:10:49,866
另外我说还有一个特点就是呃
307
00:10:49,866 --> 00:10:51,533
发作时候的临床表现
308
00:10:52,200 --> 00:10:53,166
两大特点
309
00:10:54,366 --> 00:10:55,666
有笑有喘
310
00:10:55,766 --> 00:10:56,866
对吧哎喘
311
00:10:56,866 --> 00:10:59,966
你看我们听他呼吸非常的急促气促
312
00:10:59,966 --> 00:11:00,766
这是有喘
313
00:11:00,766 --> 00:11:02,066
喘指的是气息
314
00:11:02,266 --> 00:11:04,533
那是笑喉中笑鸣有声
315
00:11:04,533 --> 00:11:05,700
刚才我们也听到
316
00:11:05,700 --> 00:11:06,700
每个人都听到了
317
00:11:06,700 --> 00:11:08,966
非常典型的第一个笑鸣音啊
318
00:11:09,366 --> 00:11:10,566
典型的临床表现
319
00:11:10,666 --> 00:11:12,100
然后做出的体征
320
00:11:12,100 --> 00:11:14,600
肺部的听诊两肺满腹笑鸣音
321
00:11:14,966 --> 00:11:15,966
那其他的呢
322
00:11:15,966 --> 00:11:18,500
对于哮喘的诊断有帮助的
323
00:11:18,500 --> 00:11:20,600
你比如说一些理发的检查
324
00:11:20,866 --> 00:11:22,166
有没有什么特异性
325
00:11:22,166 --> 00:11:23,866
比如说我们靠做一个什么样的检查
326
00:11:23,866 --> 00:11:25,566
我就确诊这小孩是哮喘
327
00:11:26,700 --> 00:11:28,100
你做一个x线的话
328
00:11:28,100 --> 00:11:30,933
我发现你发作的时候会两倍饱满
329
00:11:31,266 --> 00:11:32,966
胸口比较饱满然后两倍
330
00:11:33,600 --> 00:11:34,666
后量都会增加
331
00:11:35,266 --> 00:11:37,166
如果你查一般的血项检查
332
00:11:37,166 --> 00:11:38,733
我发现四川的也会比较多的
333
00:11:38,733 --> 00:11:40,866
但是如果他不伴感染的话
334
00:11:40,866 --> 00:11:41,933
你的癌细胞就
335
00:11:42,333 --> 00:11:44,366
不会偏高或者是正常范围内的
336
00:11:44,733 --> 00:11:47,100
你如果在做肺功能检查的话
337
00:11:47,100 --> 00:11:48,533
你就做一个支气管激发
338
00:11:48,533 --> 00:11:49,900
和支气管疏张试验
339
00:11:50,200 --> 00:11:52,500
如果都是阳性的话只是校长一个
340
00:11:52,533 --> 00:11:54,133
一个是很可靠的一个依据
341
00:11:55,666 --> 00:11:56,400
普通了一下
342
00:11:56,400 --> 00:11:57,200
其他的
343
00:11:57,700 --> 00:11:59,800
如果是你严重的话你可以做一个血
344
00:12:00,100 --> 00:12:00,800
血气分析
345
00:12:00,800 --> 00:12:02,733
那个时候就是他哮喘发作的时候
346
00:12:02,733 --> 00:12:04,066
可能会有益
347
00:12:05,900 --> 00:12:06,700
其他的
348
00:12:08,166 --> 00:12:09,100
这些检查呢
349
00:12:09,100 --> 00:12:12,000
实际上没有一个能确诊他是哮喘
350
00:12:12,133 --> 00:12:14,533
只是一个辅助的帮助我们的诊断
351
00:12:14,533 --> 00:12:16,733
你刚才讲到的实际上不准确啊
352
00:12:16,800 --> 00:12:18,166
讲这个拍一次切片
353
00:12:18,566 --> 00:12:19,866
哮喘发作的时候
354
00:12:19,866 --> 00:12:20,333
哎呦
355
00:12:20,333 --> 00:12:22,000
他就应该是有手了
356
00:12:22,533 --> 00:12:23,466
没有特异性
357
00:12:23,600 --> 00:12:25,166
可能我们拍回来的片子
358
00:12:25,166 --> 00:12:27,100
仅仅报一个两倍纹理增多
359
00:12:27,133 --> 00:12:29,200
对于诊断哮喘是没有特异性的
360
00:12:29,266 --> 00:12:31,766
当然如果是这个哮喘发作的同时
361
00:12:31,900 --> 00:12:33,200
他又伴发了一个肺炎
362
00:12:33,200 --> 00:12:35,933
他又感染了又发烧啊肺部有感染
363
00:12:35,933 --> 00:12:37,566
那你可能骗子拍回来
364
00:12:37,566 --> 00:12:39,166
他是一层肺炎的改变
365
00:12:39,500 --> 00:12:40,766
我们在听诊的时候
366
00:12:40,766 --> 00:12:42,400
你除了哮鸣音乐以外
367
00:12:42,466 --> 00:12:44,933
也可以听到哎听到失落音
368
00:12:44,933 --> 00:12:46,466
这是哮喘犯了一个感染
369
00:12:46,466 --> 00:12:48,266
在不犯感染的情况下
370
00:12:48,400 --> 00:12:50,000
他的PS没有退役性
371
00:12:50,666 --> 00:12:51,366
选项
372
00:12:51,366 --> 00:12:54,000
那你比如说刚才奶奶也讲到这个小孩
373
00:12:54,333 --> 00:12:57,066
多数时候是因为感冒以后诱发的哮喘
374
00:12:57,266 --> 00:13:00,600
那我们知道感冒其实绝大多数是病毒
375
00:13:01,166 --> 00:13:01,966
感染引起的
376
00:13:01,966 --> 00:13:03,900
学校可能没有什么改变啊
377
00:13:03,900 --> 00:13:06,066
四川心理细胞增高这个问题
378
00:13:06,100 --> 00:13:08,800
不是每一个校长的小孩查出来他都高
379
00:13:08,966 --> 00:13:11,000
当然一些过敏体质的小孩
380
00:13:11,100 --> 00:13:12,666
他反反复复有这种过敏的
381
00:13:12,666 --> 00:13:15,366
有的人查出来四川心理细胞比较高
382
00:13:15,600 --> 00:13:16,900
那像这一个小孩到
383
00:13:16,900 --> 00:13:19,000
目前为止一项检查都没有
384
00:13:19,000 --> 00:13:21,100
没有那我们倒是可以查一下
385
00:13:21,100 --> 00:13:22,300
一个是血项
386
00:13:22,366 --> 00:13:23,566
至少你可以判断一下
387
00:13:23,566 --> 00:13:25,300
多数人是病毒感染诱发
388
00:13:25,300 --> 00:13:27,266
也有的人是细菌感染诱发的
389
00:13:27,266 --> 00:13:28,900
嗯还有这一个
390
00:13:28,900 --> 00:13:31,166
呃XCP也可以拍一拍
391
00:13:31,166 --> 00:13:32,566
特别是有刮痧
392
00:13:32,600 --> 00:13:34,100
你听到你拿不准
393
00:13:34,100 --> 00:13:35,766
你说我还是听到有施洛音的
394
00:13:35,766 --> 00:13:36,500
这种情况
395
00:13:36,500 --> 00:13:37,500
你可以再拍个贴子
396
00:13:37,500 --> 00:13:39,666
看看它究竟有没有合并背影
397
00:13:40,200 --> 00:13:43,333
因为那个家长反应这一次特别的重
398
00:13:43,333 --> 00:13:44,266
才住进来了啊
399
00:13:44,266 --> 00:13:45,900
平时的哮喘可能发作的时候
400
00:13:45,900 --> 00:13:47,600
我们在家里吃吃药
401
00:13:47,600 --> 00:13:48,700
他也就好了
402
00:13:48,966 --> 00:13:50,066
那其他的呢
403
00:13:50,066 --> 00:13:51,766
还可以做些什么样的检查
404
00:13:53,333 --> 00:13:55,466
你这个小孩刚才奶奶长大了
405
00:13:55,500 --> 00:13:57,533
平时就有很容易过敏
406
00:13:57,533 --> 00:13:58,800
身上经常会疼
407
00:13:59,966 --> 00:14:00,000
经常过敏啊
408
00:14:00,266 --> 00:14:01,900
哎我们可以查一查过敏源
409
00:14:01,900 --> 00:14:04,066
现在我们医院也能开打查的啊
410
00:14:04,066 --> 00:14:05,400
能够查二十几项
411
00:14:05,400 --> 00:14:07,500
一个吸入的一个湿入的
412
00:14:07,500 --> 00:14:09,766
这个都是他可以进一步做的检查
413
00:14:09,966 --> 00:14:10,333
还有
414
00:14:10,333 --> 00:14:12,733
包括你刚才说到的一个肺功能的检测
415
00:14:12,733 --> 00:14:13,533
问题
416
00:14:14,300 --> 00:14:16,533
其实你讲到的和你说到的这个
417
00:14:16,533 --> 00:14:17,866
他也不是一回事
418
00:14:18,100 --> 00:14:19,166
肺功能的检测呢
419
00:14:19,166 --> 00:14:21,500
一般来说我们5岁以上的小孩
420
00:14:21,733 --> 00:14:22,800
可以考虑做
421
00:14:23,600 --> 00:14:25,766
小孩太小了以后他根本不配合
422
00:14:25,766 --> 00:14:26,566
做不起来
423
00:14:26,733 --> 00:14:29,700
但是对于诊断哮喘有问题的小孩
424
00:14:29,700 --> 00:14:32,266
那你是可以做这个支气管激张试验
425
00:14:32,266 --> 00:14:34,466
或者我们做支气管的舒张试验
426
00:14:35,100 --> 00:14:35,266
呃
427
00:14:35,266 --> 00:14:38,466
你比如说那个他就仅仅是偷查了三次
428
00:14:38,566 --> 00:14:41,366
或者有时候你还不典型等等啊
429
00:14:41,400 --> 00:14:42,766
年龄也比较偏小
430
00:14:42,766 --> 00:14:44,366
那你可以做这个舒张实验
431
00:14:44,466 --> 00:14:46,866
比如说那我们现在听到他这个校名
432
00:14:46,866 --> 00:14:47,800
非常的典型
433
00:14:48,000 --> 00:14:50,266
我马上给他用那个支气管的吹干机
434
00:14:50,266 --> 00:14:51,333
比如就做雾化
435
00:14:51,400 --> 00:14:52,666
做雾化以后那
