病历分析集大全（Collection of medical record analysis）.docVIP

病历分析集大全（Collection of medical record analysis） 1 case analysis: Male, 59 years old, was discharged from the left arm due to a dull pain in the non exertional precordial region, accompanied by sweating and mild nausea. The patients in the past 2 years similar symptoms of intermittent seizures, for 20 minutes or so, usually induced by exertion, sublingual nitroglycerin can be alleviated, since last month, the attack is more frequent, sometimes appear in the rest, the last 48 hours at rest or slight physical activity have several episodes of chest pain. Physical examination: BP160/100mmHg HR80 / min, the law together, there was no more abnormal. Electrocardiogram: paroxysmal: ventricular premature contraction V1-3 ST segment elevation, T wave inversion After the attack: V1-3, ST-T returned to normal, the chamber disappeared early Questions: 1. Diagnosis and diagnosis 2 、 differential diagnosis 3, further examination and treatment Case analysis: 1 、 diagnosis and diagnosis basis (1) coronary heart disease, unstable angina pectoris or variant angina pectoris Heart beats, is not accidental Sinus rhythm, cardiac function, grade II (2) hypertension (extremely dangerous group); According to: (1) repeated precordial pain, lasted 20 minutes, containing nitroglycerin can be relieved, fatigue and rest have seizures, nearly 48 hours still have seizures. (2) ST segment elevation (episode) (3) moderate elevation of hypertension; 2 、 differential diagnosis 1, acute myocardial infarction 2, pulmonary infarction 3 、 acute abdomen 3, treatment (1) antiplatelet, anticoagulant Asprin 0.1, QD Plaix 75mg QD Low molecular weight heparin (Fraxiparine or enoxaparin) subcutaneous injection of 0.4ml Bid (2) calcium antagonists, 恬尔心30mg tid或拜心同30mg time (3) 硝酸酯类药 5% gs500ml + ng25mg ivdrip 8 ~ 10gtt / 分 (4) 吸氧, 测bp bid 进一步检查1、心酶4项, 肌钙蛋白, 异常为高危患者. 2、彩超, 了解心脏情况, 定时ecg监测 3、血糖、血脂, 血脂↑加用调脂药, 如立普妥10mg qd 4、冠脉造影, 必要时ptca + 支架 2、病例分析: 刘某, 男, 58岁, 因持续性胸痛6小时入院. 患者于入院前8小时无明显诱因出现胸骨后疼痛, 疼痛呈持续性, 压榨性.活动时胸痛加重,