问题 问答题 案例分析题

【病例摘要】患者,女,70岁。患者于2小时前外出时,突然感觉心前区疼痛,休息后不能缓解,伴汗出,心悸,自含硝酸甘油15分钟后仍不能缓解,遂来我院急诊。现感胸痛剧烈,伴有心悸不宁,气短乏力,自汗盗汗,口干耳鸣,腰膝酸软。查体:T37.8℃,P65次/分,R20次/分,BP150/60mmHg。痛苦面容,心界不大,心尖部第一心音减弱。舌质红少苔,脉细数。辅助检查:急查心电图示:V1~V3导联ST段抬高,弓背向上。血肌红蛋白、肌钙蛋白Ⅰ、肌钙蛋白T均升高,血清肌酸激酶198U/L,肌酸激酶同工酶(CK-MB)27U/L。【答题要求】(1)根据上述病例摘要,完成书面辨证论治。(2)请与主动脉夹层相鉴别。

答案

参考答案:

一、西医诊断依据

(1)心前区疼痛2小时。

(2)T37.8℃,P65次/分,痛苦面容,心界不大,心尖部第一心音减弱。

(3)急查心电图示:V1~V3导联ST段抬高,弓背向上。血肌红蛋白、肌钙蛋白Ⅰ、肌钙蛋白T均升高,血清肌酸激酶198U/L,肌酸激酶同工酶(CK-MB.27U/L。

二、西医鉴别诊断

主动脉夹层胸痛迅速达高峰,呈撕裂样,常放射至背、腹、腰或下肢,两上肢血压和脉搏有明显差别,可有暂时性下肢瘫痪、偏瘫和主动脉瓣关闭不全的表现等。超声心动图多能帮助诊断。心电图及心肌酶多无心肌梗死的特征性变化。

此外,本病还需与心绞痛等鉴别。

三、中医辨证依据与病因病机分析

1.中医辨证依据心脉痹阻,故见感胸痛剧烈;心阴不足则心悸不宁、盗汗,心阴亏虚影响及肾阴,故见口干耳鸣、腰膝酸软;舌质红少苔、脉细数均为心肾阴虚之象。

2.病因病机分析胸阳不振,心脉痹阻不畅。

四、入院诊断

1.西医诊断心肌梗死。

2.中医疾病诊断胸痹。

3.中医辨证诊断心肾阴虚。

五、中医治疗

1.中医治法滋阴清热,活血养心。

2.所选方剂名称天王补心丹和左归饮。

3.药物组成、剂量及煎服法生地黄20g、玄参15g、天冬15g、麦冬15g、人参1Og、甘草6g、茯苓1Og、柏子仁1Og、酸枣仁1Og、五味子1Og、远志1Og、丹参1Og、当归15g、桔梗1Og、朱砂3g、熟地黄1Og、山茱萸1Og、枸杞子1Og、山药1Og;3剂,水煎服,日一剂,分两次服用。

六、西医治疗原则与方法

1.一般治疗休息、护理、吸氧、监护。

2.缓解疼痛哌替啶等。

3.再灌注心肌溶栓、介入等。

4.纠正心律失常利巴韦林、奥司他韦等。

5.控制休克补充血容量、升压药等。

6.治疗心力衰竭。

7.β受体阻滞剂、钙拮抗剂和血管紧张素转换酶抑制剂的应用。

8.其他治疗促进细胞代谢、抗凝等。

9.并发症的处理。

多项选择题
阅读理解

III. 阅读(共两节,满分30分)

第一节阅读理解(共10小题;每小题2分,满分20分)

阅读下列短文,从每题所给的A、B、C和D项中,选出最佳选项,并在答题卡上将该项涂黑。

Charles Dickens (1812-1870), the great nineteenth century English novelist, was born near Portsmouth. His father ran heavily into debt and when he was twelve, he had to go and work in a factory for making boot polish. The only formal education he received was a two-year schooling at a school for poor children. In fact, he had to teach himself all he knew. He worked for a time as a junior clerk in a lawyer’s office. After that, he worked as a reporter in the law courts, and later in Parliament, for London newspapers.

His career as a writer of fiction began in 1833 with short stories and essays in periodicals(期刊), and in 1837 his comic novel The Pickwick Papers made him the most popular author at his time in England.

He was a great observer of people and their places because he was attracted by life and conditions in mid-nineteenth century London. He wrote 19 novels all his life and in many of them, Dickens gave a realistic picture of all classes of England society, showing deep sympathy for the poor and unfortunate, exposing the injustice and inhumanity of the middle class. Many of his novels like Oliver Twist, David Copperfield, Nicholas Nickleby, Great Expectations, A Tale of Two Cities and so on drew attention to the unsatisfactory social conditions that existed in England over a hundred years ago. Dickens criticized capitalist society from the point of view of bourgeois humanism. He wished to see improvement in the living conditions of the poor, but failed to find any effective means to achieve that end.

46. Dickens only received a little formal education because______.

A. he wanted to teach himself

B. he wanted to work and made a lot of money

C. he was too poor to afford any more formal education

D. he wanted some working experiences to be a novelist

47. According to Dickens, society at his time in England was________.

A. just    B. poor   C. comfortable      D. unsatisfying

48. Which of the following novel made Dickens the most popular writer at his time in England?

A. Oliver Twist                  B. The Pickwick Papers 

C. A Tale of Two Cities       D. Great Expectations

49. According to the passage, which of the following about Dickens is true?

A. He didn’t go to school at all.

B. He only wrote about poor people and showed deep sympathy for them.

C. He began to write fictions when he was 21 years old.

D. He found some effective ways to improve the living conditions of the poor.

50. It can be inferred from the passage that________.

A. Dickens had a miserable(悲惨的;可怜的)childhood

B. His career as a writer of fiction began in 1833

C. Dickens wrote many novels but only some of them are popular

D. Dickens criticized capitalist society and helped to improve the living conditions of the poor