實踐技能操作考核培訓課件

1、2014年執(zhí)業(yè)醫(yī)師實踐技能操作考核培訓 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)師實踐技能操作考核培訓 實踐技能操作考核培訓輔助檢查：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.結核性心包炎、風濕免疫性疾病：1.系統(tǒng)性紅斑狼瘡2.類風濕關節(jié)炎Evaluation only.Created with Aspose.Slides

2、for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.實踐技能操作考核培訓輔助檢查：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.竇性心動過速3.竇性心動過緩4.房性期前收縮5.心房顫動6.陣發(fā)性室上性心動過速7.室性期前收縮8.室性心動過速9.心室顫動10.房室傳導阻滯11.左、右束支傳導阻滯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、復極與心電圖關系示意圖Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.R心臟除、復極與心電圖關系示意圖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.竇性心動過速Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-201

6、1 Aspose Pty Ltd.竇性心動過速Evaluation only.竇性心動過緩，一度房室傳導阻滯Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.竇性心動過緩，一度房室傳導阻滯Evaluation only竇性心動過速和竇性心動過緩Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright

7、2004-2011 Aspose Pty Ltd.竇性心動過速和竇性心動過緩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Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心房顫動Evaluation only.陣發(fā)性室上性心動過速Ev

10、aluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.陣發(fā)性室上性心動過速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)性室性心動過速Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.陣發(fā)性室性心動過速Evaluation only.心室顫動和心室撲動Evaluation only.Created with Aspose.Slides for .NET 3.5

13、 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心室顫動和心室撲動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度房室傳導阻滯（I型）Evaluation only.II度房室傳導阻滯（II型）Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.II度房室傳導阻滯（II型）Evaluation only.III度房室傳導阻滯Evaluation only.Created with Aspose.Slid

16、es for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.III度房室傳導阻滯Evaluation only.完全性右束支傳導阻滯Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.完全性右束支傳導阻滯Evaluation only.完全性左束支傳導阻滯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，因為V1和V2導聯(lián)ST段變化，被給與了不適當?shù)娜芩ㄖ委?。Eval

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，因為V1和V2導聯(lián)ST段變化，被給與了右心室勞損：右心室肥厚伴胸導聯(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)導聯(lián)的解剖關系 下壁 II、 III 和 aVF導聯(lián) 前壁 V1 to V4 導聯(lián)側壁 I、 aVL、 V5 和 V6 非標準導聯(lián) 右心室 右胸導聯(lián) V1R to V6R 后壁 V7 to V9導聯(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.導聯(lián)的解剖關系 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.結核性心包炎、風濕免疫性疾?。?.系統(tǒng)性紅斑狼瘡2.類風濕關節(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)性室上性心動過速（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)性室上性心動過速（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小時來急診。 患者4天前出現(xiàn)活動后心前區(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，未予診治。4小時前飲酒時再發(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急診?；疾∫詠頍o咯血、無大、小便失禁。既往有冠心病病史。無糖尿病、高血壓病史，無藥物過敏史，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，鞏膜無黃染，瞼結膜無蒼白，口唇無紫紺，雙肺底可聞及細濕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小時來急診。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。 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：聽診心律不齊，心電圖可見提前出現(xiàn)的寬大畸形的QRS波群。 (3)心功能(Killip)級：胸悶，體檢雙肺底可聞及細濕噦音。 2鑒別診斷 (1)不穩(wěn)定性心絞痛：可有胸悶、胸痛，持續(xù)時間短，心電圖正常或出現(xiàn)相應導聯(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、手術等栓子來源病史，右心

28、負荷急劇增加，體檢可有發(fā)紺、肺動脈瓣區(qū)S2亢進、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)熱同時出現(xiàn)，呼吸和咳嗽時加重，心電圖ST段呈弓背向下抬高。 (4)急性胰腺炎：飲酒時發(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進一步檢查 (1)動態(tài)觀察心電圖，觀察梗死范圍變化及心律失常的發(fā)展。 (2)動態(tài)觀察血清心肌

29、酶，描繪變化曲線，觀察酶峰變化。 (3)血氣分析，凝血功能檢查，除外肺栓塞診斷。 (4)血常規(guī)檢查，電解質，血脂、血糖，淀粉酶，腹部B超，除外胰腺炎。 (5)超聲心動圖了解心室壁活動及心功能。 (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、護理。 (2)解除疼痛：嗎啡，硝酸酯制劑。 (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)對癥治療：控制心律失常，改善心功能。 (6)心肌梗死的級預防：ACEl改善心臟重塑，B-受體阻滯劑減慢心率降低 心肌耗氧，他汀類調脂藥。

30、Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.3進一步檢查Evaluation only.高血壓高血壓的診斷及分級危險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Evaluation onl

31、y.分類收縮壓(mmHg)舒張壓(mmHg)正常血壓 120 80正常高值 120139 8089高血壓 140 90 1級高血壓(輕度) 140159 9099 2級高血壓(中度) 160179 100109 3級高血壓(重度)180 110單純收縮期高血壓140 90血壓水平的定義和分類注：當收縮壓與舒張壓屬不同級別時，應該取較高的級別分類。中國高血壓防治指南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.分類收縮壓(mmHg)舒張壓(mmHg)血壓水平的定義高血壓患者心血管風險分層其他危險因素和病史血壓(mmHg)1級高血壓SBP 140-159或DBP 90-992級高血壓SBP 160-179或DBP 100-1093級高血壓SBP 180或DBP 110無低危中危高危1-2個其他危險因素中危中危很高危3個其他危險因素，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險分層其他危險因素和病史血壓(mmHg)1心臟瓣膜病風濕性心臟二尖瓣狹窄并關閉不全主動脈瓣關閉不全Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.心臟瓣膜病風濕性心臟Evaluation only.結核性心包炎有結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.結核性心包炎有結核中毒癥狀Evaluation only.風濕免疫性疾病1.系統(tǒng)性紅斑狼瘡2.類風濕關節(jié)炎Evaluation only.Created with Aspose.Slides for .NET 3.5 Client Profile .Copyright 2004-2011 Aspose Pty Ltd.風濕免疫性疾病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)