英语查房教学(病例实战).pptVIP

个人史 Personal History： 生于原籍，长期居住新疆，到过全国各地 否认疫区居住史，否认化学毒物及放射性物质接触史。有吸烟史数十年，已戒烟，偶尔饮酒，无明确规律。 已婚，配偶子女均体健 大学文化程度 Has never been to epidemic area, deny history of poison touching. Has history of smoking for many years, he has already quit smoking. Drinking occasionally. His wife is healthy. The two daughters are also healthy. Bachelor degree. 家 族 史 Family History 父母双亡，死因不详 家族中无类似疾病患者 否认家族遗传病病史 It has not been found similar disease in his family. Deny history of family heritage disease. His parents were died, the reason has not been clear. 入院查体 physical examination T36.5℃ P69次/分，R18次/分BP120/80mmHg 发育良好 一般情况好，双肺呼吸音清，未闻及干、湿性罗音 T:36.5℃, HR:69 b/m, R:18t/m, Bp 120/80mmHg, Developed well Generally speaking, he is in good condition . 入院查体 physical examination 心前区无异常隆起，心尖搏动于左锁骨中线外0.5cm，无细震颤，心界增大，心率69次/分，律齐 主动脉瓣听诊区可闻及3-4/6级收缩期吹风样杂音 腹部未见阳性体征。双下肢无水肿。 Systolic murmur was heard at aortic area. The rest was normal. 心电图示：心电图不正常，窦性心动过缓，左心室肥厚伴劳损，偶发室性期前收缩。 E C G The ECG reveals sinus bradycardia, premature ventricular contractions , left ventricle hypertrophy and changes in ST segment and T wave. 入院后复查超声心动图示： 超声心动图结果：肥厚型梗阻性心肌病； 左室肥厚： 室间隔24mm，心尖部16mm，后壁19mm，侧壁16mm 收缩期左室流出道可见五彩高速血流 ΔPG＝168mmHg 较前比较ΔPG有所升高 Echocardiography Echocardiography shows left ventricle hypertrophy, left ventricle outflow narrowing at the same time. Septal wall is 24mm,the apex of left ventricle is 16mm,posterior left ventricle is 19mm,inferior surface of left ventricle is 16mm ΔPG is more than before. High speed blood flow were found in Systole. 动态心电图 动态心电图结果 Continuous ECG 频发多源室性期前收缩 部分呈双型，部分形成加速的室性逸搏性心律及室性心动过速 Continuous ECG reveals multi-focal PVCs, partly ventricular couplets and paroxysmal ventricular tachycardia . 治 疗 经 过 Treatment process  2007年3月27日植入5386DDDR型起搏器 增加β-受体阻滞剂量 超 声 心 动 图示主动脉跨瓣压缩小 ΔPG=101mmHg 于4 月18日出院 Dual-chamber, sequential atrioventricular pacing has been inserted on March 27th 2007. The dose of Beta blockers was increased to acquire better effect.