问题 问答题 案例分析题

病历摘要:男性,55岁,工人,因胸骨后持续性疼痛3小时急诊入院。患者于3小时前生气后突然感到胸骨后疼痛,压榨性,向左肩部放射,有濒死感,休息与口含硝酸甘油均不能缓解,伴大汗,无心悸、气短,二便正常。既往无高血压和心绞痛病史,无药物过敏史。吸烟20余年,每天1包,不嗜酒。查体:T36.8℃,P100次/分,R18次/分,BP130/70mmHg。急性痛苦病容,平卧位,无皮疹和发绀,浅表淋巴结未触及,巩膜无黄染,颈静脉无怒张,叩诊心界不大,心率100次/分,有期前收缩5~6次/分,心尖部有S4,未闻及杂音和心包摩擦音,肺清无啰音,腹平软,肝脾肋下未触及,下肢不肿。心电图:ST段Ⅱ、Ⅲ、aVF升高呈弓背向上型,QRS段Ⅱ、Ⅲ、aVF呈Qr型,T波倒置和室性期前收缩。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:

分析步骤:(22分)

1.诊断及诊断依据:(8分)

(1)初步印象:(4分)

冠状动脉性心脏病

急性下壁心肌梗死

心界不大

心律失常-室性期前收缩

心功能Ⅰ级(Killip分级)

(2)其诊断依据是:(4分)

①中年男性,急性病程。

②生气后胸骨后持续性压榨性疼痛3小时,向左肩部放射,有濒死感,休息与口含硝酸甘油均不能缓解,伴大汗。

③既往吸烟20余年,每天1包。

④查体:P100次/分,BP130/70mmHg,急性痛苦病容,平卧位,叩诊心界不大,心率100次/分,有期前收缩5~6次/分,心尖部有S,未闻及杂音和心包摩擦音,肺清无啰音。

⑤心电图:ST段Ⅱ、Ⅲ、aVF升高呈弓背向上型,QRS段Ⅱ、Ⅲ、aVF呈Qr型,T波倒置和室性期前收缩。

2.鉴别诊断(6分)

(1)主动脉夹层:胸痛一开始即达高峰,常放射到背、肋、腹、腰和下肢,两上肢的血压和脉搏可有明显差别。患者突发持续性胸骨后压榨性痛3小时,应考虑本病,可行超声心动,必要时行胸部CT检查以除外。

(2)急性心包炎:疼痛常与发热同时出现,早期即有心包摩擦音,心电图除aVR外,其余导联均有ST段弓背向下的抬高。

(3)心绞痛:疼痛持续时间短,多在15分钟内,一般不伴大汗,休息或口含硝酸甘油后会迅速缓解,心肌标志物不高,发作时心电图呈ST段压低,缓解后恢复。患者胸骨后持续性压榨性疼痛3小时伴大汗,休息与口含硝酸甘油均不能缓解,心电图Ⅱ、Ⅲ、aVFST段弓背向上抬高,可除外该病。

3.进一步检查(4分)

根据初步诊断和鉴别诊断,为确诊和有助于治疗应做:

(1)继续心电图检查,以观察其动态变化。

(2)血清心肌酶和肌钙蛋白测定。

(3)化验血常规、血脂、血糖、肾功能和血电解质。

(4)凝血功能检查,以备溶栓和抗凝治疗。

(5)超声心动。

(6)冠状动脉造影与介入治疗。

4.治疗原则(4分)

(1)监护和一般治疗:包括卧床休息、保持大便通畅;吸氧;持续心电监护。

(2)解除疼痛:用哌替啶或吗啡,静滴硝酸甘油等。

(3)抗血小板,抗凝治疗。

(4)溶栓治疗:发病在12小时内(本例3小时)若无溶栓禁忌证,可行溶栓治疗,或急诊PTCA及支架术。

(5)酌情治疗心律失常:可选利多卡因。

(6)β受体阻滞剂、血管紧张素转换酶抑制剂。

(7)心肌梗死二级预防。

阅读理解

It was a village in India. The people were poor but they were happy. After all, their forefathers had lived in the same way for centuries.

Then one day, some visitors from the city arrived. They told the villagers there were some people elsewhere who liked to eat frog. However, they did not have enough frogs of their own, and so they wanted to buy frogs from other places.

This seemed like money for nothing. There were millions of frogs in the fields around, and they were useless to the villagers. What they had to do was to catch them. Agreement was reached, and the children were sent into the fields to catch frogs. Every week a truck arrived to collect the catch and hand over the money. The villagers were able to dream of a better future. But the dream didn’t last long.

The change was hardly noticed at first, but it seemed as if the crops weren’t doing so well. More worry was that the children fell ill more often, and there were more insects around lately. The villagers decided that they couldn’t just wait to see the crops failing and the children getting weak. They would have to use the money earned to buy pesticides (杀剂) and medicine. Soon there was no money left.

The people realized what was happening. It was the frog. They hadn’t been useless. They had been doing an important job--- eating insects. Now with so many frogs killed, the insects were increasing more rapidly. They were damaging the crops and spreading diseases.

Now, the people are still poor. But in the evenings they sit in the village square and listen to sounds of insects and frogs. These sounds of the night now have a much deeper meaning.

小题1:From Paragraph l, we learn that the villagers_______.

A.worked very hard for centuries

B.dreamed of having a better life

C.were poor but somewhat happy

D.lived a different life from their forefathers小题2:Why did the villagers agree to sell frogs?

A.The frogs were easy money.

B.They needed money to buy medicine.

C.They wanted to please the visitors.

D.The frogs made too much noise.小题3: What might be the cause of the children’s sickness?

A.The crops didn’t do well.

B.There were too many insects.

C.The visitors brought in diseases.

D.The pesticides were overused.小题4:What is meaning of the last sentence of the article?

A.Happiness comes from peaceful life in the country.

B.Money is important.

C.The harmony between man and nature is important.

D.Good old days will never be forgotten.

单项选择题 A1/A2型题