论文部分内容阅读
病历介绍患者,女,62岁。10年前因家人意外身亡,心中悲伤过度,致使长期失眠、多梦、惊悸、心烦,近年又感乏力气短,劳则更甚。曾因心脏病而在乡镇卫生院住院多次,疗效甚微,于2011年12月4日就诊我室。接诊后,详细询问患者病情及治疗概况,发现患者说话时情绪激动,在脉诊和望诊中,看到患者手指和舌尖均有颤抖现象,脉搏结代不整。查体:T 36.8℃,R19次/分,P 95次/分,BP 160/90 mm Hg;听诊心脏第一心音强弱不等,三尖瓣听诊区可闻及3/6级收缩期吹风样杂音,双下肢呈凹陷性水肿;触诊气管居中,甲状腺不大;心电图示房颤,心律不齐,心率97次/分;X线拍片示心脏扩大。患者自述曾因心脏病住院,否认行甲功检查及甲亢病史,所用药物除强心、利尿剂外均为生脉、丹参、心血康等治疗心血管病的药物。我遂建议患者速去上级医院检查甲功3项,以明确诊断,对症下药。2011年12月6日,患者以“心力衰竭”住进本市某三甲医院,12月13日出院。出院诊断为:①甲亢;②甲亢性心脏病:房颤、心功能Ⅲ级、客观评定C期。出院医嘱:①低碘饮食;②继续口服药物,密切监测血压变化;③半个月后复查血常规、肝功,1个月后复查甲状腺素,不适随访。服用药物:甲硫咪唑、曲美他嗪、美托洛尔、维生素B、螺
Patient, female, 62 years old. Ten years ago, his family members accidentally died in the heart of over-sadness, resulting in long-term insomnia, dreams, horror, upset, in recent years and feel weak, labor is even worse. Had a heart attack in the township hospitals several times, with little effect, on December 4, 2011 for my room. After the admissions, patients were asked in detail about the patient’s condition and treatment profile, and found that the patient was emotionally excited when speaking. In the pulse diagnosis and observation, he saw the trembling of fingers and tongue of the patient, and the pulse generation was not complete. Examination: T 36.8 ℃, R19 beats / min, P 95 beats / min, BP 160/90 mm Hg; auscultatory heart first heart sounds vary, tricuspid auscultation can be heard and 3/6 systolic Hair-like murmur, depression of the lower extremities was edema; palpable tracheal center, small thyroid; atrial fibrillation, atrial fibrillation, arrhythmia, heart rate 97 beats / min; X ray film showed heart enlargement. Patient self-described had hospitalized for heart disease, denied a history of thyroid function and hyperthyroidism, the drugs used in addition to cardiac, diuretics are Shengmai, Salvia, such as cardiovascular health treatment of cardiovascular disease drugs. I then suggested that patients go to higher-level hospitals to check three items of acupuncture, in order to confirm the diagnosis and remedy. December 6, 2011, patients with “heart failure ” admitted to a city top three hospitals in the city, was discharged on December 13. Discharge diagnosis: ① hyperthyroidism; ② hyperthyroidism heart disease: atrial fibrillation, cardiac function grade Ⅲ, objective assessment of C phase. Discharge the doctor’s advice: ① low iodine diet; ② continue oral medication, close monitoring of blood pressure changes; ③ two weeks after the review of blood, liver function, 1 month after the review of thyroxine, ill follow-up. Taking drugs: methimazole, trimetazidine, metoprolol, vitamin B, snail