病例分析-PPT課件

1、病例分析 case analysis病史特點(diǎn)：（1）中年男性，病前病中無發(fā)熱 Middle-aged man,no fever （2）急性、動(dòng)態(tài)起 It was an acute case。（3）前庭性眩暈，失平衡伴輕微的植物神經(jīng)癥狀vestibulo vertigo ，loss of equilibrium ，with autonomic nerve 病例分析case analysis病史特點(diǎn)：（4）不伴耳蝸癥狀（耳鳴、耳聾） without symptom of cochlea(no tinnitus or deafness ) （5）不伴復(fù)視、黑矇、視野缺損 Without diplop

2、ia、amaurosis 、 defect of visual field（6）雖有頭痛（三天后），但顱內(nèi)高壓癥狀不明顯Eventhough he had headache after 3 days, symtomps of acute intracranial hypertension is not obvious.病例分析 case analysis病史特點(diǎn)：（7）有血管病的危險(xiǎn)因素（高血壓、血脂異常、 腹型肥胖、不良生活習(xí)慣）Risk of vessel disease（ hypertension 、 hyperlipemia 、 abdominal fat 、bad living ha

3、bit )（8）既往無類似病史，無耳疾史 No siminal medical history ,no disease history of ear病例分析 case analysis體征 physical sign ：（1）左視有輕微水平眼震 slight level nystagmus when he looks left （2）左手輪替運(yùn)動(dòng)輕微笨拙 Alternating movements of his left hand is slight unskilled.病例分析 case analysis影像 images：頭CT示左小腦半球大面積低密度灶 Head CT showed la

4、rge low density area in his left cerebellar hemisphere .病例分析 case analysis定位診斷 topical diagnosis （1）根據(jù)癥狀性前庭性眩暈、失平衡定位于前庭小腦系統(tǒng)（損害） vestibulo vertigo ，loss of equilibrium located at vestibulo cerebellum(injury） 病例分析 case analysis定位診斷 topical diagnosis （2)根據(jù)左手輪替運(yùn)動(dòng)輕微笨拙、頭CT左小腦半球低密度灶，定位于左小腦半球受損slight unskil

5、ledly alternating movements of his left hand and large lower density area in his left cerebellar hemisphere showing by his head CT scan located at his left cerebellar hemisphere .病例分析 case analysis定性診斷 etiologic diagnosis：（1）根據(jù)中年男性，病前病中無發(fā)熱;急 性、動(dòng)態(tài)起病；有血管病的危險(xiǎn)因素 -定性為急性腦血管病（腦卒中）病例分析 case analysis定性診斷 eti

6、ologic diagnosis ：（2）根據(jù)顱內(nèi)高壓癥狀不明顯；頭CT示左 小腦半球大面積低密度 -定性為后循環(huán)缺血(posterior circulation ischemia -小腦梗塞（動(dòng)脈粥樣硬化性atherosclerotic ）病例分析 case analysis鑒別診斷 differential diagnosis ：（1）椎基底動(dòng)脈供血不足 Vertebrobasilar insufficiency （2）蛛網(wǎng)膜下腔出血（以眩暈為首發(fā)癥狀）subarachnoid hemorrhageH:C腦蛛下血1b.jpg（3）小腦炎（急性小腦性共濟(jì)失調(diào)） cerebellitis （a

7、cute cerebellar ataxia ）（4）小腦出血 Cerebellar hemorrhage 病例分析 case analysis鑒別診斷 differential diagnosis （5）小腦腫瘤 cerebellar tumorH:髓母1c.tif H:髓母2a.tif（6）突發(fā)性耳聾 sudden hearing loss （7）體位性低血壓（直立性低血壓 ） postural hypotension病例分析 case analysis診療計(jì)劃 plans of therapy（1）檢查計(jì)劃 頭MRI； 頭CTA； TCD，頸動(dòng)脈椎動(dòng)脈彩超，心臟彩超病例分析 case analysis診療計(jì)劃 plans of therapy: (1)檢查計(jì)劃： 血常規(guī)，血脂，血糖，腎功； 心電圖，腎動(dòng)脈超聲； 尿常規(guī)（白蛋白尿）病例分析case analysis（2 ）治療計(jì)劃 1） 一般治療 general therapy 2） 降顱壓 lower ICP 3）消栓 thrombolysis 4）腦保護(hù)