英文病例分析-心肌梗死

1、Case analysis病例分析病例分析Chief ComplaintsvParoxysmal precordium pain for 2 months，exacerbation for 16 hours.病例分析病例分析vMedical history：achevlocation、 character、 degree？ radiation？vduration ？vInducing and relief factor ？v treatment process?病例分析病例分析Present illnessvParoxysmal precordium pain in the past 2 mo

2、nths.vBroke out after agitation or overwork ed,last for 2-3minutes， relieved after rest , didnt treatment.病例分析病例分析Present illnessv Precordium pain aggravated without i n d u c i n g f a c t o r 1 6 h o u r s ago,accompanied with back and both upper limbs pain, left shoulder and upper limb obviously

3、, accompanied with nausea.vTaken omeprazole capsule,the symptom couldnt relieve,precordium pain still existed persistently after local hospital treatment.病例分析病例分析Present illnessv In emergency room of our hospital,vtaken“aspirin 300mg, ticagrelor 180mg”,“isosorbide mononitrate 20mg” intravenous drip.

4、病例分析病例分析vPast Medical History：2014.09.19 gastroscope : esophagitis, gastric ulcer , erosive gastritis, duodenal bulb inflammation. v Family History：His mother have history of hypertension, coronary heart disease and diabetes.Brother has history of diabetes and hypertension.病例分析病例分析Physical examinati

5、on：vVital signs!vChest and heart examinationv abdomen examination病例分析病例分析vT 36.7 , P 72/min, R 20/min, BP117/75mmHg. Regular respirations. No edema in eye-lips. The lips are red. No sternum tenderness. Breathing sounds are rough, with both bottom of the lung moist rales. No abnormal pulsation an upl

6、ift in precordial region. The heart percussed normal in size. Heart beat 72. Abdomen is flat, No tenderness. No distension. 病例分析病例分析Chest pain DiagnosisDifferential diagnosis病例分析病例分析gastrointestinalCardiovascular Mental neuromuscularpleuralPulmonary Chest pain 病例分析病例分析 Differential diagnosis？pAngina

7、 pAcute pericarditis pAcute pulmonary embolism pAcute abdominal pain pAortic dissection 病例分析病例分析vAuxiliary examinations ？病例分析病例分析vECG：The most important the most quicklyLocation Inferior wall aVF Anterior wall V16 Anteroseptal wall V1-3 Apical or lateral wall V46 Posterior wall-V7-9 Right-sided -V4R

8、-V5R15病例分析病例分析cTnI 7.092ng/mL, CK-MB 156.43ng/mL，MYO 251.09 ng/ml。vX-ray: heart shadow increased, bronchitis .vUCG： Segmental ventricular wall motion abnormalities ,EF：45%.病例分析病例分析 Diagnosis v1.coronary heart disease acute anterior wall myocardial infarction Killip class II.v 2.bronchial pneumonia.v

9、3. esophagitis, gastric ulcer , erosive gastritis, duodenal bulb inflammation.病例分析病例分析vComplications ？pDysfunction or rupture of papillary muscle pRupture of the heart pEmbolism pCardiac aneurysm p Postinfarction syndrome 病例分析病例分析Treatment vGeneral ：Stay in bed monitoring, oxygen Pain relief vanti-ischemiavAnti-plateletvanti-coagulationvRe