實(shí)踐技能操作考核培訓(xùn)課件

1、2014年執(zhí)業(yè)醫(yī)師實(shí)踐技能操作考核培訓(xùn) 心電圖及病例分析楊作富Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.2014年執(zhí)業(yè)醫(yī)師實(shí)踐技能操作考核培訓(xùn) 實(shí)踐技能操作考核培訓(xùn)輔助檢查：心電圖病例分析：心血管系統(tǒng)：1.心力衰竭2.心律失常3.冠心病4.高血壓5.心臟瓣膜病6.結(jié)核性心包炎、風(fēng)濕免疫性疾?。?.系統(tǒng)性紅斑狼瘡2.類(lèi)風(fēng)濕關(guān)節(jié)炎Evaluation only.Created with Aspose.Slides

2、for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.實(shí)踐技能操作考核培訓(xùn)輔助檢查：心電圖Evaluation o一、輔助檢查心電圖Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.一、輔助檢查心電圖Evaluation only.PQRSTEvaluation only.Created with Aspose.Slides for

3、 .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.PQRSTEvaluation only.心電圖1.正常心電圖2.竇性心動(dòng)過(guò)速3.竇性心動(dòng)過(guò)緩4.房性期前收縮5.心房顫動(dòng)6.陣發(fā)性室上性心動(dòng)過(guò)速7.室性期前收縮8.室性心動(dòng)過(guò)速9.心室顫動(dòng)10.房室傳導(dǎo)阻滯11.左、右束支傳導(dǎo)阻滯12.左、右心室肥厚13.急性心肌梗死Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-201

4、1 Aspose Pty Ltd.心電圖1.正常心電圖Evaluation only.R心臟除、復(fù)極與心電圖關(guān)系示意圖Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.R心臟除、復(fù)極與心電圖關(guān)系示意圖Evaluation onl心電圖各波段組成與命名UEvaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyri

5、ght 2004-2011 Aspose Pty Ltd.心電圖各波段組成與命名UEvaluation only.正常心電圖Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.正常心電圖Evaluation only.竇性心動(dòng)過(guò)速Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-201

6、1 Aspose Pty Ltd.竇性心動(dòng)過(guò)速Evaluation only.竇性心動(dòng)過(guò)緩，一度房室傳導(dǎo)阻滯Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.竇性心動(dòng)過(guò)緩，一度房室傳導(dǎo)阻滯Evaluation only竇性心動(dòng)過(guò)速和竇性心動(dòng)過(guò)緩Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright

7、2004-2011 Aspose Pty Ltd.竇性心動(dòng)過(guò)速和竇性心動(dòng)過(guò)緩Evaluation only.竇性心律不齊Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.竇性心律不齊Evaluation only.房性期前收縮 房早Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2

8、011 Aspose Pty Ltd.房性期前收縮 房早Evaluation only.竇性停搏Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.竇性停搏Evaluation only.房撲Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.房撲

9、Evaluation only.房顫Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.房顫Evaluation only.心房顫動(dòng)Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心房顫動(dòng)Evaluation only.陣發(fā)性室上性心動(dòng)過(guò)速Ev

10、aluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.陣發(fā)性室上性心動(dòng)過(guò)速Evaluation only.陣發(fā)性室上速Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.陣發(fā)性室上速Evaluation only.Evaluation only.Crea

11、ted with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.Evaluation only.室早二聯(lián)律Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.室早二聯(lián)律Evaluation only.短陣室速Evaluation only.Created with Aspose.Slides for

12、 .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.短陣室速Evaluation only.陣發(fā)性室性心動(dòng)過(guò)速Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.陣發(fā)性室性心動(dòng)過(guò)速Evaluation only.心室顫動(dòng)和心室撲動(dòng)Evaluation only.Created with Aspose.Slides for .NET 3.5

13、 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心室顫動(dòng)和心室撲動(dòng)Evaluation only.室顫Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.室顫Evaluation only.I度房室傳導(dǎo)阻滯（P-R間期0.27s）Evaluation only.Created with Aspose.Slides for .NET 3.5 Client

14、 Profile .Copyright 2004-2011 Aspose Pty Ltd.I度房室傳導(dǎo)阻滯（P-R間期0.27s）Evaluation竇性心律，一度房室阻滯。Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.竇性心律，一度房室阻滯。Evaluation only.II度房室傳導(dǎo)阻滯（I型）Evaluation only.Created with Aspose.Slides for .NET

15、 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.II度房室傳導(dǎo)阻滯（I型）Evaluation only.II度房室傳導(dǎo)阻滯（II型）Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.II度房室傳導(dǎo)阻滯（II型）Evaluation only.III度房室傳導(dǎo)阻滯Evaluation only.Created with Aspose.Slid

16、es for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.III度房室傳導(dǎo)阻滯Evaluation only.完全性右束支傳導(dǎo)阻滯Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.完全性右束支傳導(dǎo)阻滯Evaluation only.完全性左束支傳導(dǎo)阻滯Evaluation only.Created with Aspose.Slid

17、es for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.完全性左束支傳導(dǎo)阻滯Evaluation only.左右心室肥厚左心室肥厚右心室肥厚Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.左右心室肥厚左心室肥厚Evaluation only.胸痛伴左心室肥厚患者，因?yàn)閂1和V2導(dǎo)聯(lián)ST段變化，被給與了不適當(dāng)?shù)娜芩ㄖ委煛val

18、uation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.胸痛伴左心室肥厚患者，因?yàn)閂1和V2導(dǎo)聯(lián)ST段變化，被給與了右心室勞損：右心室肥厚伴胸導(dǎo)聯(lián)廣泛T波倒置Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.右心室勞損：右心室肥厚伴胸導(dǎo)聯(lián)廣泛T波倒置Eval

19、uatio心肌缺血T波增高Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心肌缺血T波增高Evaluation only.不穩(wěn)定性心絞痛表現(xiàn)為導(dǎo)致的T波Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.不穩(wěn)定性心絞痛表現(xiàn)為導(dǎo)致的T波Evalu

20、ation onl胸痛患者可逆性的ST段變化：ST段抬高隨胸痛緩解轉(zhuǎn)變?yōu)檎valuation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.胸痛患者可逆性的ST段變化：ST段抬高隨胸痛緩解轉(zhuǎn)變?yōu)檎前壁心肌梗死存在顯著ST段抬高 （表現(xiàn)為 “墓碑”樣 R波)Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright

21、 2004-2011 Aspose Pty Ltd.前壁心肌梗死存在顯著ST段抬高 （表現(xiàn)為 “墓碑”樣 R波)導(dǎo)聯(lián)的解剖關(guān)系 下壁 II、 III 和 aVF導(dǎo)聯(lián) 前壁 V1 to V4 導(dǎo)聯(lián)側(cè)壁 I、 aVL、 V5 和 V6 非標(biāo)準(zhǔn)導(dǎo)聯(lián) 右心室 右胸導(dǎo)聯(lián) V1R to V6R 后壁 V7 to V9導(dǎo)聯(lián)心肌梗死梗死部位的定位Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.導(dǎo)聯(lián)的解剖關(guān)系 心肌梗死梗死部位的定位E

22、valuation 病例分析心血管系統(tǒng)：1.心力衰竭2.心律失常3.冠心病4.高血壓5.心臟瓣膜病6.結(jié)核性心包炎、風(fēng)濕免疫性疾病：1.系統(tǒng)性紅斑狼瘡2.類(lèi)風(fēng)濕關(guān)節(jié)炎Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.病例分析心血管系統(tǒng)：1.心力衰竭2.心律失常3.冠心病4.高心血管系統(tǒng)1.心力衰竭2.心律失常3.冠心病4.高血壓5.心臟瓣膜病6.結(jié)核性心包炎、Evaluation only.Created with A

23、spose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心血管系統(tǒng)1.心力衰竭Evaluation only.心力衰竭左心衰:呼吸困難+端坐呼吸+奔馬律+粉工色泡沫痰右心衰：肝大+肝頸靜脈回流征陽(yáng)性+水腫全心衰：具備以上兩者Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心力衰竭左心衰:呼吸困難+端坐呼吸+

24、奔馬律+粉工色泡沫痰Ev心律失常陣發(fā)性室上性心動(dòng)過(guò)速（PSVT）心房纖顫室早、室速Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心律失常陣發(fā)性室上性心動(dòng)過(guò)速（PSVT）Evaluation冠心病心絞痛急性心肌梗死Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspo

25、se Pty Ltd.冠心病心絞痛Evaluation only. 男性，62歲，陣發(fā)性胸痛4天，再發(fā)4小時(shí)來(lái)急診。 患者4天前出現(xiàn)活動(dòng)后心前區(qū)鈍痛、放散至咽部，伴輕度出汗，持續(xù)10余分鐘后自行好轉(zhuǎn)，未予診治。4小時(shí)前飲酒時(shí)再發(fā)心前區(qū)疼痛，有壓迫感，伴胸悶、大汗、惡心，未吐。自服“速效救心丸”6粒，胸痛仍不緩解被家人送來(lái)急診。患病以來(lái)無(wú)咯血、無(wú)大、小便失禁。既往有冠心病病史。無(wú)糖尿病、高血壓病史，無(wú)藥物過(guò)敏史，吸煙20年，30支日，少量飲酒。 查體：T 364。C，P 98次分，R l8次分，BP l2060mmH9，神志清，鞏膜無(wú)黃染，瞼結(jié)膜無(wú)蒼白，口唇無(wú)紫紺，雙肺底可聞及細(xì)濕l羅音，心界不

26、大，心率98次分，律不齊，可聞及早搏5次分，心音稍低，未聞及雜音。腹平軟，肝脾未觸及，雙下肢不腫。 輔助檢查：心電圖：V1-5導(dǎo)聯(lián)sT段弓背向上抬高03mV05mV，有提前出現(xiàn)的寬大畸形的QRS波群。CK及CK-MB正常，肌鈣蛋白T 096n9ml(正常值005n9ml)。 Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd. 男性，62歲，陣發(fā)性胸痛4天，再發(fā)4小時(shí)來(lái)急診。Evalu分析步驟： 1初步診斷及診斷依據(jù) 本

27、例初步診斷：冠心病，急性廣泛前壁心肌梗死，心臟不大，室性早搏，心功能(Killip)級(jí)。 其診斷依據(jù)是： (1)急性廣泛前壁心肌梗死：有冠心病家族史，吸煙；急性起病，有先兆胸痛，壓迫感，用藥后不緩解；查體：心音低；輔助檢查：心電圖：V1 ST段弓背向上抬高；肌鈣蛋白T增高。 (2)室性早搏：聽(tīng)診心律不齊，心電圖可見(jiàn)提前出現(xiàn)的寬大畸形的QRS波群。 (3)心功能(Killip)級(jí)：胸悶，體檢雙肺底可聞及細(xì)濕噦音。 2鑒別診斷 (1)不穩(wěn)定性心絞痛：可有胸悶、胸痛，持續(xù)時(shí)間短，心電圖正常或出現(xiàn)相應(yīng)導(dǎo)聯(lián)的ST段壓低，心肌酶、TNT正常。 (2)肺栓塞：多有下肢靜脈血栓、外傷、手術(shù)等栓子來(lái)源病史，右心

28、負(fù)荷急劇增加，體檢可有發(fā)紺、肺動(dòng)脈瓣區(qū)S2亢進(jìn)、頸靜脈充盈、肝大、下肢浮腫等表現(xiàn)。 (3)急性心包炎：胸痛伴心電圖變化，癥狀多與發(fā)熱同時(shí)出現(xiàn)，呼吸和咳嗽時(shí)加重，心電圖ST段呈弓背向下抬高。 (4)急性胰腺炎：飲酒時(shí)發(fā)病，有胃腸道表現(xiàn)。 Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.分析步驟：Evaluation only.3進(jìn)一步檢查 (1)動(dòng)態(tài)觀察心電圖，觀察梗死范圍變化及心律失常的發(fā)展。 (2)動(dòng)態(tài)觀察血清心肌

29、酶，描繪變化曲線，觀察酶峰變化。 (3)血?dú)夥治?，凝血功能檢查，除外肺栓塞診斷。 (4)血常規(guī)檢查，電解質(zhì)，血脂、血糖，淀粉酶，腹部B超，除外胰腺炎。 (5)超聲心動(dòng)圖了解心室壁活動(dòng)及心功能。 (6)胸部X片，了解心臟大小及肺部情況。 (7)冠脈造影確定血管病變程度。 ， 4治療原則 (1)一般治療：休息，吸氧，監(jiān)測(cè)、護(hù)理。 (2)解除疼痛：?jiǎn)岱龋跛狨ブ苿?(3)抗凝及抗血小板藥物：阿司匹林，氯吡格雷，肝素。 (4)再灌注治療，溶栓和(或)介入治療 (5)對(duì)癥治療：控制心律失常，改善心功能。 (6)心肌梗死的級(jí)預(yù)防：ACEl改善心臟重塑，B-受體阻滯劑減慢心率降低 心肌耗氧，他汀類(lèi)調(diào)脂藥。

30、Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.3進(jìn)一步檢查Evaluation only.高血壓高血壓的診斷及分級(jí)危險(xiǎn)分層注意合并癥的診斷Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.高血壓高血壓的診斷及分級(jí)Evaluation onl

31、y.分類(lèi)收縮壓(mmHg)舒張壓(mmHg)正常血壓 120 80正常高值 120139 8089高血壓 140 90 1級(jí)高血壓(輕度) 140159 9099 2級(jí)高血壓(中度) 160179 100109 3級(jí)高血壓(重度)180 110單純收縮期高血壓140 90血壓水平的定義和分類(lèi)注：當(dāng)收縮壓與舒張壓屬不同級(jí)別時(shí)，應(yīng)該取較高的級(jí)別分類(lèi)。中國(guó)高血壓防治指南2010修訂版和和/或和/或和/或和/或和/或和Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004

32、-2011 Aspose Pty Ltd.分類(lèi)收縮壓(mmHg)舒張壓(mmHg)血壓水平的定義高血壓患者心血管風(fēng)險(xiǎn)分層其他危險(xiǎn)因素和病史血壓(mmHg)1級(jí)高血壓SBP 140-159或DBP 90-992級(jí)高血壓SBP 160-179或DBP 100-1093級(jí)高血壓SBP 180或DBP 110無(wú)低危中危高危1-2個(gè)其他危險(xiǎn)因素中危中危很高危3個(gè)其他危險(xiǎn)因素，或靶器官損害高危高危很高危臨床并發(fā)癥或合并糖尿病很高危很高危很高危Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copy

33、right 2004-2011 Aspose Pty Ltd.高血壓患者心血管風(fēng)險(xiǎn)分層其他危險(xiǎn)因素和病史血壓(mmHg)1心臟瓣膜病風(fēng)濕性心臟二尖瓣狹窄并關(guān)閉不全主動(dòng)脈瓣關(guān)閉不全Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心臟瓣膜病風(fēng)濕性心臟Evaluation only.結(jié)核性心包炎有結(jié)核中毒癥狀心包積液的體征Evaluation only.Created with Aspose.Slides for .NET

34、 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.結(jié)核性心包炎有結(jié)核中毒癥狀Evaluation only.風(fēng)濕免疫性疾病1.系統(tǒng)性紅斑狼瘡2.類(lèi)風(fēng)濕關(guān)節(jié)炎Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.風(fēng)濕免疫性疾病1.系統(tǒng)性紅斑狼瘡Evaluation onl系統(tǒng)性紅斑狼瘡診斷依據(jù)臨床表現(xiàn)Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.系統(tǒng)性紅斑狼瘡診斷依據(jù)