心力衰竭致血性胸水一例

患者,女,59岁。患风湿性心脏病10余年,半年来反复心悸、气促伴下肢浮肿,用强心利尿药后病情好转。4天前因劳累心悸、气促加重,稍咳,咯少量白泡状痰,问有几次粉红色泡沫痰,尿少,不能平卧。无发热、呕痛及关节痛。既往无肺结核病史。检查:体温36.2℃,呼吸28次/分,血压17.3/9.3kPa(130/70mmHg)。端坐呼吸,唇绀,颈静脉怒张,气管稍偏左,右胸下部叩实音,呼吸     

诊断思路尤重要 CT检查分辨高——1例缩窄性心包炎的误诊教训

患者男,20岁.因活动后气促2年,加重伴咳嗽、腹胀15日收入本院.患者近2年剧烈活动后气促,休息后即可缓解,未引起重视.15日前患者轻微活动后即感气促,并咳嗽,咳白色黏液痰,腹胀,纳差,无伴发热、胸痛,无双下肢水肿.体格检查:血压100/60 mmHg(10 mmHg=1.33 kPa).口唇无发绀,颈静脉怒张,肝颈静脉反流征( ).双肺未闻及干、湿啰音,心界无扩大,心率80次/分,心律整齐,心尖部可闻及Ⅲ级收缩期杂音.腹部微膨隆,移动性浊音( ),肝下缘在右肋下平脐部,质地硬、边缘钝,肝区叩击痛( ),双下肢无水肿.实验室检查:血、尿常规均正常.ESR 18 mm/h,抗O(-),血总蛋白58 g/L、白蛋白32 g/L、球蛋白26 g/L,A/G为1.2:1;电解质正常,心、肾功能正常,乙型、丙型病毒性肝炎血清标志物均阴性.心电图示:窦性心律、左心房增大?     

甲基强地松龙冲击治疗狼疮性肾炎致癫痫大发作1例

患者,女,37岁。因全身浮肿二月余于1996年7月22口入院。体检:BP16/13kPa,双眼睑水肿,颜面蝶形红斑,腹部移动性浊音阳性,下肢浮肿,余无异常发现。检查:尿蛋白(卅),尿RBC30～35/HP。血BUN9.6mmol/L,Cr141.4μmol/L,白蛋白17g/L,血中连续二次找到狼疮细胞,ANA 1∶60阳性;B超发现少量腹水,少量心包积液。诊断:系统性红斑狼疮性肾炎(LN)。入院后给予强地松50mg/天治疗四周后尿蛋白仍(卅),24小时尿蛋白定量7.8g,同时患者出现头晕,测BP23/14kPa,血EUN15mmol/L,Cr282.9μmol/L,即停服强地松,予甲基强地松龙     

阿奇霉素致白细胞减少1例

患者,女,35岁。因咳嗽,胸闷,咳少量黄色黏痰5日于2007年4月26日入院。既往无药物过敏及白细胞减少史。查体:体温37.2℃,脉搏82次/min,呼吸20次/min,血压120/80 mm Hg(1 mm Hg=0.133 kPa),咽充血,扁桃体不肿大,双肺呼吸音粗,双肺可闻及干性啰音,心、腹部及四肢、脊柱无异常。血常规示:红细胞4.2×1012/L,白细胞11.3×109/L,中性粒细胞0.83,淋巴细胞0.17,血小板176×109/L。X线胸片示:双肺纹理增多。诊断为急性支气管感染。给予阿奇霉素0.5 g(江西赣南海欣药业股份有限公司,批号07011501),溶入5%葡萄糖注射液500 ml,静脉滴注,每日1次,抗感…     

以脓胸为首发症状的结肠脾曲癌一例

患者男,42 岁,因"胸痛伴呼吸困难、发热1 d"于2011 年7 月25 日经急诊收治入院.患者入院前1 d 无明显诱因突发左侧 胸部锐性疼痛,伴呼吸困难、胸闷、心慌症状,伴寒战、发热,体温 最高39 ℃,伴咳嗽,咳少量白色泡沫痰.入院查体: 体温 38.5 ℃,心率140 次/min,血压115/65 mm Hg,呼吸45 次/min, 急性痛苦面容,喘息状,张口呼吸,口唇无发绀,左侧呼吸动度减 弱,触觉语颤增强,叩诊浊音,右侧叩诊清音,左肺呼吸音减弱, 可闻及少量湿啰音,右肺呼吸音清.实验室检查:血常规示白细 胞计数35 ×109 /L,粒细胞91.7%,血红蛋白84 g/L,血小板790 ×109 /L;生化示肝肾功能及电解质基本正常,总蛋白70 g/L,白 蛋白26 g/L;血气分析示pH 值7.47,PCO2 24 mm Hg,PO2 58 mm Hg,SO2 92%,HCO- 3 17.2 mmol/L,BE -5.3 mmol/L.胸部 X 线及胸部CT 示左侧大量胸腔积液,纵隔及气管右移,右侧支 气管肺炎(图1,2).心电图示窦性心动过速.     

人血白蛋白联合机械通气治疗海水淹溺一例

患者男, 69岁, 既往无高血压、冠状动脉粥样硬化性心脏病、心力衰竭等病史, 诉于约16:20在海边溺水, 约16:40被成功捞救, 约17:00由平车推入92493部队医院急诊医学科。患者入院时意识清楚, 极度呼吸困难, 血氧饱和度40%, 心率95次/分, 血压180/106 mmHg(1 mmHg=0.133 kPa), 体温34.0℃, 两肺听诊满布湿啰音。立即给予面罩高流量吸氧, 血氧饱和度升至75.0%, 完善血气分析检查:pH 7.3, 氧分压39.0 mmHg, 钠离子148.0 mmol/L, 钾离子3.1 mmol/L, 氯离子115.0 mmol/L, 乳酸4.1 mmol/L。血常规:白细胞计数11.6×109/L, 中性粒细胞百分比65.4%;生化指标:钠149.0 mmol/L、钙2.6 mmol/L、丙氨酸氨基转移酶73.0 U/L、天门冬氨酸氨基转移酶48.0 U/L、葡萄糖10.5 mmol/L、C反应蛋白7.1 mg/L、降钙素原0.2 μg/L。面罩吸氧后患者呼吸困难症状不缓解, 血氧饱和度维持约在75.0%, 遂行经鼻气管插管及机械通气, 初始通...     

食管裂孔疝入肺 杯弓蛇影肺脓疡——1例食管裂孔疝误诊为肺脓疡

患者女,80岁,退休工人。因反复咳嗽、气促3年,伴心悸1月于1995年2月18日入院。3年前患者无明显诱因出现间歇轻咳、无痰,无发热,间中轻度气促,活动后稍加重,休息可缓解。1月前上述症状再发,伴心悸,上腹隐痛就诊,X线胸片示:左下肺后基底段见斑片状模糊影及两个气液平面,各宽约2.5cm,拟诊左下肺脓疡。收入院治疗。体检:体温36.5℃,脉搏80次/分,呼吸18次/分,血压19/11kPa。神清、呼吸顺、无发绀、桶状胸、双肺叩诊过清音,双肺呼吸音低,未闻干、湿性音,腹部(-)。实验室检查:红细胞4.27×1012/L,血红蛋白134g/L;白细胞5.0×109/L,淋巴0.40,中…     

表现为巨大肿块之闭塞性周围动脉粥样硬化1例报告

1病例报告男,58岁.因睡眠中突然憋醒,呼吸困难2小时于1999年3月12日入院.既往发现高血压1个月,最高血压为29kPa/16kPa.体格检查:呼吸30次/分,血压40kPa/17kPa.急性病容,呼吸困难,口吐白沫,双肺底有小水泡音,心率100次/分,心律整齐,肝未触及,下肢无浮肿.诊断:高血压(Ⅲ级),急性左侧心力衰竭(Ⅲ度).     

异搏定联用心得安致心源性休克1例

患者女,52岁,因反复心悸、气促、浮肿一年余,症状加重半个月于1989年8月17日入院。查体:体温36.5℃,脉率104次,呼吸24次,血压16/9kPa。营养情况较差,体重37公斤。两肺(-)。心律齐,闻及S_3、P_2稍亢、心尖区2°～3°/6°sm 及轻度舒张期隆隆样杂音。肝肋下1 cm,面部、下肢轻度浮肿。Hb 9.5g/L,WBC 8.9×10~9/L、N 0.6,L 0.4。尿常规:蛋白++～+++,24小时尿蛋白定量1.2g,尿素氮7.0mmol/L,肌酐150mmol/L。肝功能正常。血甘油三酯2.0mmol/L,胆固醇4.4mmol/L。血沉28mm/h,抗“O”<500单位。心电图、窦性心动过速,肢联低电压、Tv_(3-5)低平。胸片:心影增大,考虑为心     

急性心肌梗死IABP治疗后大面积脑栓塞1例

<正>患者,男,75岁,因"胸痛3h,呼吸困难30min"急诊入院。查体:T 36.0℃,P 130次/min,RR40次/min,BP 68/40 mmHg(1 mmHg=0.133kPa),SpO285%。神志清,全身皮肤湿冷,颈静脉无怒张,咳粉红色泡沫痰,双肺呼吸音粗,可闻及大量湿性啰音。心率130次/min,律齐,未闻及杂音。腹平软,肝脾肋下未及,肠鸣音4次/min。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.