最新实践技能操作考核培训PPT课件 61页

'实践技能操作考核培训 实践技能操作考核培训辅助检查：心电图病例分析：心血管系统：1.心力衰竭2.心律失常3.冠心病4.高血压5.心脏瓣膜病6.结核性心包炎、风湿免疫性疾病：1.系统性红斑狼疮2.类风湿关节炎Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 窦性心动过速Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 窦性心动过缓，一度房室传导阻滞Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 窦性心动过速和窦性心动过缓Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 窦性心律不齐Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 房性期前收缩房早Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 窦性停搏Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 房扑Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 房颤Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 心房颤动Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 阵发性室上性心动过速Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 阵发性室上速Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 室早二联律Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 短阵室速Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 阵发性室性心动过速Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 心室颤动和心室扑动Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 室颤Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. I度房室传导阻滞（P-R间期0.27s）Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 窦性心律，一度房室阻滞。Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. II度房室传导阻滞（I型）Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. II度房室传导阻滞（II型）Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. III度房室传导阻滞Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 完全性右束支传导阻滞Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 完全性左束支传导阻滞Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 左右心室肥厚左心室肥厚右心室肥厚Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 胸痛伴左心室肥厚患者，因为V1和V2导联ST段变化，被给与了不适当的溶栓治疗。Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 右心室劳损：右心室肥厚伴胸导联广泛T波倒置Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 心肌缺血T波增高Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 不稳定性心绞痛表现为导致的T波Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 胸痛患者可逆性的ST段变化：ST段抬高随胸痛缓解转变为正常Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 前壁心肌梗死存在显著ST段抬高（表现为“墓碑”样R波)Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 导联的解剖关系下壁II、III和aVF导联前壁V1toV4导联侧壁I、aVL、V5和V6非标准导联右心室右胸导联V1RtoV6R后壁V7toV9导联心肌梗死梗死部位的定位Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 病例分析心血管系统：1.心力衰竭2.心律失常3.冠心病4.高血压5.心脏瓣膜病6.结核性心包炎、风湿免疫性疾病：1.系统性红斑狼疮2.类风湿关节炎Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 心血管系统1.心力衰竭2.心律失常3.冠心病4.高血压5.心脏瓣膜病6.结核性心包炎、Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 心力衰竭左心衰:呼吸困难+端坐呼吸+奔马律+粉工色泡沫痰右心衰：肝大+肝颈静脉回流征阳性+水肿全心衰：具备以上两者Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 心律失常阵发性室上性心动过速（PSVT）心房纤颤室早、室速Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 冠心病心绞痛急性心肌梗死Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 男性，62岁，阵发性胸痛4天，再发4小时来急诊。患者4天前出现活动后心前区钝痛、放散至咽部，伴轻度出汗，持续10余分钟后自行好转，未予诊治。4小时前饮酒时再发心前区疼痛，有压迫感，伴胸闷、大汗、恶心，未吐。自服“速效救心丸”6粒，胸痛仍不缓解被家人送来急诊。患病以来无咯血、无大、小便失禁。既往有冠心病病史。无糖尿病、高血压病史，无药物过敏史，吸烟20年，30支／日，少量饮酒。查体：T36．4。C，P98次／分，Rl8次／分，BPl20／60mmH9，神志清，巩膜无黄染，睑结膜无苍白，口唇无紫绀，双肺底可闻及细湿l罗音，心界不大，心率98次／分，律不齐，可闻及早搏5次／分，心音稍低，未闻及杂音。腹平软，肝脾未触及，双下肢不肿。辅助检查：心电图：V1-5导联sT段弓背向上抬高0．3mV～0．5mV，有提前出现的宽大畸形的QRS波群。CK及CK-MB正常，肌钙蛋白T0．96n9／ml(正常值<0．05n9／ml)。Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 分析步骤：1．初步诊断及诊断依据本例初步诊断：冠心病，急性广泛前壁心肌梗死，心脏不大，室性早搏，心功能(Killip)Ⅱ级。其诊断依据是：(1)急性广泛前壁心肌梗死：①有冠心病家族史，吸烟；②急性起病，有先兆胸痛，压迫感，用药后不缓解；③查体：心音低；④辅助检查：心电图：V1ST段弓背向上抬高；肌钙蛋白T增高。(2)室性早搏：听诊心律不齐，心电图可见提前出现的宽大畸形的QRS波群。(3)心功能(Killip)Ⅱ级：胸闷，体检双肺底可闻及细湿哕音。2．鉴别诊断(1)不稳定性心绞痛：可有胸闷、胸痛，持续时间短，心电图正常或出现相应导联的ST段压低，心肌酶、TNT正常。(2)肺栓塞：多有下肢静脉血栓、外伤、手术等栓子来源病史，右心负荷急剧增加，体检可有发绀、肺动脉瓣区S2亢进、颈静脉充盈、肝大、下肢浮肿等表现。(3)急性心包炎：胸痛伴心电图变化，症状多与发热同时出现，呼吸和咳嗽时加重，心电图ST段呈弓背向下抬高。(4)急性胰腺炎：饮酒时发病，有胃肠道表现。Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 3．进一步检查(1)动态观察心电图，观察梗死范围变化及心律失常的发展。(2)动态观察血清心肌酶，描绘变化曲线，观察酶峰变化。(3)血气分析，凝血功能检查，除外肺栓塞诊断。(4)血常规检查，电解质，血脂、血糖，淀粉酶，腹部B超，除外胰腺炎。(5)超声心动图了解心室壁活动及心功能。(6)胸部X片，了解心脏大小及肺部情况。(7)冠脉造影确定血管病变程度。，4．治疗原则(1)一般治疗：休息，吸氧，监测、护理。(2)解除疼痛：吗啡，硝酸酯制剂。(3)抗凝及抗血小板药物：阿司匹林，氯吡格雷，肝素。(4)再灌注治疗，溶栓和(或)介入治疗(5)对症治疗：控制心律失常，改善心功能。(6)心肌梗死的Ⅱ级预防：ACEl改善心脏重塑，B-受体阻滞剂减慢心率降低心肌耗氧，他汀类调脂药。Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 高血压高血压的诊断及分级危险分层注意合并症的诊断Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 分类收缩压(mmHg)舒张压(mmHg)正常血压<120<80正常高值120~13980~89高血压≥140≥901级高血压(轻度)140~15990~992级高血压(中度)160~179100~1093级高血压(重度)≥180≥110单纯收缩期高血压≥140<90血压水平的定义和分类注：当收缩压与舒张压属不同级别时，应该取较高的级别分类。中国高血压防治指南2010修订版和和/或和/或和/或和/或和/或和Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 高血压患者心血管风险分层其他危险因素和病史血压(mmHg)1级高血压SBP140-159或DBP90-992级高血压SBP160-179或DBP100-1093级高血压SBP≥180或DBP≥110无低危中危高危1-2个其他危险因素中危中危很高危≥3个其他危险因素，或靶器官损害高危高危很高危临床并发症或合并糖尿病很高危很高危很高危Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 心脏瓣膜病风湿性心脏二尖瓣狭窄并关闭不全主动脉瓣关闭不全Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 结核性心包炎有结核中毒症状心包积液的体征Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 风湿免疫性疾病1.系统性红斑狼疮2.类风湿关节炎Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 系统性红斑狼疮诊断依据临床表现Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 美国SLE诊断标准(美国风湿病学会1997年修订)1、颧部红斑；2、盘状红斑；3、光过敏；4、口腔溃疡；5、关节炎；6、浆膜炎；7、肾脏病变；8、神经系统异常：1)抽搐；2)精神病。9、血液学异常：1)溶血性贫血伴网织红细胞增多；2)白细胞减少,2次或2次以上检测<4.0*109/L；3)淋巴细胞少,2次或2次以上检测<1.5*109/L；4)血小板减少,<100*109/L,但非药物所致。10、免疫学异常：1)抗dsDNA抗体阳性；2)抗Sm抗体阳性；3)APL阳性：ACL阳性；狼疮抗凝物阳性；梅毒血清学试验假阳性11、抗核抗体。★病人如果达到11条中的4条或4条以上，即能诊断为系统性红斑狼疮Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 类风湿关节炎临床表现诊断标准Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 礼仪：着装得体，文明礼貌消除紧张情绪充分理解题意，冷静思考，认真作答同一问题多项考核把握时间，根据题目的难易程度选择作答切记空题不答应试技巧！Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 成功总是偏爱勤奋和有准备头脑的人，祝你们取得优异成绩，马到成功！再见Evaluationonly.CreatedwithAspose.Slidesfor.NET3.5ClientProfile5.2.0.0.Copyright2004-2011AsposePtyLtd. 结束语谢谢大家聆听！！！61'