实践技能操作考核培训课件

1、2014年执业医师实践技能操作考核培训 心电图及病例分析杨作富Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.2014年执业医师实践技能操作考核培训 实践技能操作考核培训辅助检查：心电图病例分析：心血管系统：1.心力衰竭2.心律失常3.冠心病4.高血压5.心脏瓣膜病6.结核性心包炎、风湿免疫性疾病：1.系统性红斑狼疮2.类风湿关节炎Evaluation only.Created with Aspose.Slides

2、for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.实践技能操作考核培训辅助检查：心电图Evaluation o一、辅助检查心电图Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.一、辅助检查心电图Evaluation only.PQRSTEvaluation only.Created with Aspose.Slides for

3、 .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.PQRSTEvaluation only.心电图1.正常心电图2.窦性心动过速3.窦性心动过缓4.房性期前收缩5.心房颤动6.阵发性室上性心动过速7.室性期前收缩8.室性心动过速9.心室颤动10.房室传导阻滞11.左、右束支传导阻滞12.左、右心室肥厚13.急性心肌梗死Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-201

4、1 Aspose Pty Ltd.心电图1.正常心电图Evaluation only.R心脏除、复极与心电图关系示意图Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.R心脏除、复极与心电图关系示意图Evaluation onl心电图各波段组成与命名UEvaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyri

5、ght 2004-2011 Aspose Pty Ltd.心电图各波段组成与命名UEvaluation only.正常心电图Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.正常心电图Evaluation only.窦性心动过速Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-201

6、1 Aspose Pty Ltd.窦性心动过速Evaluation only.窦性心动过缓，一度房室传导阻滞Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.窦性心动过缓，一度房室传导阻滞Evaluation only窦性心动过速和窦性心动过缓Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright

7、2004-2011 Aspose Pty Ltd.窦性心动过速和窦性心动过缓Evaluation only.窦性心律不齐Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.窦性心律不齐Evaluation only.房性期前收缩 房早Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2

8、011 Aspose Pty Ltd.房性期前收缩 房早Evaluation only.窦性停搏Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.窦性停搏Evaluation only.房扑Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.房扑

9、Evaluation only.房颤Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.房颤Evaluation only.心房颤动Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心房颤动Evaluation only.阵发性室上性心动过速Ev

10、aluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.阵发性室上性心动过速Evaluation only.阵发性室上速Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.阵发性室上速Evaluation only.Evaluation only.Crea

11、ted with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.Evaluation only.室早二联律Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.室早二联律Evaluation only.短阵室速Evaluation only.Created with Aspose.Slides for

12、 .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.短阵室速Evaluation only.阵发性室性心动过速Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.阵发性室性心动过速Evaluation only.心室颤动和心室扑动Evaluation only.Created with Aspose.Slides for .NET 3.5

13、 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心室颤动和心室扑动Evaluation only.室颤Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.室颤Evaluation only.I度房室传导阻滞（P-R间期0.27s）Evaluation only.Created with Aspose.Slides for .NET 3.5 Client

14、 Profile .Copyright 2004-2011 Aspose Pty Ltd.I度房室传导阻滞（P-R间期0.27s）Evaluation窦性心律，一度房室阻滞。Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.窦性心律，一度房室阻滞。Evaluation only.II度房室传导阻滞（I型）Evaluation only.Created with Aspose.Slides for .NET

15、 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.II度房室传导阻滞（I型）Evaluation only.II度房室传导阻滞（II型）Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.II度房室传导阻滞（II型）Evaluation only.III度房室传导阻滞Evaluation only.Created with Aspose.Slid

16、es for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.III度房室传导阻滞Evaluation only.完全性右束支传导阻滞Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.完全性右束支传导阻滞Evaluation only.完全性左束支传导阻滞Evaluation only.Created with Aspose.Slid

17、es for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.完全性左束支传导阻滞Evaluation only.左右心室肥厚左心室肥厚右心室肥厚Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.左右心室肥厚左心室肥厚Evaluation only.胸痛伴左心室肥厚患者，因为V1和V2导联ST段变化，被给与了不适当的溶栓治疗。Eval

18、uation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.胸痛伴左心室肥厚患者，因为V1和V2导联ST段变化，被给与了右心室劳损：右心室肥厚伴胸导联广泛T波倒置Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.右心室劳损：右心室肥厚伴胸导联广泛T波倒置Eval

19、uatio心肌缺血T波增高Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心肌缺血T波增高Evaluation only.不稳定性心绞痛表现为导致的T波Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.不稳定性心绞痛表现为导致的T波Evalu

20、ation onl胸痛患者可逆性的ST段变化：ST段抬高随胸痛缓解转变为正常Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.胸痛患者可逆性的ST段变化：ST段抬高随胸痛缓解转变为正常E前壁心肌梗死存在显著ST段抬高 （表现为 “墓碑”样 R波)Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright

21、 2004-2011 Aspose Pty Ltd.前壁心肌梗死存在显著ST段抬高 （表现为 “墓碑”样 R波)导联的解剖关系 下壁 II、 III 和 aVF导联 前壁 V1 to V4 导联侧壁 I、 aVL、 V5 和 V6 非标准导联 右心室 右胸导联 V1R to V6R 后壁 V7 to V9导联心肌梗死梗死部位的定位Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.导联的解剖关系 心肌梗死梗死部位的定位E

22、valuation 病例分析心血管系统：1.心力衰竭2.心律失常3.冠心病4.高血压5.心脏瓣膜病6.结核性心包炎、风湿免疫性疾病：1.系统性红斑狼疮2.类风湿关节炎Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.病例分析心血管系统：1.心力衰竭2.心律失常3.冠心病4.高心血管系统1.心力衰竭2.心律失常3.冠心病4.高血压5.心脏瓣膜病6.结核性心包炎、Evaluation only.Created with A

23、spose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心血管系统1.心力衰竭Evaluation only.心力衰竭左心衰:呼吸困难+端坐呼吸+奔马律+粉工色泡沫痰右心衰：肝大+肝颈静脉回流征阳性+水肿全心衰：具备以上两者Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心力衰竭左心衰:呼吸困难+端坐呼吸+

24、奔马律+粉工色泡沫痰Ev心律失常阵发性室上性心动过速（PSVT）心房纤颤室早、室速Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心律失常阵发性室上性心动过速（PSVT）Evaluation冠心病心绞痛急性心肌梗死Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspo

25、se Pty Ltd.冠心病心绞痛Evaluation only. 男性，62岁，阵发性胸痛4天，再发4小时来急诊。 患者4天前出现活动后心前区钝痛、放散至咽部，伴轻度出汗，持续10余分钟后自行好转，未予诊治。4小时前饮酒时再发心前区疼痛，有压迫感，伴胸闷、大汗、恶心，未吐。自服“速效救心丸”6粒，胸痛仍不缓解被家人送来急诊。患病以来无咯血、无大、小便失禁。既往有冠心病病史。无糖尿病、高血压病史，无药物过敏史，吸烟20年，30支日，少量饮酒。 查体：T 364。C，P 98次分，R l8次分，BP l2060mmH9，神志清，巩膜无黄染，睑结膜无苍白，口唇无紫绀，双肺底可闻及细湿l罗音，心界不

26、大，心率98次分，律不齐，可闻及早搏5次分，心音稍低，未闻及杂音。腹平软，肝脾未触及，双下肢不肿。 辅助检查：心电图：V1-5导联sT段弓背向上抬高03mV05mV，有提前出现的宽大畸形的QRS波群。CK及CK-MB正常，肌钙蛋白T 096n9ml(正常值005n9ml)。 Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd. 男性，62岁，阵发性胸痛4天，再发4小时来急诊。Evalu分析步骤： 1初步诊断及诊断依据 本

27、例初步诊断：冠心病，急性广泛前壁心肌梗死，心脏不大，室性早搏，心功能(Killip)级。 其诊断依据是： (1)急性广泛前壁心肌梗死：有冠心病家族史，吸烟；急性起病，有先兆胸痛，压迫感，用药后不缓解；查体：心音低；辅助检查：心电图：V1 ST段弓背向上抬高；肌钙蛋白T增高。 (2)室性早搏：听诊心律不齐，心电图可见提前出现的宽大畸形的QRS波群。 (3)心功能(Killip)级：胸闷，体检双肺底可闻及细湿哕音。 2鉴别诊断 (1)不稳定性心绞痛：可有胸闷、胸痛，持续时间短，心电图正常或出现相应导联的ST段压低，心肌酶、TNT正常。 (2)肺栓塞：多有下肢静脉血栓、外伤、手术等栓子来源病史，右心

28、负荷急剧增加，体检可有发绀、肺动脉瓣区S2亢进、颈静脉充盈、肝大、下肢浮肿等表现。 (3)急性心包炎：胸痛伴心电图变化，症状多与发热同时出现，呼吸和咳嗽时加重，心电图ST段呈弓背向下抬高。 (4)急性胰腺炎：饮酒时发病，有胃肠道表现。 Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.分析步骤：Evaluation only.3进一步检查 (1)动态观察心电图，观察梗死范围变化及心律失常的发展。 (2)动态观察血清心肌

29、酶，描绘变化曲线，观察酶峰变化。 (3)血气分析，凝血功能检查，除外肺栓塞诊断。 (4)血常规检查，电解质，血脂、血糖，淀粉酶，腹部B超，除外胰腺炎。 (5)超声心动图了解心室壁活动及心功能。 (6)胸部X片，了解心脏大小及肺部情况。 (7)冠脉造影确定血管病变程度。 ， 4治疗原则 (1)一般治疗：休息，吸氧，监测、护理。 (2)解除疼痛：吗啡，硝酸酯制剂。 (3)抗凝及抗血小板药物：阿司匹林，氯吡格雷，肝素。 (4)再灌注治疗，溶栓和(或)介入治疗 (5)对症治疗：控制心律失常，改善心功能。 (6)心肌梗死的级预防：ACEl改善心脏重塑，B-受体阻滞剂减慢心率降低 心肌耗氧，他汀类调脂药。

30、Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.3进一步检查Evaluation only.高血压高血压的诊断及分级危险分层注意合并症的诊断Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.高血压高血压的诊断及分级Evaluation onl

31、y.分类收缩压(mmHg)舒张压(mmHg)正常血压 120 80正常高值 120139 8089高血压 140 90 1级高血压(轻度) 140159 9099 2级高血压(中度) 160179 100109 3级高血压(重度)180 110单纯收缩期高血压140 90血压水平的定义和分类注：当收缩压与舒张压属不同级别时，应该取较高的级别分类。中国高血压防治指南2010修订版和和/或和/或和/或和/或和/或和Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004

32、-2011 Aspose Pty Ltd.分类收缩压(mmHg)舒张压(mmHg)血压水平的定义高血压患者心血管风险分层其他危险因素和病史血压(mmHg)1级高血压SBP 140-159或DBP 90-992级高血压SBP 160-179或DBP 100-1093级高血压SBP 180或DBP 110无低危中危高危1-2个其他危险因素中危中危很高危3个其他危险因素，或靶器官损害高危高危很高危临床并发症或合并糖尿病很高危很高危很高危Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copy

33、right 2004-2011 Aspose Pty Ltd.高血压患者心血管风险分层其他危险因素和病史血压(mmHg)1心脏瓣膜病风湿性心脏二尖瓣狭窄并关闭不全主动脉瓣关闭不全Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心脏瓣膜病风湿性心脏Evaluation only.结核性心包炎有结核中毒症状心包积液的体征Evaluation only.Created with Aspose.Slides for .NET

34、 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.结核性心包炎有结核中毒症状Evaluation only.风湿免疫性疾病1.系统性红斑狼疮2.类风湿关节炎Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.风湿免疫性疾病1.系统性红斑狼疮Evaluation onl系统性红斑狼疮诊断依据临床表现Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.系统性红斑狼疮诊断依据