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2017-09-19 何金山 医学界心血管频道

人们常用侦探来形容医生,因为医生常常从细微处着手找到正确的诊断;前辈们经常教导我们,做医生要认真,因为一个小小的线索就能成为诊断和鉴别诊断的关键;我们也常常告诫自己,要从问病史、查体这些细节做起,避免误诊、漏诊,为患者提供最佳的医疗。

人们常用侦探来形容医生,因为医生常常从细微处着手找到正确的诊断;前辈们经常教导我们,做医生要认真,因为一个小小的线索就能成为诊断和鉴别诊断的关键;我们也常常告诫自己,要从问病史、查体这些细节做起,避免误诊、漏诊,为患者提供最佳的医疗。

但是所谓“纸上得来终觉浅”,听了再多的经验,也没有一个实例带来的教训深刻。借着最近发表在心内科顶级杂志《Circulation》上的一个病例,我们来看看查体如何能够在误诊的边缘力挽狂澜。

病例简介

患者18岁年轻男性,因突发右侧胸痛伴呼吸困难就诊。

查看患者意识清楚,呼吸窘迫貌,Bp 95/66 mmHg,HR 121 bpm,RR 38 次/分,SPO2 在吸氧4 L/min情况下由88%升至98%。患者心律齐,各瓣膜听诊区未闻及杂音。心电图(图1)提示窦性心动过速,II、III、aVF导联ST段抬高,I、aVL导联ST段压低。急查血清心肌坏死标记物(TNI)回报:0.39 ng/ml(正常 < 0.04 ng/ml)。


图1:患者心电图提示窦性心动过速,II、III、aVF导联ST段抬高,I、aVL导联ST段压低,急性下壁ST段抬高型心肌梗死可能性大。

那么,下一步该如何处置该患者呢?

咱们来分析下。

>>>>

A:急诊冠脉介入?

患者有胸痛症状,心电图可见下壁导联ST段抬高,TNI也高于正常,符合了我们对急性心肌梗死的所有预期,既然为ST短抬高型心肌梗死,那么直接走绿色通道,准备急诊冠脉介入吧。

>>>>

B:急诊溶栓?

当然,有的地方可能没有急诊冠脉介入的条件,或者导管室正在占用,预计很长时间后才能进行冠脉介入手术,又不能在短时间内转运至具有介入资质的医院,因而有人建议溶栓也是一种治疗方法。

可是,患者毕竟才18岁,虽然临床中可见早发冠心病者,但是18岁并不是该病的高发年纪,且患者表现为右侧胸痛,呼吸频率加快,SPO2降低,是否有心梗之外的其他原因导致胸痛和上述心电图改变呢?

>>>>

C:拍胸片?

胸痛是我们常碰到的症状,其原因较多,鉴别涉及到胸壁、胸膜、肺、心包、心脏等各个方面。这对这个患者,患者除胸痛外,呼吸加快,SPO2降低等呼吸系统症状明显,是否有呼吸系统导致胸痛的原因呢?常见的包括气胸、肺炎、肺栓塞等。

总之,先查个胸片是必要的。

该病例的处置也是如此,急查胸片(图2)提示右侧大量气胸,可见气管及纵膈右偏,于是未行急诊冠脉介入,而是做了胸腔闭式引流(图3),气胸缓解,右偏的纵膈复位,患者胸痛消失,复查心电图可见抬高的下壁导联回落,遗留III导联T波倒置(图4)。


图2:胸片提示气胸,箭头指示气胸线,可见气管及纵膈右偏。


图3:闭式引流后,气胸缓解,纵膈恢复正常位置。


图4:气胸缓解后复查心电图,可见下壁导联回落,遗留III导联T波倒置。

是不是正确答案就是C了呢?

C是正确的答案,但也不是一定正确的答案,所以会有D。

>>>>

D:其他……

如果没有条件拍胸片呢?

难道就要去急诊介入或者溶栓?就不能发现气胸了吗?

患者没有发热,突发剧烈的右侧胸痛,肺炎可能性不大。患者年轻男性,既往无特殊高凝状态病史,无双下肢肿胀,没有听到P2亢进,肺栓塞证据不足。患者血压不高,双侧对称,主动脉夹层的可能性不大。

如果没有条件拍胸片,我们最重要的就是问一下患者胸痛的具体性质,范围?持续时间?和呼吸是否相关?和活动是否相关?如果患者烦躁明显,不能配合,需要检查一下患者气管是否居中,要听诊双侧呼吸音是否对称,要叩诊双侧是鼓音还是清音。

我想,这些就是选项D的答案,作为C行不通时的补充。

可能有了选项D,有了一次关键的听诊,患者就能少进一次不必要的导管室。

其实,临床上,提供给我们诊断思路最重要的来源是病史和查体,所有的化验和检查,都是辅助诊断和鉴别诊断进行的,很多检查具有一定的特异性,但不能本末倒置,看到辅助检查的结果,就进行了想当然的诊断,不再进行必要的鉴别。

心电图ST段抬高≠急性心肌梗死,现在开始,需要确立这个概念,对于年轻患者,气胸是鉴别诊断之一。

很多临床疾病的诊断,就像讲一个故事一样,总体特征的符合很关键,生长在北极,白色,隶属熊类,北极熊可能性超大,而不能见到白毛的都叫北极熊,这就会出问题。

那么,这个患者到底发生了心肌梗死没有?患者在TNI升高的基础上,有心电图的动态改变(抬高再回落,III导联T波倒置),可以明确心肌梗死的诊断。只是不是我们传统意义上和动脉粥样硬化斑块相关的心肌梗死。

患者心肌梗死的原因是什么呢?考虑为继发性心肌梗死,即氧供/氧需不匹配形成的。气胸引起的缺氧可以导致;气胸导致的机械压迫影响到右冠状动脉可以导致;气胸、纵膈移位诱发了冠脉痉挛可以导致。存在上述可能,但是确切机制未明。

在检查日益先进的近日,我们需要依靠检查,但不能依赖检查,问病史+查体这些基本功,是诊断的关键,是先进的检查所不能替代我们的地方,让我们用自己侦探一样的眼睛和头脑,守住误诊的最后一道关卡!

原始出处:

1.Mahmoud Abdelghany,haudhary A, Liu K, et al. Chest Pain in an 18-Year-Old Man. Circulation. 2017;136:502-504.

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    2017-09-23 欣然梅斯

    分析很到位

    0

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    2017-09-22 欣然梅斯

    学习了

    0

  3. 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createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDM9swhbgTo7nzqRKzMmzckmEoeTyLQVDCgjqsicjyhxPs0vPoYU6GsSYbCjSkNHicJkz3NL0a0EbUMVdNjkctXI6FocpGKaVr9E/0, createdBy=29392048316, createdName=王秀, createdTime=Wed Sep 20 10:00:58 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245953, encodeId=0a9d245953e1, content=心肌梗塞的诊断不能明确., beContent=null, objectType=article, channel=null, level=null, likeNumber=119, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3zSn0GqHrsfLKbEHxIRqLAt9e2EibibeqlvwSQjrAgxJ17yflY6gvEKbsW6Sh8rib7Mb1kQfeb1MQsvO2ffs1xTHXs/0, createdBy=b21d1497233, createdName=ligengquan, createdTime=Wed Sep 20 09:26:08 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245925, encodeId=6e12245925e9, content=第一反应这个年纪发生心梗可能性不大.且胸痛位于右侧.肯定是首要排除气胸的, beContent=null, objectType=article, 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topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo5nmIH5IQqCKjJgSCuicPWUWOUcdqt1ROPnEiaOYN4pSHibDv8la3OxNLalvuvUXn8clpJlrpuyTpckgt9OPkeSSdT/0, createdBy=8fd71930726, createdName=半夏微凉, createdTime=Wed Sep 20 07:11:49 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245883, encodeId=ba7524588347, content=学习了.感谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/C20CB8E4EBB36F5B821651C710BCB491/100, createdBy=18de1715848, createdName=lofter, createdTime=Wed Sep 20 06:58:12 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245876, encodeId=ca3d2458e658, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Wed Sep 20 06:55:44 CST 2017, time=2017-09-20, status=1, ipAttribution=)]
    2017-09-20 王秀

    学习了.涨知识了!

    0

  4. 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topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo5nmIH5IQqCKjJgSCuicPWUWOUcdqt1ROPnEiaOYN4pSHibDv8la3OxNLalvuvUXn8clpJlrpuyTpckgt9OPkeSSdT/0, createdBy=8fd71930726, createdName=半夏微凉, createdTime=Wed Sep 20 07:11:49 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245883, encodeId=ba7524588347, content=学习了.感谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/C20CB8E4EBB36F5B821651C710BCB491/100, createdBy=18de1715848, createdName=lofter, createdTime=Wed Sep 20 06:58:12 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245876, encodeId=ca3d2458e658, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Wed Sep 20 06:55:44 CST 2017, time=2017-09-20, status=1, ipAttribution=)]
    2017-09-20 王秀

    学习了.涨知识了!

    0

  5. 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topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo5nmIH5IQqCKjJgSCuicPWUWOUcdqt1ROPnEiaOYN4pSHibDv8la3OxNLalvuvUXn8clpJlrpuyTpckgt9OPkeSSdT/0, createdBy=8fd71930726, createdName=半夏微凉, createdTime=Wed Sep 20 07:11:49 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245883, encodeId=ba7524588347, content=学习了.感谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/C20CB8E4EBB36F5B821651C710BCB491/100, createdBy=18de1715848, createdName=lofter, createdTime=Wed Sep 20 06:58:12 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245876, encodeId=ca3d2458e658, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Wed Sep 20 06:55:44 CST 2017, time=2017-09-20, status=1, ipAttribution=)]
    2017-09-20 ligengquan

    心肌梗塞的诊断不能明确.

    0

  6. 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channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cabb1969833, createdName=semrour, createdTime=Wed Sep 20 08:03:07 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245909, encodeId=cce9245909d6, content=学习了新知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201006/4db877c2887649beb09cb5effd0b38c7/916f66edd48a4e77b20ebc3e14b6e45c.jpg, createdBy=141e1980133, createdName=Y—xianghai, createdTime=Wed Sep 20 07:49:49 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245893, encodeId=d4f02458938c, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo5nmIH5IQqCKjJgSCuicPWUWOUcdqt1ROPnEiaOYN4pSHibDv8la3OxNLalvuvUXn8clpJlrpuyTpckgt9OPkeSSdT/0, createdBy=8fd71930726, createdName=半夏微凉, createdTime=Wed Sep 20 07:11:49 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245883, encodeId=ba7524588347, content=学习了.感谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://q.qlogo.cn/qqapp/1103841572/C20CB8E4EBB36F5B821651C710BCB491/100, createdBy=18de1715848, createdName=lofter, createdTime=Wed Sep 20 06:58:12 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245876, encodeId=ca3d2458e658, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Wed Sep 20 06:55:44 CST 2017, time=2017-09-20, status=1, ipAttribution=)]
    2017-09-20 semrour

    第一反应这个年纪发生心梗可能性不大.且胸痛位于右侧.肯定是首要排除气胸的

    0

  7. 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likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Wed Sep 20 06:55:44 CST 2017, time=2017-09-20, status=1, ipAttribution=)]
    2017-09-20 Y—xianghai

    学习了新知识

    0

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    2017-09-20 半夏微凉

    学习了谢谢分享

    0

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likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Wed Sep 20 06:55:44 CST 2017, time=2017-09-20, status=1, ipAttribution=)]
    2017-09-20 lofter

    学习了.感谢分享

    0

  10. 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    2017-09-20 明月清辉

    谢谢分享.学习了

    0

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