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男，32岁，冠心病心绞痛间断发作胸闷病例

2020-06-29 刘医生 病例网

冠状动脉粥样硬化性心脏病心绞痛
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本次发病于1月前，患者无明显诱因出现胸闷，位于剑突下呈憋闷感，呈间断性发作，偶有心悸，日常劳作即可发作，休息后症状约1分钟可自行缓解，无胸痛汗出，无恶心呕吐，无烧心反酸，无肩背部放射痛，在当地口服药物

[患者姓名]：略 
[患者年龄]：32
[性别]：男
[科室]：心血管内科

【主诉】

患者主因"间断发作胸闷1月余"入院；

【现病史】

本次发病于1月前，患者无明显诱因出现胸闷，位于剑突下呈憋闷感，呈间断性发作，偶有心悸，日常劳作即可发作，休息后症状约1分钟可自行缓解，无胸痛汗出，无恶心呕吐，无烧心反酸，无肩背部放射痛，在当地口服药物治疗﹙具体不详﹚，上述症状仍反复发作，今为进一步诊治而来院。现症：胸闷，舌质淡，苔白，脉沉细。自发病以来，神清，精神稍差，饮食及睡眠稍差，大小便未见明显异常。

【既往史】

既往体健，否认心脏病，高血压、糖尿病病史。否认肝炎、结核等传染病史；否认药、食物过敏史；否认重大外伤及手术史，否认输血史；预防接种史不详。

【查体】

T:36.3℃,P:78次/分,R:19次/分,BP:151/80mmhg。神志清，精神稍差，呼吸平稳，口唇无紫绀，双侧颈静脉无充盈，颈动脉无异常搏动，双侧肺呼吸音粗，未闻及干湿性啰音，心率78次/分，律齐，心音低钝，未闻及杂音，腹软，无压痛，肝脾肋下未触及，双下肢无浮肿，四肢肌力5级，肌张力正常，双侧巴氏征阴性。

【辅助检查】

心电图：窦性心律，T波改变。

[图片与造影]

【初步诊断】

1.冠状动脉粥样硬化性心脏病心绞痛

【鉴别诊断】

1.主动脉夹层胸痛一开始即达高峰，常放射到背、肋、腹、腰和下肢，两上肢的血压和脉搏可有明显差别，可有下肢暂时性瘫痪、偏瘫和主动脉瓣关闭不全的表现，但无血清心肌坏死标记物升高等可资鉴别。二维超声心动图检查、X线或磁共振体层显像有助于诊断。

2.急性肺动脉栓塞可发生胸痛、咯血、呼吸困难和休克。但有右心负荷急剧增加的表现如发绀、肺动脉瓣区第二心音亢进、颈静脉充盈、肝大、下肢水肿等。心动图I导联S波加深，III导联Q波显著T波倒置，胸导联过度区左移，右胸导联T波倒置等改变，可资鉴别。

【诊治经过】

入院后给予中医科护理常规、Ⅱ级护理、低盐低脂饮食、留陪人、测血压；治疗上给予静点香丹注射液、西咪替丁注射液、水溶性维生素等以活血化瘀及对症支持治疗；配合静脉给氧治疗以增加心脑氧供应。

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#插入话题
  1. [GetPortalCommentsPageByObjectIdResponse(id=1632810, encodeId=9f2f163281026, content=<a href='/topic/show?id=10a09e25096' target=_blank style='color:#2F92EE;'>#间断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97250, encryptionId=10a09e25096, topicName=间断)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c86a21951359, createdName=TZF0811, createdTime=Fri Feb 12 02:13:39 CST 2021, time=2021-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=894437, encodeId=da5589443e78, content=是呀，我35也有了冠心病, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bf435331051, createdName=148ccaa6m02暂无昵称, createdTime=Sun Oct 25 23:56:01 CST 2020, time=2020-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=813468, encodeId=8aa5813468b8, content=<a href='/topic/show?id=77c33081e40' target=_blank style='color:#2F92EE;'>#冠心病#</a>近年来年轻人得冠心病的越来越多了, beContent=null, objectType=article, channel=null, level=null, likeNumber=217, replyNumber=1, topicName=null, topicId=null, topicList=[TopicDto(id=30817, encryptionId=77c33081e40, topicName=冠心病)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Wed Aug 26 16:38:56 CST 2020, time=2020-08-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1341026, encodeId=eed9134102677, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, 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=Wed Jul 01 01:13:39 CST 2020, time=2020-07-01, status=1, ipAttribution=)]
    2021-02-12 TZF0811

    #间断#

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1632810, encodeId=9f2f163281026, content=<a href='/topic/show?id=10a09e25096' target=_blank style='color:#2F92EE;'>#间断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97250, encryptionId=10a09e25096, topicName=间断)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c86a21951359, createdName=TZF0811, createdTime=Fri Feb 12 02:13:39 CST 2021, time=2021-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=894437, encodeId=da5589443e78, content=是呀，我35也有了冠心病, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bf435331051, createdName=148ccaa6m02暂无昵称, createdTime=Sun Oct 25 23:56:01 CST 2020, time=2020-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=813468, encodeId=8aa5813468b8, content=<a href='/topic/show?id=77c33081e40' target=_blank style='color:#2F92EE;'>#冠心病#</a>近年来年轻人得冠心病的越来越多了, beContent=null, objectType=article, channel=null, level=null, likeNumber=217, replyNumber=1, topicName=null, topicId=null, topicList=[TopicDto(id=30817, encryptionId=77c33081e40, topicName=冠心病)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Wed Aug 26 16:38:56 CST 2020, time=2020-08-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1341026, encodeId=eed9134102677, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, 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=Wed Jul 01 01:13:39 CST 2020, time=2020-07-01, status=1, ipAttribution=)]
    2020-10-25 148ccaa6m02暂无昵称

    是呀，我35也有了冠心病

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1632810, encodeId=9f2f163281026, content=<a href='/topic/show?id=10a09e25096' target=_blank style='color:#2F92EE;'>#间断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97250, encryptionId=10a09e25096, topicName=间断)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c86a21951359, createdName=TZF0811, createdTime=Fri Feb 12 02:13:39 CST 2021, time=2021-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=894437, encodeId=da5589443e78, content=是呀，我35也有了冠心病, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bf435331051, createdName=148ccaa6m02暂无昵称, createdTime=Sun Oct 25 23:56:01 CST 2020, time=2020-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=813468, encodeId=8aa5813468b8, content=<a href='/topic/show?id=77c33081e40' target=_blank style='color:#2F92EE;'>#冠心病#</a>近年来年轻人得冠心病的越来越多了, beContent=null, objectType=article, channel=null, level=null, likeNumber=217, replyNumber=1, topicName=null, topicId=null, topicList=[TopicDto(id=30817, encryptionId=77c33081e40, topicName=冠心病)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Wed Aug 26 16:38:56 CST 2020, time=2020-08-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1341026, encodeId=eed9134102677, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, 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=Wed Jul 01 01:13:39 CST 2020, time=2020-07-01, status=1, ipAttribution=)]
    2020-08-26 lovetcm

    #冠心病#近年来年轻人得冠心病的越来越多了

    1

    展开1条回复
  4. [GetPortalCommentsPageByObjectIdResponse(id=1632810, encodeId=9f2f163281026, content=<a href='/topic/show?id=10a09e25096' target=_blank style='color:#2F92EE;'>#间断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97250, encryptionId=10a09e25096, topicName=间断)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c86a21951359, createdName=TZF0811, createdTime=Fri Feb 12 02:13:39 CST 2021, time=2021-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=894437, encodeId=da5589443e78, content=是呀，我35也有了冠心病, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=bf435331051, createdName=148ccaa6m02暂无昵称, createdTime=Sun Oct 25 23:56:01 CST 2020, time=2020-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=813468, encodeId=8aa5813468b8, content=<a href='/topic/show?id=77c33081e40' target=_blank style='color:#2F92EE;'>#冠心病#</a>近年来年轻人得冠心病的越来越多了, beContent=null, objectType=article, channel=null, level=null, likeNumber=217, replyNumber=1, topicName=null, topicId=null, topicList=[TopicDto(id=30817, encryptionId=77c33081e40, topicName=冠心病)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=lovetcm, createdTime=Wed Aug 26 16:38:56 CST 2020, time=2020-08-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1341026, encodeId=eed9134102677, content=<a href='/topic/show?id=27b98424ea9' target=_blank style='color:#2F92EE;'>#胸闷#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, 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=Wed Jul 01 01:13:39 CST 2020, time=2020-07-01, status=1, ipAttribution=)]
    2020-07-01 12498cb5m13暂无昵称

    #胸闷#

    0