孟庆义胸痛诊治思维_培训课件.ppt

肺总动脉的一支堵塞，可胸痛、昏厥、休克而猝死。 仅肺动脉一分支堵塞，则症状轻重随血管堵塞的大小而不同，主要表现为突发性胸痛、呼吸困难与紫绀。 疼痛可为刺痛、绞痛，部位在胸骨后，向肩部放射，随呼吸加剧，同时伴有发热、咳嗽、咯血，白细胞增高与转氨酶GOT升高。检查病变部位有浊音，并可听到胸膜摩擦音。 诊断 D－二聚体初步筛选 ECGSIQ3T3少见，V1-４ ST-T改变 血气分析 X线摄片见梗死部位呈楔形致密影，底边近胸膜，尖端向肺门，亦可为圆形或多发性小片状影。 选择性肺动脉造影和放射性核素肺扫描可确定诊断。 注意事项 尽早对疾病进行危险评估，诊断思路应从高危到低危。 高危者生命体征不稳，稳定生命体征放在首位，先救命，后诊病; 动态的严密观察病情变化; 思路广、避免先入为主掌握全面资料，必要时请相关科室会诊; 6.作好沟通解释工作; 7.诊断不清时一定要写待查， 查体要写清麦氏点，莫非氏，肝区有否叩痛，有否胸膜摩檫音; 8. 忌用强镇静剂、镇痛剂; 诊断问题: 临床表现(直觉) 直觉和临床印象很难用语言来描述; 临床上最重要的能力是对病人的诊断;对临床表现直觉地去归纳,并与以前相似的经验进行比较,从而做出正确的判断; 医疗艺术原则上是无法学习的,可通过不断的实践和经验的积累得到提高; -Walter Siegenthaler * Nature of Pain The pain of AMI is variable in intensity; in most patients it is severe and in some instances intolerable. The pain is prolonged, usually lasting for more than 30 minutes and frequently for a number of hours. Described as constricting, crushing, oppressing, or compressing; often the patient complains of a sensation of a heavy weight or a squeezing in the chest. Although the discomfort is typically described as a choking, viselike, or heavy pain, it may also be characterized as a stabbing, knifelike, boring, or burning discomfort. The pain is usually retrosternal in location, spreading frequently to both sides of the anterior chest, with predilection for the left side. Often the pain radiates down the ulnar aspect of the left arm, producing a tingling sensation in the left wrist, hand, and fingers. Some patients note only a dull ache or numbness of the wrists in association with severe substernal or precordial discomfort. In some instances, the pain of AMI may begin in the epigastrium and simulate a variety of abdominal disorders, a fact that often causes MI to be misdiagnosed as “indigestion In other patients the discomfort of AMI radiates to the shoulders, upper extremities, neck, jaw, and interscapular region, again usually favoring the left side. In patients with preexisting angina pectoris, the pain of infarction usually resembles that of angina with respect to location