病例讨论:头晕耳鸣胸闷心悸

2012-02-15 上海市虹桥街道社区卫生服务中心 中国医学论坛报

       病历摘要   主诉   患者,老年女性,67岁。因“反复头晕、耳鸣10年,胸闷、心悸2年,加重2周”入院。   现病史   10年前开始出现反复头晕、眼花、耳鸣,在当地医院查血压升高,最高达180/100 mmHg,曾服用珍菊降压片、钙离子拮抗剂(CCB)等治疗,但血压控制不稳定。近2年出现胸闷、心悸,近2周上述症状加重,测血压160~170/100~116&nb

    

  病历摘要

  主诉

  患者,老年女性,67岁。因“反复头晕、耳鸣10年,胸闷、心悸2年,加重2周”入院。

  现病史

  10年前开始出现反复头晕、眼花、耳鸣,在当地医院查血压升高,最高达180/100 mmHg,曾服用珍菊降压片、钙离子拮抗剂(CCB)等治疗,但血压控制不稳定。近2年出现胸闷、心悸,近2周上述症状加重,测血压160~170/100~116 mmHg。患者无劳累后胸痛、活动后气促、夜间阵发性呼吸困难、双下肢浮肿,无黑公式、晕厥。

  既往史

  否认糖尿病、脑梗塞等病史。其父有高血压病史。

  查体

  体温36.9℃,脉搏76次/分,呼吸18次/分,血压160/102 mmHg。心率76次/分,心律不齐,主动脉瓣部分心音(A2)> 肺动脉瓣部分心音(P2),主动脉瓣第1听诊区闻及收缩期杂音(2级)。其余体检无异常。

  辅助检查

  血常规、肝肾功能、血糖、电解质正常。血脂检查提示总胆固醇(TC)为5.12 mmol/L(正常值范围2.86~5.98 mmol/L),甘油三酯(TG)为1.43 mmol/L(正常值范围0.56~1.7 mmol/L),低密度脂蛋白胆固醇(LDL-C)为3.25 mmol/L(正常值范围2.07~3.12 mmol/L,老年人偏高),高密度脂蛋白胆固醇(HDL-C)为0.98 mmol/L(正常值范围 0.94~2.0 mmol/L,老年人偏高)。N端脑钠肽前体(NT-proBNP)为67 ng/L。心肌标志物、凝血功能、甲状腺功能正常。心电图提示左心室肥厚、室性早搏。24h动态心电图提示平均心率68次/分,最高心率116次/分,最低心率52次/分,室性早搏1120次和房性早搏13次。胸片、心脏超声、腹部超声、冠脉CT血管造影(CTA)、肾上腺和肾脏超声均无异常。

  诊断

  高血压病3级(极高危),高血压性心脏病,心律失常,房性早搏,室性早搏。

  入院后处理

  ① 控制体重:限制钠盐、脂肪、胆固醇的摄入,以及限制酒、蔗糖及含糖食物的摄入,同时进行有规律中等强度的体育活动,循序渐进。

  ② 限钠补钾:每人每天食盐摄入量不超过5 g,多食新鲜水果、蔬菜,香蕉、橙子富含钾,有利于防治高血压。

  ③ 生活要有规律,注意休息,保证一定的睡眠时间及质量,平衡心理,保持乐观的人生态度。

  ④ 药物治疗:厄贝沙坦片 150 mg qd。

  全科医师讨论要点

  Q1.结合病例,如何明确诊断、鉴别诊断及治疗原则?

  诊断及鉴别诊断 患者诊断为高血压病3级(极高危),临床医生应进一步明确高血压性质(原发性还是继发性)。原发性高血压以血压升高为主要临床表现,是伴或不伴多种心血管危险因素的综合征,通常简称为高血压;继发性高血压是指由某些确定的疾病或病因引起的血压升高。继发性高血压尽管所占比例并不高,但绝对人数仍相当多。继发性高血压的主要疾病和病因包括肾实质性高血压、肾血管性高血压、原发性醛固酮增多症、嗜铬细胞瘤、皮质醇增多症及主动脉缩窄等。

  治疗方案 降压治疗5点基本原则见表,具体治疗方案包括:① 健康教育;②药物治疗,如血管紧张素Ⅱ受体阻滞剂(ARB)+ CCB或血管紧张素转换酶抑制剂(ACEI)+CCB;③ 阿司匹林、他汀类药物;④ 定期随访等。

  Q2.什么是高血压的晨峰现象? 对于晨峰现象应该如何选择降压治疗策略?

  血压晨峰现象 24小时血压变异程度最大的时间段在清晨,即从睡眠状态转为清醒并开始活动时。此时的人体血压在短时间内从较低水平迅速升至较高水平,甚至达到一天内最高水平,该现象称为血压晨峰现象。

  高血压晨峰现象与神经体液因素有关,包括交感神经系统激活、肾素血管紧张素醛固酮系统激活、血浆皮质醇水平等。近年,多项研究证实,血压晨峰现象与心血管事件密切相关。研究发现,每日24小时的心血管事件(如心绞痛、心肌梗死、心源性猝死、脑血管意外等)发生率随昼夜节律而变化,心脑血管事件的夜间发生率最低,而每日上午6:00~10:00发生率最高,约占全天心血管事件数量的35%~40%,提示高血压晨峰现象在触发严重不良心血管事件中扮演着极为重要的角色。

  降压策略 由于血压晨峰是心血管事件发生的独立危险因素,因此在降压治疗中,应有效控制高血压患者清晨时段血压上升速度与幅度,抑制血压晨峰现象。控制方法包括:① 生活干预,起床后,先在床上稍坐片刻,再下床活动;起床5分钟内服药,空腹服药不影响药效或者导致胃黏膜损伤;②改善生活方式,如减肥、戒烟、限酒、限盐、坚持体育锻炼;③ 联合药物疗法与非药物疗法,合理锻炼身体和保持乐观情绪等;④ 选择合适的降压药物,尽量使用药效持续时间较长且降压平稳的药物,每日清晨起床后服药1次,不仅能控制整个 24 小时血压的平均水平,而且能有效阻遏服药后 18~24小时(最后 6小时)血压上升幅度,这是目前最佳的治疗方法;对于夜间和清晨血压难于控制的患者,可在午后或睡前再服药1次(例如,起床后服用第1次药,18:00再服药1次);对于接受联合药物治疗的患者,可分2次服用药物,以延长药物的降压时间。若有条件,则可使用药物定时释放制剂(COER),该制剂包含吸收后迅速起效的短效降压药物,患者在临睡前服用COER后,短效降压药物在清晨定时释放,控制即刻血压,COER制剂的缺点是种类较少且价格昂贵;⑤ 定时测量血压(如晨起后5分钟内、服药前测量),如果发现任何血压异常,则应及时就医和调整治疗药物。

  Q3.全科服务团队如何提高社区慢性病管理效能?

  健康宣教 全科团队应强化健康教育,提高居民知识、态度和行为(KAP)水平;各级医院应尽快建立成年人首诊测量血压制度;积极创建示范社区,筛查、建档、随诊高血压患者;成年人应经常测量血压,每年至少测量血压1次,高血压患者至少每2~3个月测压1次;对早期或轻症高血压患者,首选非药物治疗。

  定期随访 对于低中危患者,至少每6个月随访1次;对于药物治疗3个月后未达到降压目标的非高危或极高危患者,至少每3个月随访1次;对于发生药物不良反应的患者,可加用其他类药物联合治疗,如果患者药物不良反应明显,则改用其他类药物治疗。

  危险因素控制 全科医生应加强健康教育,劝患者戒烟;政府应尽快制定合理的公共场所吸烟法规;动员全社会参与戒烟。对不饮酒者,不提倡通过饮酒预防心脑血管病;对饮酒者,应控制饮酒量,不可酗酒。男性饮酒者每日饮白酒量<50 ml(1两),啤酒量<640 ml(1瓶),葡萄酒量<200 ml(4 两);女性饮酒量减半,孕妇禁止饮酒。(Q1~Q3根据潍坊社区卫生服务中心、殷行社区卫生服务中心、虹桥街道社区卫生服务中心、古美社区卫生服务中心发言综合整理,下转15版)

  (上海市长宁区虹桥街道社区卫生服务中心提供病例,讨论部分根据潍坊社区卫生服务中心、殷行社区卫生服务中心、、虹桥街道社区卫生服务中心、古美社区卫生服务中心、定海社区卫生服务中心和中山医院全科医学科发言整理,14~15版均由 杜文琪 整理,上海市浦东新区潍坊社区卫生服务中心 杜兆辉 审阅)

  上海全科医师沙龙

  特邀编委

  上海中山医院 祝公式珠 教授

 {nextpage}

  

Q4.如何理解以社区为导向的基层医疗(COPC)?

  COPC是指以个人为单位、治疗为目的的基层医疗联合以社区为单位、重视预防保健的社区医疗。该定义强调,健康服务不应该局限于个人疾病治疗,而应该注意社区环境与行为的关系,从狭义的个人健康扩展至社区人群健康。COPC比较符合现代医学模式的转变,以及多元化、多层次的慢性病防治基本要素。其特征是将全科医学理论和方法与临床医学相结合,通过社区诊断确定社区健康问题以及影响因素,设计可行的解决方案。基层医疗扮演协调者角色,运用社区资源实施社区健康项目并予以评价,保证医疗保健的可及性和连续性。

  COPC实施过程包括,确定社区人群及管理者、评价人群健康状况并做出社区诊断、确定须优先解决的健康问题并制定社区干预计划、建立慢性病患者档案,以及统计分析评估。实施阶段分为0~4级。0级:无社区概念,不了解所在社区的健康问题,仅对就医患者提供非连续性的照顾。1级:对所在社区的健康统计资料有所了解,缺乏社区内个人健康问题的资料,根据医生个人的主观印象确定健康问题的优先顺序以及解决方案。2级:对所在社区的健康问题有进一步了解,间接得到相关资料。3级:掌握90%以上的个人健康问题,可采取策略,但缺乏预防措施。4级:掌握社区与个人详细资料,建立档案,具有慢性病管理和预防措施,以及评价系统,具备协调和动员社区资源的能力。(根据定海社区卫生服务中心发言整理)

  

Q5.如何控制其他危险因素?

  结合该患者血脂检查结果,依据2007版《中国成人血脂异常防治指南》(表1),应给予调脂治疗。研究显示,高血压、高胆固醇、高血糖、吸烟、家族史、年龄增加、肥胖、体力活动不足等危险因素的协同作用,可导致血管内皮功能紊乱、氧化反应、炎症反应,进而加速动脉粥样硬化进展。弗雷明汉(Framingham)研究显示,当危险因素同时存在时,心血管事件发生风险倍增。中度高血压患者,在合并血脂升高、低HDL-C、糖尿病、吸烟、左心室肥厚等心血管危险因素时,心血管事件发生风险倍增。2007年《美国心脏学会防治缺血性心脏病高血压治疗指南》指出,无论冠心病的一级预防或二级预防,高血压患者治疗的主要目的均是为了延缓或逆转潜在动脉粥样硬化进展。因此,对于高血压患者,尤其是高血压合并危险因素者在降压同时接受抗动脉粥样硬化治疗极为重要。

  对于血压控制在正常范围的高血压患者,其冠心病风险亦高于血压正常者。一项大规模前瞻性队列研究入选686例男性高血压患者和6810例血压正常人群,随访22~23年发现,高血压患者即使血压控制良好,其冠心病死亡率仍高于无高血压人群。进一步分析发现,高血压患者总死亡率比非高血压人群高1.6 倍,其中主要是冠心病死亡率增加(20.1%对10.3%)。研究头10年,两组的总死亡率和冠心病死亡率相似,但10年后即使患者血压控制良好,其冠心病死亡率仍陡然增加。

  欧洲最大规模高血压患者冠心病一级预防研究(ASCOT)显示,对于合并≥3个危险因素(TC≤6.5 mmol/L)的10305例高血压患者,降压同时接受阿托伐他汀治疗,可进一步降低36%的冠心病发生率,27%的卒中发生率,该研究因显著获益而被提前2年结束。可见,对于高血压合并危险因素的患者,在降压基础上加用阿托伐他汀,可减少心脑血管事件发生率。(根据上海中山医院全科医生发言整理)

版权声明:
本网站所有内容来源注明为“梅斯医学”或“MedSci原创”的文字、图片和音视频资料,版权均属于梅斯医学所有。非经授权,任何媒体、网站或个人不得转载,授权转载时须注明来源为“梅斯医学”。其它来源的文章系转载文章,或“梅斯号”自媒体发布的文章,仅系出于传递更多信息之目的,本站仅负责审核内容合规,其内容不代表本站立场,本站不负责内容的准确性和版权。如果存在侵权、或不希望被转载的媒体或个人可与我们联系,我们将立即进行删除处理。
在此留言
评论区 (6)
#插入话题
  1. [GetPortalCommentsPageByObjectIdResponse(id=37348, encodeId=7a163e34810, content=What an awesome way to explain this-now I know evhnyteirg!, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=dalia, createdTime=Sun Sep 27 07:00:00 CST 2015, time=2015-09-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1986279, encodeId=006c19862e9b7, content=<a href='/topic/show?id=7454e07856a' target=_blank style='color:#2F92EE;'>#病例讨论#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70785, encryptionId=7454e07856a, topicName=病例讨论)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4cea26, createdName=yxch36, createdTime=Tue Apr 03 06:26:00 CST 2012, time=2012-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1284801, encodeId=84c6128480181, content=<a href='/topic/show?id=16134436817' target=_blank style='color:#2F92EE;'>#头晕#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44368, encryptionId=16134436817, topicName=头晕)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=917c196, createdName=sjzlzc007, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1295730, encodeId=3ae11295e30a9, content=<a href='/topic/show?id=86158052809' target=_blank style='color:#2F92EE;'>#耳鸣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80528, encryptionId=86158052809, topicName=耳鸣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3609256, createdName=zhu_jun9837, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1340987, encodeId=748c134098e92, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84247, encryptionId=27b98424ea9, topicName=胸闷)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1423715, encodeId=03c81423e15e2, content=<a href='/topic/show?id=de16510080e' target=_blank style='color:#2F92EE;'>#心悸#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51008, encryptionId=de16510080e, topicName=心悸)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55bb3833215, createdName=yeaweam, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=)]
    2015-09-27 dalia

    What an awesome way to explain this-now I know evhnyteirg!

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=37348, encodeId=7a163e34810, content=What an awesome way to explain this-now I know evhnyteirg!, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=dalia, createdTime=Sun Sep 27 07:00:00 CST 2015, time=2015-09-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1986279, encodeId=006c19862e9b7, content=<a href='/topic/show?id=7454e07856a' target=_blank style='color:#2F92EE;'>#病例讨论#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70785, encryptionId=7454e07856a, topicName=病例讨论)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4cea26, createdName=yxch36, createdTime=Tue Apr 03 06:26:00 CST 2012, time=2012-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1284801, encodeId=84c6128480181, content=<a href='/topic/show?id=16134436817' target=_blank style='color:#2F92EE;'>#头晕#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44368, encryptionId=16134436817, topicName=头晕)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=917c196, createdName=sjzlzc007, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1295730, encodeId=3ae11295e30a9, content=<a href='/topic/show?id=86158052809' target=_blank style='color:#2F92EE;'>#耳鸣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80528, encryptionId=86158052809, topicName=耳鸣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3609256, createdName=zhu_jun9837, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1340987, encodeId=748c134098e92, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84247, encryptionId=27b98424ea9, topicName=胸闷)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1423715, encodeId=03c81423e15e2, content=<a href='/topic/show?id=de16510080e' target=_blank style='color:#2F92EE;'>#心悸#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51008, encryptionId=de16510080e, topicName=心悸)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55bb3833215, createdName=yeaweam, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=)]
  3. [GetPortalCommentsPageByObjectIdResponse(id=37348, encodeId=7a163e34810, content=What an awesome way to explain this-now I know evhnyteirg!, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=dalia, createdTime=Sun Sep 27 07:00:00 CST 2015, time=2015-09-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1986279, encodeId=006c19862e9b7, content=<a href='/topic/show?id=7454e07856a' target=_blank style='color:#2F92EE;'>#病例讨论#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70785, encryptionId=7454e07856a, topicName=病例讨论)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4cea26, createdName=yxch36, createdTime=Tue Apr 03 06:26:00 CST 2012, time=2012-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1284801, encodeId=84c6128480181, content=<a href='/topic/show?id=16134436817' target=_blank style='color:#2F92EE;'>#头晕#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44368, encryptionId=16134436817, topicName=头晕)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=917c196, createdName=sjzlzc007, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1295730, encodeId=3ae11295e30a9, content=<a href='/topic/show?id=86158052809' target=_blank style='color:#2F92EE;'>#耳鸣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80528, encryptionId=86158052809, topicName=耳鸣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3609256, createdName=zhu_jun9837, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1340987, encodeId=748c134098e92, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84247, encryptionId=27b98424ea9, topicName=胸闷)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1423715, encodeId=03c81423e15e2, content=<a href='/topic/show?id=de16510080e' target=_blank style='color:#2F92EE;'>#心悸#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51008, encryptionId=de16510080e, topicName=心悸)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55bb3833215, createdName=yeaweam, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=)]
    2012-02-17 sjzlzc007
  4. [GetPortalCommentsPageByObjectIdResponse(id=37348, encodeId=7a163e34810, content=What an awesome way to explain this-now I know evhnyteirg!, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=dalia, createdTime=Sun Sep 27 07:00:00 CST 2015, time=2015-09-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1986279, encodeId=006c19862e9b7, content=<a href='/topic/show?id=7454e07856a' target=_blank style='color:#2F92EE;'>#病例讨论#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70785, encryptionId=7454e07856a, topicName=病例讨论)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4cea26, createdName=yxch36, createdTime=Tue Apr 03 06:26:00 CST 2012, time=2012-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1284801, encodeId=84c6128480181, content=<a href='/topic/show?id=16134436817' target=_blank style='color:#2F92EE;'>#头晕#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44368, encryptionId=16134436817, topicName=头晕)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=917c196, createdName=sjzlzc007, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1295730, encodeId=3ae11295e30a9, content=<a href='/topic/show?id=86158052809' target=_blank style='color:#2F92EE;'>#耳鸣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80528, encryptionId=86158052809, topicName=耳鸣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3609256, createdName=zhu_jun9837, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1340987, encodeId=748c134098e92, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84247, encryptionId=27b98424ea9, topicName=胸闷)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1423715, encodeId=03c81423e15e2, content=<a href='/topic/show?id=de16510080e' target=_blank style='color:#2F92EE;'>#心悸#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51008, encryptionId=de16510080e, topicName=心悸)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55bb3833215, createdName=yeaweam, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=37348, encodeId=7a163e34810, content=What an awesome way to explain this-now I know evhnyteirg!, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=dalia, createdTime=Sun Sep 27 07:00:00 CST 2015, time=2015-09-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1986279, encodeId=006c19862e9b7, content=<a href='/topic/show?id=7454e07856a' target=_blank style='color:#2F92EE;'>#病例讨论#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70785, encryptionId=7454e07856a, topicName=病例讨论)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4cea26, createdName=yxch36, createdTime=Tue Apr 03 06:26:00 CST 2012, time=2012-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1284801, encodeId=84c6128480181, content=<a href='/topic/show?id=16134436817' target=_blank style='color:#2F92EE;'>#头晕#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44368, encryptionId=16134436817, topicName=头晕)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=917c196, createdName=sjzlzc007, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1295730, encodeId=3ae11295e30a9, content=<a href='/topic/show?id=86158052809' target=_blank style='color:#2F92EE;'>#耳鸣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80528, encryptionId=86158052809, topicName=耳鸣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3609256, createdName=zhu_jun9837, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1340987, encodeId=748c134098e92, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84247, encryptionId=27b98424ea9, topicName=胸闷)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1423715, encodeId=03c81423e15e2, content=<a href='/topic/show?id=de16510080e' target=_blank style='color:#2F92EE;'>#心悸#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51008, encryptionId=de16510080e, topicName=心悸)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55bb3833215, createdName=yeaweam, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=)]
  6. [GetPortalCommentsPageByObjectIdResponse(id=37348, encodeId=7a163e34810, content=What an awesome way to explain this-now I know evhnyteirg!, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=dalia, createdTime=Sun Sep 27 07:00:00 CST 2015, time=2015-09-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1986279, encodeId=006c19862e9b7, content=<a href='/topic/show?id=7454e07856a' target=_blank style='color:#2F92EE;'>#病例讨论#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70785, encryptionId=7454e07856a, topicName=病例讨论)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4cea26, createdName=yxch36, createdTime=Tue Apr 03 06:26:00 CST 2012, time=2012-04-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1284801, encodeId=84c6128480181, content=<a href='/topic/show?id=16134436817' target=_blank style='color:#2F92EE;'>#头晕#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=44368, encryptionId=16134436817, topicName=头晕)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=917c196, createdName=sjzlzc007, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1295730, encodeId=3ae11295e30a9, content=<a href='/topic/show?id=86158052809' target=_blank style='color:#2F92EE;'>#耳鸣#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80528, encryptionId=86158052809, topicName=耳鸣)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=3609256, createdName=zhu_jun9837, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1340987, encodeId=748c134098e92, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84247, encryptionId=27b98424ea9, topicName=胸闷)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=838d2500169, createdName=12498cb5m13暂无昵称, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1423715, encodeId=03c81423e15e2, content=<a href='/topic/show?id=de16510080e' target=_blank style='color:#2F92EE;'>#心悸#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=22, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=51008, encryptionId=de16510080e, topicName=心悸)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55bb3833215, createdName=yeaweam, createdTime=Fri Feb 17 13:26:00 CST 2012, time=2012-02-17, status=1, ipAttribution=)]
    2012-02-17 yeaweam

相关资讯

病例讨论:发现第二性征发育异常11年,血糖升高5年

MedSci提问:该患者诊断为何病? 唐欣  周薇薇  张翼飞  孙首悦  蒋怡然  宁光   上海交通大学附属瑞金医院内分泌科   患者,男,24岁。发现第二性征发育异常11年,血糖升高5年。患者足月顺产,出生时体重2.7 kg,出生后按男孩养育,母乳喂养,自幼身高增长速度快于同龄人,成绩中等。 

病例讨论:胃上皮内肿瘤

    病理初尝   拨云见日   病历简介   患者男性,63岁,因上腹不适2个月就诊。胃镜检查显示:胃窦多发片状红斑糜烂,局部取活检。   这些细胞核的表现没有明显的异型性,不支持肿瘤性病变。再看活检表面,有些炎性分泌物,表面不完整,看不出有无成熟趋势,对诊断没有什么实质性帮助。此时,诊断遇到了很大困难,病变结构异常与细胞改变不一致,到底能否诊断上皮内肿瘤?确诊的决心很难下

病例讨论:介入还是手术?

  病例简介   患者女,27岁,因“发作性头晕、晕厥8年,胸闷1年余,加重伴胸痛2个月”于2010年7月17日入院。   既往史:否认高血压、糖尿病、冠心病、高脂血症、肝炎、结核病史;否认外伤、手术、输血史;否认药物及食物过敏史。个人史:不嗜烟酒。婚育史:G2P0,第一胎自然流产。家族史无特殊。   2002年   患者无明显诱因出现发作性头晕、视物不清,持续1~2分钟后自行好转,曾有1