循环系统病例分析PPT课件PPT文档

,*,*,*,*,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,循环系统病例分析PPT课件PPT文档,一、病例分析与执业医师考试,【病例分析模板】,(,一,),诊断及诊断依据,1.,初步诊断：,2.,诊断依据：按症状、体征、各项支持诊断的辅助检查顺序列出。,(,二,),鉴别诊断（,同系统或同症状,）。,(,三,),进一步检查。,(,四,),治疗原则,可以归纳为一般治疗，内科治疗和外科治疗。,循环系统疾病诊断公式,（一）心衰,颈静脉充盈,+,肝大和肝颈静脉反流征阳性,+,双下肢水肿,=,右心衰,突发严重呼吸困难,+,咳粉红色泡沫痰,+,皮肤苍白,+,双肺底干、湿罗音、喘鸣音,=,急性左心衰,（,二）心律失常,P,波提前出现,+QRS,波形态正常,+,不完全代偿间歇,=,房性期前收缩（房早）,S1,强弱不等、心律绝对不齐,+,脉搏短绌,+ECG,示,P,波消失、代之以,f,波,=,房颤,宽大畸形,QRS,波提前出现,+,无相关,P,波,+,完全代偿间歇,=,室性期前收缩（室早）,QRS-T,波消失,+,大小不等的低小波（心率,250,500,次,/,分）,=,室颤,青中年患者,+,阵发性心慌,+,突发突止,+ECG,（,QRS,波室上型,+,未见明显,P,波）,=,阵发性室上速,窦性心搏的,PR,间期短于秒,+,某些导联,PR,间期超过秒、,QRS,波起始部粗钝,+ST-T,与,QRS,波主波方向相反,=,预激综合征,P,波、,QRS,波完整,+PR,间期秒,=,一度房室传导阻滞,PR,间期逐渐延长,+,直至第,1,个,QRS,波脱漏,+,改善后周而复始,=,二度,型房室传导阻滞,PR,间期恒定,+,部分,P,波后无,QRS,波,=,二度,型房室传导阻滞,P,波与,QRS,波毫无关系,+QRS,波宽大畸形,=,三度房室传导阻滞,（三）心脏骤停,意识突然丧失,+,呼吸断续至停止,+,皮肤发绀,+,瞳孔散大,+,二便失禁,=,心脏骤停,意识突然丧失,+,急性发作后,1,小时内死亡,=,怀疑心脏性猝死,（四）高血压,血压水平的定义和分类,类别 收缩压（,mmHg,） 舒张压（,mmHg,）,正常血压 ,120,80,正常高值,120,139 80,89,1,级高血压（轻度）,140,159 90,99,2,级高血压（中度）,160,179 100,109,3,级高血压（重度） ,180,110,单纯收缩期高血压 ,140,90,高血压患者心血管危险分层标准,危险因素和病史,1,级,2,级,3,级,S,BP,140-159,或,D,BP,90-99 S,BP,160-179,或,D,BP,100-109 S,BP,180,或,D,BP,110,：无其他危害因素,低危 中危,高危,：,1-2,个危险因素,中危,中危 极高危,：,3,个危险因素,或靶器官损害或糖尿病,高危 高危 极高危,：并存临床情况,极高危 极高危 极高危,（五）,冠心病,中老年患者,+,吸烟史,+,胸痛,3,5,分钟,+,服用硝酸甘油,缓解,+ST,段水平下移,=,心绞痛,中老年患者,+,吸烟史,+,胸痛,30,分钟,+,服用硝酸甘油,不缓解,+ST,段弓背抬高,=,心肌梗死,V1,V6,广泛前壁心梗,V1,V3,前间壁心梗,V3,V5,局限前壁心梗,、,、,aVF,下壁心梗,、,aVL,高侧壁心梗,V5,V6,、,、,aVL,前侧壁心梗,（六）心脏瓣膜病,主要瓣膜杂音,病名 出现时期 杂音性质,二狭 舒张期 隆隆样,主闭 舒张期 叹气样,二闭 收缩期 吹风样,主狭 收缩期 喷射样,心脏瓣膜听诊顺序及听诊部位,心脏瓣膜听诊区 听诊部位,二尖瓣区（,M,） 心尖区（心尖搏动最强点）,肺动脉瓣区（,P,） 胸骨左缘第,2,肋间,主动脉瓣区（,A,） 胸骨右缘第,2,肋间,主动脉瓣第二听诊区（,A,） 胸骨左缘第,3,肋间,三尖瓣区（,T,） 胸骨左缘第,4,、,5,肋间,（七）炎症,青年,+,上感染症状,+,急性左心衰,+,心大,+ST,段水平压低,+,血清肌钙蛋白、,CK-MB,+,病毒抗体滴度,=,心肌炎,心前区疼痛,+,心包摩擦音,=,纤维蛋白性心包炎（“干性心包炎”）,（八）休克,P,、,Bp,+,脉搏细速、四肢发凉,=,休克体征,出血,+ P,、,Bp,+,四肢湿冷、脉压变小,=,失血性休克,左心衰,+,休克体征,=,心源性休克,T38,+,心率,90,次,/,分,+,呼吸,20,次,/,分、,PaCO,2,35mmHg+WBC1210,9,/L=,全身炎症反应综合征,全身炎症反应综合征,+,休克体征,=,感染性休克,三、循环系统病例分析,Case1,Name:,LiuHui,Age:,60 years old,Sex:,Female,Chief complaint:,Paroxysmal pain ex-area in cardiac loop for five years, aggravated for half a month.,Present history:,The patient has had paroxysmal pain ex-area in cardiac loop for five years . The pain last for 2-3 minutes , then disappeared . Half a month ago, the symptom aggravated . The pain is a stuffy pain(,闷痛,),locating behind the sternum , and spreading to the mandible(,下颌,),lasting for 5-10 minutes , it can be abated by rest . The pain attack after he walked for 50 meters . During the course , there is no cough, no sputum , no pant(,喘息,). He came to our hospital for further therapy.,Past medical history:,The patient has hypertensions for 3 years,，,the highest bp is 180/100mmHg,，,never had any medicine,。,Heart disease for 20 years, no allelgic history of drug and food, no history of operation and injury, no history of tuberculosis contact.,Personal history:,He had no hobby of alcohol or cigarette.,Family history:,The patient denied the history of familial diseases.,Physical examination,T 36.7C,P 68bpm,R 17bpm,BP 150/90mmHg.The patient is in Full development, good nutritional ,he is consciousness and clear speech , and cooperation to examination. Normal breath sound. No abnormal rales are heard. The heart rhythm is regular, heart rate is 72 bpm, no murmurs, The cordis sound is abated,（减弱）,. His abdomen is soft , he has no tenderness and rebound tenderness, liver and spleen are not palpable.,Laboratory tests:,ECG：ST-T abnormal.,Questions,1.What is your primary diagnosis?,2.And your diagnosis basis?,3. What is your differential diagnosis？,4.If your diagnosis are right,whats your further examination?,5.Give some treatment principle.,1.What is your primary diagnosis?,Answer,：,1,）,coronary heart disease,angina,（心绞痛）,2,）,Hypertension level 3,（,extremely high risk,）,2.And your diagnosis basis?,Answer,：,1,）,Old female, paroxysmal pain in cardiac loop for five years.The pain last for 2-3 minutes, aggravated for half month, can be abated by rest.,2,）,The patient has hypertensions for 3 years,，,the highest bp is 180/100mmHg,，,never had any medicine.,3),Physical examination:,BP 150/90mmHg,4) ECG,：,ST-T abnormal,3.,What is your,differential diagnosis,？,1)Acute myocadial infarction,2) Intercostal neuralgia,（肋间神经痛）,3) cholecystalgia(,胆绞痛,),4.,If your diagnosis are right,whats your further examination?,Answer,：,1,）,Electrocardiogram,2,）,Coronary angiography or CTA,3,）,Myocardial enzyme,4,）,echocardiogram,5,）,Abdominal ultrasound,5.Give some treatment principle.,1)Rest,oxygen,salt limiting（限盐）,2)Control hypertention,3) Expanding drugs （扩血管药物）such as nitrate（硝酸酯类）,Case2,Male, 80 years old.,Chief complaint: paroxysmal chest pain for 2 years , aggrevate for 20 days and syncope（昏厥） 1 time.,Present history,:,2 years ago ,the patient had retrosternal pain after fast walking , stuffy pain ,located at the middle segment of the sternum, rest after about 3 5 minutes the pain gradually relieved.20 days ago retrosternal stuffy pain appeared again after walking accompanied by sweat, pain significantly worse than before, the symptom remission after rest about 20 minutes.The attacks was frequently than before.10 days ago, the patient was awareness suddenly on the way home, fall to the ground, urinary incontinence, the duration was unknown, without nausea vomiting, no physical activity dysfunction.After he wake up retrosternal pain was sustained accompanied by sweat, For further diagnosis and treatment he was sent to our hospital.,Past history:,Hypertension for 30years,，,the highest bp is 180/120mmHg,had Nifedipine Tablets 30mg/d.No drug and food allergies.,Physical examination,T 36.5C, P 104bpm R20 bpm, BP179/97 mmHg, SPO2 90%, The patient is consciousness and clear speech,and cooperation to examination. Normal breath sound. No abnormal rales are heard. Heart rate is 104 bpm,Premature beat can be heard,about 4-5 times / minute, no murmurs, His abdomen is soft , he has no tenderness and rebound tenderness, liver and spleen are not palpable. bilateral Hoffmann sign was negative.,Auxiliary examination,辅助检查,:,Blood routine:WBC 9.8*10,9,/L, N 59.4% Hb 127 g / L, PLT 191*10,9,/L, HCT 38.5%.,Glu 6.6 mmol / L, K,+,3.3 mmol / L, Na,+, 138 mmol / L, Cl,-,102 mmol / L, lac 4.0 mmol / L,ECG as follows:,Questions:,1.What is your primary diagnosis?,2.And your diagnosis basis?,3. What is your differential diagnosis？,4.If your diagnosis are right,whats your further examination?,5.Give some treatment principle.,1.What is your primary diagnosis?,Answer,：,1,）,acute myocardial infarction(high lateral wall ),2,）,arrhythmia,3) Hypertension level 3,（,extremely high risk,）,2.And your diagnosis basis?,Answer,：,1) retrosternal pain after fast walking , stuffy pain, can be relieved by rest for 2years.And aggrevated for 20 days ago.Syncope for 1 time 10 days ago.,2) Hypertension for 30years,，,the highest bp is 180/120mmHg,had Nifedipine Tablets 30mg/d,3),P 104bpm, BP179/97 mmHg, SPO2 90%, Heart rate is 104 bpm,Premature beat can be heard,about 4-5 times / minute,4)I,、,aVL lead see a pathological Q wave,Premature beat 4-5 times/ min and sinus tachycardia can be seen in ECG.,3.What is your differential diagnosis？,1) angina pectoris（心绞痛）,2) dissection of aorta（主动脉夹层）,3) acute abdominal disease,4) acute pulmonary embolism,4.,If your diagnosis are right,whats your further examination?,Answer,：,1,）,18 lead ECG,2,）,Myocardial enzyme,3,）,echocardiogram,4,）,blood gas analysis,5.Give some treatment principle.,1)oxygen, ECG monitoring, and intravenous access established.,2) Relieve pain like morphine,3)anti-platelet : aspirin tablets 300mg, clopidogrel氯吡格雷300mg oral.,4) Expanding drugs such as nitrate,5) Anticoagulation such as heparin,6) Reperfusion therapy:PCI,7)anti-shock,执业医师实践技能考试病例分析真题,病例摘要,1,男性，,55,岁，胸骨后压榨性痛，伴恶心、呕吐,2,小时,患者于,2,小时前搬重物时突然感到胸骨后疼痛，压榨性，有濒死感，休息与口含硝酸甘油均不能缓解，伴大汗、恶心，呕吐过两次，为胃,内容物，二便正常。既往无高血压和心绞痛病史，无药物过敏史，吸烟,20,余年，每天,1,包,查体：,T36.8,P100,次,/,分，,R20,次,/,分，,BP100/60mmHg,，急性痛苦病容，平卧位，无皮疹和紫绀，浅表淋巴结未触及，巩膜不黄，颈软，颈静脉无怒张，心界不大，心率,100,次,/,分，有期前收缩,5-6,次,/,分，心尖部有,S4,， 肺清无啰音，腹平软，肝脾未触及，下肢不肿。,心电图示：,STV1-5,升高，,QRSV1-5,呈,Qr,型，,T,波倒置和室性早搏。,思考题,1.,诊断及诊断依据？,2.,鉴别诊断？,3.,进一步检查？,4.,治疗原则？,诊断,冠心病、急性前壁心肌梗死,室性期前收缩,心功能,级,诊断依据,1.,典型心绞痛而持续,2,小时不缓解，休息与口含硝酸甘油均无效，有吸烟史,2.,心电图示急性前壁心肌梗死，室性期前收缩,3.,查体心界不大，有期前收缩，心尖部有,S4,鉴别诊断,1.,夹层动脉瘤,2.,心绞痛,3.,急性心包炎,进一步检查,1.,继续心电图检查，观察其动态变化,2.,化验心肌酶谱,3.,凝血功能检查，以备溶栓抗凝治疗,4.,化验血脂、血糖、肾功,5.,恢复期作运动核素心肌显像、,Holter,、超声,心动图检查，找出,高危因素，作冠状动脉造影与介入性治疗,治疗原则,1.,绝对卧床休息,3-5,天，持续心电监护，低脂半流食，保持大便通畅,2.,溶栓治疗：发病,6,小时内，无出凝血障碍及溶栓禁忌证，可用尿激酶、,链激酶或,t-PA,溶栓治疗；抗凝治疗：溶栓后用肝素静滴，口服阿期匹林,3.,吸氧，解除疼痛：哌替啶或吗啡，静滴硝酸甘油；,消除心律失常：利多卡因,4.,有条件和必要时行介入治疗,病例摘要,2,男性，,65,岁，持续心前区痛,4,小时。,4,小时前即午饭后突感心前区痛，伴左肩臂酸胀，自含硝酸甘油,1,片未见好转，伴憋气、乏力、出汗，二便正常。既往高血压病史,6,年，最高血压,160/100mmHg,，未规律治疗，糖尿病史,5,年，一直口服降糖药物治疗，无药物过敏史，吸烟,10,年，每日,20,支左右，不饮酒。,查体：,T37,，,P100,次,/,分，,R24,次,/,分，,Bp150/90mmHg,，半卧位，无皮疹及出血点，全身浅表淋巴结不大，巩膜无黄染，口唇稍发绀，未见颈静脉怒张，心叩不大，心律,100,次,/,分，律齐，心尖部,/6,级收缩期吹风样杂音，两肺叩清，两肺底可闻及细小湿罗音，腹平软，肝脾未及，双下肢不肿。,化验：,109/L,分类：中性分叶粒,72%,，淋巴,26%,，单核,2%,，,plt250,109/L,尿蛋白微量，尿糖,(+),尿酮体,(-),，镜检,(-),思考题,1.,诊断及诊断依据？,2.,鉴别诊断？,3.,进一步检查？,4.,治疗原则？,诊断,1.,冠心病急性心肌梗死心不大,急性左心衰竭,2.,高血压病,1,级，极高危险组,3.,糖尿病,诊断依据,1.,老年男性，持续心绞痛,4,小时不缓解，口服硝酸甘油无效,2.,有急性左心衰表现：憋气、半卧位，口唇稍发绀，两肺底细小湿罗音,3.,高血压病,期（,1,级、极高危险组），有糖尿病和吸烟等冠心病危险因素,鉴别诊断,(5,分,),1.,心绞痛,2.,高血压心脏病,3.,夹层动脉瘤,进一步检查,(4,分,),1.,心电图、心肌酶谱,2.,床旁胸片、超声心动图,3.,血糖、血脂、血电解质、肝肾功能、血气分析,治疗原则,(3,分,),1.,心电监护和一般治疗：包括吸氧等,2.,治疗急性左心衰竭和止痛（吗啡或哌替啶）、,利尿剂、血管扩张剂,3.,溶栓和抗凝治疗,4.,糖尿病治疗可加用胰岛素,5.,高血压暂不处理，注意观察,病例摘要,3,男性，,60,岁，心前区痛,1,周，加重,2,天。,1,周前开始在骑车上坡时感心前区痛，并向左肩放射，经休息可缓解，,2,天来走路快时,亦有类似情况发作，每次持续,3-5,分钟，含硝酸甘油迅速缓解，为诊治来诊，发病以来进食,好，二便正常，睡眠可，体重无明显变化。既往有高血压病史,5,年，血压,150-180/90-100mmHg,，,无冠心病史，无药物过敏史，吸烟十几年，,1,包,/,天，其父有高血压病史,。,查体：，,P84,次,/,分，,R18,次,/,分，,Bp180/100mmHg,，一般情况好，无皮疹，浅表,淋巴结未触及，巩膜不黄，心界不大，心率,84,次,/,分，律齐，无杂音，肺叩清，无啰音，腹,平软，肝脾肋下未触及，下肢不肿。,思考题,1.,诊断及诊断依据？,2.,鉴别诊断？,3.,进一步检查？,4.,治疗原则？,诊断,1.,冠心病：不稳定性心绞痛,(,初发劳力型,),心功能,级,2.,高血压病,3,级，极高危险组,诊断依据,1.,冠心病,典型心绞痛发作，既往无心绞痛史，在一个月内新出现的,由体力活动所诱发的心绞痛，休息和用药后能缓解,查体：心界不大，心律齐，无心力衰竭表现,。,2.,高血压病,期,(3,级，极高危险组）,血压达到,3,级，高血压标准,(,收缩压,180mmHg),而,未发现其他引起高血压的原因，有心绞痛,。,鉴别诊断,(,5,分,)1.,急性心肌梗死,2.,反流性食管炎,3.,心肌炎、心包炎,4.,夹层动脉瘤,进一步检查,(4,分,),1.,心绞痛时描记心电图或作,Holter,2.,病情稳定后，病程大于,1,个月可作核素运动心肌显像,3.,化验血脂、血糖、肾功能、心肌酶谱,4.,眼底检查，超声心动图，必要时冠状动脉造影,治疗原则,(3,分,),1.,休息，心电监护,2.,药物治疗：硝酸甘油、消心痛、抗血小板聚集药,3.,疼痛仍犯时行抗凝治疗，必要时,PTCA,治疗,病例摘要,3,男性，,61,岁，渐进性活动后呼吸困难,5,年，明显加重伴下肢浮肿,1,个月,5,年前，因登山时突感心悸、气短、胸闷，休息约,1,小时稍有缓解。以后自觉体力日渐,下降，稍微活动即感气短、胸闷，夜间时有憋醒，无心前区痛。曾在当地诊断为“心律不整”，,服药疗效不好。,1,个月前感冒后咳嗽，咳白色粘痰，气短明显，不能平卧，尿少，颜面及两,下肢浮肿，腹胀加重而来院。,既往,20,余年前发现高血压,(170/100mmHg),未经任何治疗，,8,年前有阵发心悸、气短发,作；无结核、肝炎病史，无长期咳嗽、咳痰史，吸烟,40,年，不饮酒。,查体：,P72,次,/,分，,R20,次,/,分，,Bp160/96mmHg,，神清合作，半卧位，口唇轻,度发绀，巩膜无黄染，颈静脉充盈，气管居中，甲状腺不大；两肺叩清，左肺可闻及细湿罗,音，心界两侧扩大，心律不整，心率,92,次,/,分，心前区可闻,/6,级收缩期吹风样杂音；腹,软，肝肋下，有压痛，肝颈静脉反流征,(+),，脾未及，移动浊音,(-),，肠鸣音减弱；双,下肢明显可凹性水肿。,化验：血常规,Hb129g/L,WBC6.7109/L,尿蛋白,(-),，比重，镜检,(-),，,BUN7.0mmol/L,Cr113umol/L,肝功能。,思考题,1.,诊断及诊断依据？,2.,鉴别诊断？,3.,进一步检查？,4.,治疗原则？,诊断,1.,高血压性心脏病：心脏扩大，心房纤颤，心功能,IV,级,2.,高血压病,2,级，极高危险组,3.,肺部感染,诊断依据,1.,高血压性性心脏病：,高血压病史长，未治疗；左心功能不全,(,夜间憋醒，不能平卧）；右心功能不全,(,颈静脉充盈，肝大和肝颈静脉反,流征阳性，双下肢水肿）；心脏向两侧扩大，心律不整，,心率,脉率,2.,高血压病,期,(2,级，极高危险组,),二十余年血压高,(170/100mmHg);,现在,Bp160/100mmHg,；,心功能,IV,级,3.,肺部感染：咳嗽，发烧，一侧肺有细小湿罗音,鉴别诊断,(5,分,),1.,冠心病,2.,扩张性心肌病,3.,风湿性心脏病二尖瓣关闭不全,进一步检查,(4,分,),1.,心电图、超声心动图,线胸片，必要时胸部,CT,3.,腹部,B,超,4.,血,A/G,，,血,K+,，,Na+,，,Cl-,治疗原则,(3,分,),1.,病因治疗：合理应用降血压药,2.,心衰治疗：吸氧、利尿、扩血管、强心药,3.,对症治疗：控制感染等,四、练习题,1.,诊断冠心病最常用的非创伤性检查方法是,A,休息时心电图,B,24,小时动态心电图,C,心电图运动负荷试验,D,超声心动图,E,心脏,CT,检查,C,2.,风湿性心脏病二尖瓣狭窄最具诊断价值的检查是,A,心电图检查,B,胸部,X,线摄片,C,血沉检查,D,抗,O,检查,E,心脏听诊,E,3.,急性心肌梗死早期最重要的治疗措施是,A,抗心绞痛,B,消除心律失常,C,补充血量,D,心肌再灌注,E,增加心肌营养,D,4.,单纯左心衰竭的典型体征是,A,下垂性对称性水肿,B,肝颈静脉回流征阳性,C,双肺底闻及湿哕音,D,胸腔积液,E,颈静脉怒张,C,5.,不属于冠心病主要危险因素的是,A,吸烟,B,高血压,C,酗酒,D,年龄,E,高胆固醇血症,C,6.,发现心包积液最简便准确的方法是,A,心电图,B,超声心动图,C,冠状动脉造影,D,核素心肌显像,E,心包穿刺,B,7.,男性，,61,岁。患有高血压，同时伴有,2,型糖尿病，尿蛋白,(+),。选择最佳降压药物为,A,利尿剂,B,钙离子拮抗剂,C,ACEI,D,a,受体阻滞剂,E,8,受体阻滞剂,C,8.,男性，,40,岁，腹痛、发热,48,小时，血压,80/ 60mmHg,，神志清醒，面色苍白，四肢湿冷，全腹肌紧张，肠鸣音消失，诊断为,A,低血容量性休克,B,感染性休克,C,神经源性休克,D,心源性休克,E,过敏性休克,B,9.,男性，,49,岁。晚上饱餐饮酒后突然出现胸骨后压榨性疼痛，持续半小时不缓解，伴出汗、,恶心、呕吐来诊。首先采用的诊断方法是,A,腹部,B,超,B,胸部,X,线,C,化验血常规,D,心电图,E,尿淀粉酶检查,D,10.,急性下壁心肌梗死最易合并,A,室性早搏,B,房室传导阻滞,C,心房颤动,D,房性心动过速,E,右束支传导阻滞,11.,女性，,38,岁。活动后心悸、气喘,1,年余，查体轻度贫血，心率快，律整，胸骨右缘第,2,肋间闻及响亮而粗糙的收缩期杂音（,级），首先应想到的疾病为,A,动脉导管未闭,B,主动脉瓣关闭不全,C,二尖瓣关闭不全,D,室间隔缺损,E,主动脉瓣狭窄,12.,患者男性，,64,岁。头晕、心悸,4,5,年，心尖搏动向左下移位，呈抬举性搏动，于胸骨左缘第,3,、,4,肋间闻及叹气样舒张期杂音，为递减型，向心尖传导，在心尖部闻及隆隆样舒张早期杂音，股动脉可闻及射枪音，首先应想到的诊断为,A,二尖瓣狭窄,B,主动脉瓣关闭不全,C,二尖瓣关闭不全,D,主动脉瓣狭窄,E,室间隔缺损,13.,男性，,40,岁，,10,小时前搬重物时突发上胸部疼痛，呈撕裂样，并逐渐向下胸部和腹部延伸。高血压病史,15,年。查体：,T 36.3,，,BP 170/lOOmmHg,（左上肢），,BP,（右上肢）,140/75mmHg,（右上肢）。心率,105,次分，心律齐。腹平软，,Murphy,征阴性。,CK-MB,正常。心电图：正常。胸部,X,线片显示主动脉明显增宽。该患者胸痛最可能的病因是,A,急性心肌梗死,B,变异型心绞痛,C,主动脉夹层,D,急性胆囊炎,E,急性心包炎,14.,女性，,32,岁。有心脏病病史,4,年。最近感到心悸，听诊发现心率,100,次分，心律绝对不齐，第一心音强弱不等，心尖部有舒张期隆隆样杂音。听诊的发现最可能是,A,窦性心律不齐,B,窦性心动过速,C,心房颤动,D,室性早搏,E,房性早搏,15.,男性，,40,岁，腹痛、发热,48,小时，血压,80/ 60mmHg,，神志清醒，面色苍白，四肢湿冷，全腹肌紧张，肠鸣音消失，诊断为,A,低血容量性休克,B,感染性休克,C,神经源性休克,D,心源性休克,E,过敏性休克,16.,住院第,2,日患者出现胸闷、大汗、面色苍白，体检心率,126,次分，律齐，双肺未闻及干湿哕音，血压,90/60mmHg,，考虑合并心源性休克。此时不宜使用,A,主动脉内球囊反搏术,B,静注呋塞米,C,静滴多巴胺,D,静滴多巴酚丁胺,E,皮下注射低分子肝素,谢谢观赏！,2020/11/5,80,