胸痛讲课.pptx

胸痛的诊断及鉴别诊断,五康刘玉冰2018.10,胸痛,Chest pain appears in many forms, ranging from a sharp stab to a dull ache. Sometimes chest pain feels crushing or burning. In certain cases, the pain travels up the neck, into the jaw, and then radiates to the back or down one or both arms. Many different problems can cause chest pain. The most life-threatening causes involve the heart or lungs. Because chest pain can indicate a serious problem, its important to seek immediate medical help.,胸部感觉神经纤维,肋间神经感觉纤维 支配主动脉的交感神经纤维 支配气管与支气管的迷走神经纤维 膈神经的感觉纤维,病因,.,Gastroesophageal disease 42 Gastroesophageal reflux Esophageal motility disorders Peptic ulcer Gallstones Ischemic heart disease 31 Chest wall disease 28 Pericarditis 4 Pleuritis/pneumonia 2 Pulmonary embolism 2 Lung cancer 1.5 Aortic aneurysm 1 Aortic stenosis 1 Herpes zoster 1,Diagnosis percentage,Different diagnosis of patients admitted to hospital with acute chest pain ruled not myocardial infarction. Fruergaard P et. al: Eur Heart J 17:1028,1996,胸痛的分类与常见病因,胸痛规范化评估与诊断中国专家共识ppt,鉴别要点,发病年龄 胸痛部位 胸痛性质 持续时间 影响因素 伴随症状,问诊要点 1、起病缓急、胸痛部位、范围大小、放射部位、疼痛严重度和对患者的影响 2、胸痛性质、轻重及持续时间、发生的诱因、加重与缓解方式，咳嗽/深呼吸的影响，与活动、进餐、情绪的关系 3、有无发热/咳嗽/咳痰/咯血/心悸/发绀/呼吸困难及其程度 4、是否伴有呼吸困难/吞咽时疼痛加重与反酸 5、其他如职业/嗜好/既往发作情况及其诱因、缓解方式等,临床诊断学 第二版,胸痛部位,胸壁疾病常固定性、压痛、炎症性表现 带状疱疹水疱沿肋间神经分布伴剧痛 肋软骨炎第1、2肋软骨处单个或多个隆起、局部压痛、无红肿 夹层动脉瘤多位于胸背部，向下放射至下腹部、腰部、两侧腹股沟和下肢 胸膜炎胸侧部 食管及纵隔胸骨后 肝胆疾病及膈下肿瘤右下胸，右肩部 肺尖部肺癌肩部/腋下为主，向上肢内侧放射,心绞痛,多40岁以上，危险因素 胸骨后和心前区、剑突下、左肩、左臂内侧或左颈、左侧面颊与咽部 绞榨样、重压窒息感，MI更剧烈伴恐惧、濒死感 时间短暂，含服硝酸酯类药物后缓解,腹痛-肝与胆囊,内脏大神经 胸脊节78 右上腹及右肩胛,肺栓塞筛查量表,注：0-3分低度可疑，4-10分中度可疑，11+分高度可疑,主动脉夹层筛查量表,tips,Chest pain：There is little correlation between the severity of chest pain and the seriousness of its cause. The range of disorders that cause chest discomfort is shown in