问题 问答题

病历摘要男性,55岁,胸痛17小时,气促、烦躁半小时。患者17小时前在高速路上驾车时突感胸部压榨样疼痛,呈持续性,伴胸闷,大汗,来急诊做心电图检查显示:V1~V6ST段弓背向上抬高0.3~0.5mV,遂收入院。半小时前躺在床上排便时突感气促,并咳粉红色泡沫痰,伴大汗淋漓、烦躁。既往体健,否认有高血压、心脏病、糖尿病等病史,吸烟史30年,每天20支,无家族遗传史。查体:T36.5℃,P130次/分,R30次/分,BP80/60mmHg。烦躁,端坐位,呼吸浅速,皮肤湿冷,脉搏微弱,肢端轻度发绀、颈静脉未见充盈,甲状腺无肿大。双肺可闻及大量湿啰音。心尖搏动位于左第五肋间。要求:根据以上病历摘要,请写出初步诊断、诊断依据(如有两个以上诊断,应分别写出各自诊断依据,未分别写出扣分)、鉴别诊断、进一步检查与治疗原则。

答案

参考答案:

评分要点:(总分22分)

一、初步诊断及诊断依据(9分)

(一)初步诊断1.冠心病(0.5分)2.急性广泛前壁心肌梗死(1.5分)3.心功能Ⅳ级(Killip分级)(1分)

(二)主要诊断依据1.冠心病,急性广泛前壁心肌梗死(1)患者中年男性,有吸烟史(0.5分)(2)突发持续性胸痛伴胸闷(1分)(3)心电图检查显示:V1~V6ST段弓背向上抬高0.3~0.5mV(1分)(4)CK、CK-MB升高(1分)2.心功能Ⅳ级(Killip分级)(1)有急性心肌梗死的病史,排便时突感气促,并咳粉红色泡沫痰,伴大汗淋漓(0.5分)(2)低血压(BP80/60mmHg),P130次/分,烦躁,皮肤湿冷,脉搏微弱,肢端轻度发绀(1分)(3)呼吸浅速,双肺可闻及大量湿啰音,心尖部可闻及奔马律(1分)

二、鉴别诊断(5分)1.心绞痛(1分)2.主动脉瓣关闭不全(1分)3.急性肺栓塞(1分)4.急性心包炎(1分)5.神经源性休克(1分)

三、进一步检查(3分)1.、动态检查心肌坏死标记物和心电图(1分)2.血常规、血气分析、凝血功能、血生化(1分)3.胸部X线片及超声心动图(1分)

四、治疗原则(5分)1.监护和一般治疗(0.5分)2.解除疼痛、治疗急性心衰,抗休克治疗(2分)3.再灌注治疗(1分)4.其他治疗:如抗凝、抗血小板治疗(1分)5.处理并发症及冠心病二级预防(0.5分)

单项选择题
阅读理解

More than two decades ago, a 10-year-old schoolgirl threw a bottle into the sea off the coast of Hull as she went on a ship on a family holiday, hoping to get a response from a stranger in a faraway land. Inside the bottle was a scrawled letter from Zoe Lemon, a youngster with a love of "ballet, playing the flute and the piano", who had just boarded a ship heading for a holiday in Germany.

She told her expected recipients of her pet hamster and fish, both called Sparkle, and her parents who were both teachers.

Miss Lemon, of Salford, Greater Manchester, soon forgot about her act of fantastic, eventually marrying and having a child herself.

But this Christmas she was extremely surprised to receive a reply after 23 years.

It turned out to be a reply to her letter from Piet and Jacqueline Lateur from near Rotterdam. Mr Lateur was walking his dog in the Oosterschelde dykes(坝), near where he and his wife live in Serooskerke, when he found the bottle with Zoe’s letter inside.

Mrs Averianov, 33, who works in a jewellery shop, said: “It’s been a bit crazy really. My parents came to visit on Christmas day and they had this letter from Europe addressed to my maiden name, Lemon.

Since receiving the letter, Mrs Averianov has been in contact with Mr Lateur via email and asked to see photographs of where the bottle was found.

He told her: “I am keeping your little letter on my piano. I know you are no longer a little girl but you asked me to write you so I have.”

Mrs Averianov’s father, John Lemon, 68, had encouraged his daughter to throw the message into the sea on a family holiday and now she is considering doing the same for her five-year-old son Maksim.

She said: “I’ll probably wait until he’s a bit older and can understand and write a letter, but maybe we’ll do it by attaching it to a balloon.”

From http://www.dailymail.co.uk, (Jan,2014)

小题1:When did Zoe Lemon write the letter?

A.In 1990.

B.In 1991.

C.In 2013.

D.In 2014小题2:What does the underlined phrase in paragraph 6 mean?

A.her given name

B.her nick name

C.family name used before marriage

D.family name used after marriage小题3:What can we know about the letter written 23 years ago?

A.Its reply was received by Zoe herself.

B.It is still carefully kept by Mr Lateur.

C.Zoe was sure it would be replied one day.

D.Zoe’s father discouraged her from writing it.小题4:Which of the following can be the best title of the passage?

A.An Unexpected Letter

B.A Reply Waited for Long

C.A Reply from a Stranger

D.A Letter from a Faraway Land