问题 问答题

男性,27岁,10分钟前左上胸部被汽车撞伤,既往体健,无特殊可载查体:Bp80/50mmHg,脉搏148次/分,R40次/分。神清合作,痛苦状,呼吸急促,吸氧下呼吸紧迫反而加重,伴口唇青紫,颈静脉怒张不明显。气管移向右侧。左胸廓饱满,呼吸运动较右胸弱。左胸壁有骨擦音(第4,5,6肋)局部压痛明显。皮下气肿。上自颈部、胸部直至上腹部均可触及皮下气肿。左胸叩鼓,呼吸音消失,未闻及罗音,右肺呼吸者较粗,未闻及罗音。左心界叩诊不清,心律整,心率148次/分,心音较弱,未闻及杂音。腹部平软,无压痛肌紧张,肠鸣音正常,肝脾未及,下肢无浮肿,四肢活动正常,未引出病理反射。请简要分析诊断、诊断依据、鉴别诊断和需要做的进一步检查。

答案

参考答案:

一、诊断及诊断依据(8分)

(一)诊断

1.张力性气胸2.休克3.多根肋骨骨折

(二)诊断依据

1.外伤性休克(胸外病史,BP80/50mmHg)

2.2.多根肋骨骨折(左胸肋有骨擦音,局限性压痛明显)

3.张力性气胸(外伤性肋骨骨折,休克,呼吸困难,青紫,主要是广泛性皮下气肿,气管右移,左胸叩鼓,呼吸音消失)

二、鉴别诊断(5分)

1.闭合性气胸(多半无紫绀,休克等)

2.心包堵塞(无颈静脉努张,无舒张压上升,脉压差缩小等

3.血胸(无胸腔积液体征,如伤侧胸部叩浊等)

4.多根多处肋骨骨折(无浮动胸壁,无反常呼吸等)

三、进一步检查(4分)

1.立即胸穿,闭式引流2.胸片正侧位3.EKG、Bp持续监测,血气分析等

四、治疗原则(3分)

1.纠正休克,输血输液,保证呼吸道通畅,吸O2

2.胸腔穿刺、闭式引流,必要时开胸探查

3.抗生素防治感染,对症治疗:镇痛、固定胸廓

阅读理解

Mark was walking home from school one day when he noticed a boy ahead of him. He had tripped(绊倒) and dropped all of the books he was carrying, along with some clothes, a baseball bat and a glove.

Mark knelt(跪) down and helped the boy pick up the things. Since they were going the same way, he offered to carry some things for the boy.

As they walked, Mark discovered the boy's name was Bill. He loved video games, baseball and history, but he was having trouble with some of his subjects.

They arrived at Bill's home first.  Mark was invited in for a Coke and to watch some television. The afternoon passed pleasantly with some laughs and talk. Then Mark went home.

They continued to see each other around school, had lunch together once or twice, then both graduated from junior school.

Three days before graduation, Bill asked Mark if they could talk.

Bill reminded(提醒)Mark of the day years ago when they had first met. "Did you ever wonder why I was carrying so many things home that day?" asked Bill.

“You see, I took away all my things from school. I had stored away some of my mother's sleeping pills(安眠药). I was going home to kill myself. But after we spent some time talking and laughing, I realized that if I had died, I would have missed so many good time. So you see, Mark, when you picked up those books that day, you did a lot more. "

小题1:When Bill fell down on his way home, Mark      .

A.didn't notice that

B.went away quickly

C.helped him pick up the things

D.carried all the things for him小题2:Which of the following is NOT true?

A.Mark was a warm—hearted boy.

B.Bill was good at all of his subjects.

C.Bill and Mark were in the same school.

D. Bill loved video games, baseball and history.小题3:At Bill's home, they didn't         .

A.drink some Coke

B.watch TV

C.have a pleasant talk

D.play video games小题4:Three days before graduation, Bill asked Mark to talk because he          .

A.wanted to tell him his story

B.wanted to kill himself again

C.hoped to have lunch together

D.hoped to go on holiday together小题5:What would Bill probably say at last?

A.I should die.

B. You saved. my life.

C.You did a good job.

D.You helped me a lot.

单项选择题