胡大一:说说过度检查、过度治疗

2017-05-31 胡大一 胡大一大夫

人们总说基层医疗水平不够高,这些临床上让人哭笑不得的荒唐故事都发生在省级医院,最主要问题是忽视基本功。


近期在家乡河南走基层,在济源看到两例患者。

患者1,女性,61岁,三年前无任何不适,查体心电图发现室性早搏,后做动态心电图,24小时500多个室性早搏。此后,开始出现心悸、心慌,无胸痛和胸闷,入睡困难,不时会自己摸脉搏,无高血压,血糖正常,血脂正常,不吸烟,无冠心病早发家族史,超声心动图正常。用美托洛尔出现哮喘加重,改用胺碘酮后严重腹部不适,不能耐受。近复查动态心电图,24小时室性早搏8000多次。患者高度紧张,到郑州三甲医院看病,门诊看后即收住院(挂的专家是做冠心病介入的),次日做了冠状动脉造影,结果完全正常,将患者转回济源。

这个造影是典型的过度检查!

(1)患者为无任何冠心病危险因素的女性;

(2)无胸闷或胸痛,根本无冠状动脉造影的适应证。

多亏转回了基层医院,未转给省医院的电生理病房,至少免除了导管消融过度手术的可能。

这位患者症状发生在体检发现早搏之后,而且越来越过度关注早搏,符合“虑病”的焦虑症状。治疗应针对焦虑,而非直接针对早搏。更不宜用毒副作用大的胺碘酮。

这位患者早搏,既非器质性心脏病,也无风险,最好的治疗是不治疗(不针对早搏治疗)。而是耐心和患者“话疗”,讲明早搏的良性,让患者放心,安心与早搏“为伴”,而不是“为敌”。

患者2,男性21岁,大学三年级学生,学习紧张、熬夜后,间断出现胸闷,心悸,左手小拇指与无名指发麻,运动中从未发生过上述不适,无高血压,无糖尿病,血脂正常,无冠心病早发家族史,体重理想。

到省医院看病,立即给患者做了冠状动脉CT,冠状动脉各分支无狭窄,左回旋支肌桥。由于患者家长不清楚肌桥是什么问题,对孩子的病放心不下,问医生如何处理?回答是建议做PET,必要时可手术治疗。

听了这些建议,家长更为紧张。通过郑州我北医的老同学打听到当日我正在济源,家长带着孩子连夜赶到济源。我与北大六院梁军大夫一起看了患者,明确告知家长,孩子根本不是冠心病心绞痛,冠状动脉CT是典型过度检查,肌桥不必处理,PET不需要做。平时坚持运动,如健走,注意有足够睡眠,症状发作时可即刻用一片劳拉西泮。

这是一个十分荒唐的检查治疗流程。人们总说基层医疗水平不够高,这些临床上让人哭笑不得的荒唐故事,都发生在省级医院,博士专家正高最多的医院,设备最现代化的医院。最主要问题是忽视基本功,忽视甚至忽略诊治疾病最基本环节——问诊(症状学)

为什么给一个没有危险因素,症状根本不是心绞痛的年青人做冠状动脉CT?不但无益,而且射线对年青孩子带来一生的影响。肌桥需要做PET么?肌桥需要手术么?这不是在为患者解除疾苦,而是在用高成本、有危害的检查技术,加上信口开河的不负责任的解释,在制造“医源性疾病”!

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    2019-04-03 125a288cm13暂无昵称

    学习了,谢谢分享

    0

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    2017-05-31 daiyaozu

    学习了,不错

    0

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    2017-05-31 flyingzyx

    看起很怕

    0

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    2017-05-31 惠映实验室

    浪费公共资源,误治

    0

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    2017-05-31 楠博One

    医院也要吃饭过日子,医生也有任务和指标

    0

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