英语查房教学(病例实战)

CaseReport病例报告第一页，共53页。买买提·艾山，男，58岁，新疆籍新疆军区副政委。

主因发现心脏杂音32年，发作性心悸5年于2007年3月7日入院。

PatientMaiMaiTi,male,58year-old,wasborninxinjiang.HewasadmittedtothehospitalonMarch7th2007.Chiefcomplaint:

Hehashadcardiacmurmursfor32years,Palpitationfor5years.第二页，共53页。现病史

PresentHealthHistory缘于32年前查体发现心脏杂音，患者始终无症状。自5年前经常于劳累或饮酒后感心悸，伴轻度胸闷Thepatienthadcardiacmurmurs32yearsago,buthewasasymptomatic.Hefeltpalpitationafterfatigueoralcoholintake5yearsago,sometimesaccompaniedbychestdiscomfort.

第三页，共53页。现病史

PresentHealthHistory无头晕、恶心、呕吐及晕厥,无胸痛休息后可缓解

Nonauseaandvomiting,chestpain,dizzy,faint.Thesesymptomscanberelievedbyrest.

第四页，共53页。现病史

PresentHealthHistory2005年6月动态心电图显示频发多型室性早搏和阵发性室速给予口服胺腆酮治疗超声心动图提示左室流出道压力阶差高,ΔPG＝113mmHgContinuousECGrevelsprematureventricularcontractionsandparoxysmalventriculartachycardiaonJune2006.OralAmiodaronewasgivenhimtocontrolthem.Echocardiographyshowsleftventriclehypertrophy,leftventricleoutflowwasnarrow.ΔPGis113mmHg.第五页，共53页。现病史

PresentHealthHistory2005年7月明确诊断为肥厚型梗阻性心肌病会诊决定暂时应用β-受体阻滞剂和钙拮抗剂行药物治疗观察血流动力学，如左室流出道压差降低，则继续药物治疗，如左室流出道压力阶差降低不明显，考虑射频消融结合起搏治疗。HewasdiagnosedasHCM(HypertrophicCardiomyopathy)onJuly2005.Betablockersandcalciumchannelblockerswereused.Thehaemodynamymustbeobserved.第六页，共53页。既往史

PastHealthHistory否认冠心病、糖尿病病史否认肝炎、结核等传染病史否认手术外伤及输血史无药物过敏史

DenyhistoryofCAD,diabetesmellitus.DenyhistoryofheritagefamilydiseaseDenyhistoryofsurgicaloperations,injuriesandbloodtransfusion.Nomedicineallergy第七页，共53页。个人史

PersonalHistory：

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

Hasneverbeentoepidemicarea,denyhistoryofpoisontouching.Hashistoryofsmokingformanyyears,hehasalreadyquitsmoking.Drinkingoccasionally.Hiswifeishealthy.Thetwodaughtersarealsohealthy.Bachelordegree.第八页，共53页。家族史

FamilyHistory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

Ithasnotbeenfoundsimilardiseaseinhisfamily.Denyhistoryoffamilyheritagedisease.Hisparentsweredied,thereasonhasnotbeenclear.第九页，共53页。入院查体

physicalexaminationT36.5℃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:69b/m,R:18t/m,Bp120/80mmHg,DevelopedwellGenerallyspeaking,heisingoodcondition.第十页，共53页。入院查体

physicalexamination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。Systolicmurmurwasheardataorticarea.Therestwasnormal.

第十一页，共53页。

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。第十二页，共53页。ECGTheECGrevealssinusbradycardia,prematureventricularcontractions,leftventriclehypertrophyandchangesinSTsegmentandTwave.第十三页，共53页。

入院后复查超声心动图示：第十四页，共53页。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有所升高第十五页，共53页。EchocardiographyEchocardiographyshowsleftventriclehypertrophy,leftventricleoutflownarrowingatthesametime.Septalwallis24mm,theapexofleftventricleis16mm,posteriorleftventricleis19mm,inferiorsurfaceofleftventricleis16mmΔPGismorethanbefore.HighspeedbloodflowwerefoundinSystole.

第十六页，共53页。

动态心电图第十七页，共53页。动态心电图结果

ContinuousECG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ContinuousECGrevealsmulti-focalPVCs,partlyventricularcoupletsandparoxysmalventriculartachycardia.第十八页，共53页。治疗经过

Treatmentprocess

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,sequentialatrioventricularpacinghasbeeninsertedonMarch27th2007.ThedoseofBetablockerswasincreasedtoacquirebettereffect.ΔPGislessthanbefore.TheclientwasdischargedonApril18th.第十九页，共53页。心理社会评估

PsychosocialAssessment鉴于肥厚性心肌病无法根治以及无法预料的严重后果，患者有明显的不确定感，并导致恐惧和焦虑患者担心女儿患病Becauseoftheincurablenatureofthedisorderandtheunforeseeableoftheseriousconsequencesofthedisease,theclientisfacedwithuncertaintythatmaycreatefearandanxiety.Hewasworriedabouthisdaughter’conditions第二十页，共53页。NursingDiagnosis1PotentialComplicationsincludingarrhythmias,heartfailure,andsuddendeathNursingGoals

Nooccurrenceoforearlydetectionofcomplicationsincludingarrhythmias,heartfailure,andsuddendeath第二十一页，共53页。护理诊断潜在并发症心律失常心衰猝死

护理目标无心律失常无心衰无猝死等并发症第二十二页，共53页。NursinginterventionsAvoidimpairingventricularfilling,suchassuddenpositionchange,strenuousphysicalactivities,competitiveexercise.

Observetheeffectsoftherapyapplied,thepossiblesideeffectsofmedications,complicationsObservevitalsigns,complaints.paymoreattentiontosuddendeath.第二十三页，共53页。护理措施避免可降低心室充盈的情况，如突然变换体位、体力活动、竞技运动药物治疗的护理：观察药物作用与付作用病情观察：生命体征、主诉，警惕猝死第二十四页，共53页。NursingDiagnosis2ActivityintolerancerelatedtotheimbalancebetweenoxygensupplyanddemandasaresultofcardiacinsufficiencyNursingGoals

Increasedexercisetolerance第二十五页，共53页。护理诊断活动无耐力

与心功能受损所致的氧供需失调有关

护理目标足够的心排出量活动耐力增强第二十六页，共53页。NursinginterventionsInstructthepatientonpacingthedailyactivitiesandresttopromptcomfortCarefullymonitoringbeforeandafterpacemakerinsertion第二十七页，共53页。护理措施指导患者合理安排休息与活动，增进舒适安置起搏器前后的护理第二十八页，共53页。NursingDiagnosis3Fear/AnxietyrelatedtotheunknowingofandperceivedthreatofthediseaseNursingGoals

Less

anxietyandapprehensionabouthisconditionandprognosis第二十九页，共53页。护理诊断恐惧或焦虑与对疾病缺乏了解和感知疾病威胁有关

护理目标对疾病和预后的焦虑与恐惧感减轻第三十页，共53页。NursinginterventionsEmotionalsupport:creatinganenvironmentinwhichhecanexpressconcernsandacknowledgefearsshowingacaringattitudeofferingencouragement,acceptance.第三十一页，共53页。护理措施心理支持：接纳和理解患者创造有利于患者倾诉的环境给予关怀、鼓励、支持促进有效应对第三十二页，共53页。NursingDiagnosis4LackofHCMself-managementknowledgeandskillsNursingGoals

Adequateself-management

knowledgeandskills第三十三页，共53页。护理诊断知识缺乏

缺乏肥厚性心肌病自我管理知识与技能

护理目标有足够的自我管理知识与技能第三十四页，共53页。NursinginterventionsKnowledgeofHCMExplaintheeffectsandsideeffectsofmedicationCarryamedicalconditioncardincaseofemergencyFamilymembersbetrainedthebasiclifesupporttechniquesKeepadherencetothetherapeuticalregimenandself-monitoringPromptself-managementbyhealthteaching

第三十五页，共53页。护理措施健康教育有关疾病知识有关用药知识家庭成员急救技能训练携带病历简卡遵从治疗方案，加强自我监测促进自我管理第三十六页，共53页。NursingEvaluationDemonstrateanadequatecardiacoutputIncreasedexercisetolerance,improvetheclient’squalityoflife.Demonstratepropermanagementofphysicalandemotionalactivities.Administermedicationssafelyandrecognizepossiblesideeffects.Obeythetherapeuticalregimen.第三十七页，共53页。护理评价足够的心输出量，无并发症发生患者活动耐力增加，生活质量提高患者显示对活动与情绪的恰当管理患者能安全用药和识别可能发生的副作用遵从治疗方案第三十八页，共53页。InstructionsAvoidoverexcitingandbeemotionallystable.Adjustlifestyles.Monitortheeffectsandsideeffectsofmedications.Comebacktothehospitalforfollowupchecksregularly.Familymembercanmasterthebasiclifesupporttechniques.第三十九页，共53页。出院指导避免情绪激动，保持情绪稳定改变生活方式监测药物作用与付作用定时复查患者家庭成员掌握基本生命支持技术第四十页，共53页。讨论为什么该病人非常关心女儿的健康？第四十一页，共53页。DiscussionWhywasheworriedabouthisdaughter’shealth?TheexactetiologyofHCMisyetunclear.Aboutonethirdoftheaffectedclientshavefamilyhistory.Itiscurrentlyrecognizedasageneticallytransmitteddiseasethatisassociatedwithmultiplegenealterations.第四十二页，共53页。讨论患有HCM的病人常有明显的心理问题，为什么？第四十三页，共53页。DiscussionThepatientswithHCMoftenhavemoreemotionalreactions,why?Tomanypeople,heartisthesymboloftheirlife.AclientwithHCMperceivesitasamajorlifecrisis.Theymayconfrontnotonlythepossibilityofdeath,butalsofears,forcedchangesofdailylife,familyandsocialroles.第四十四页，共53页。讨论起搏器治疗的目的是什么？第四十五页，共53页。DiscussionWhatisthegoalbypacema