本文選題：肺栓塞 + 右心功能不全　； 參考：《山東大學(xué)》2012年碩士論文

【摘要】：目的：提高臨床醫(yī)師對不典型急性肺栓塞及早期診斷線索的認(rèn)識,提高早期臨床檢出率,降低誤診率。 方法：對1例不典型急性肺栓塞的臨床病例資料進(jìn)行回顧分析,檢索相關(guān)醫(yī)學(xué)文獻(xiàn),深入探討該類疾病的病理生理學(xué)改變、發(fā)病機(jī)制、臨床表現(xiàn)、影像學(xué)表現(xiàn)、診斷及鑒別診斷,并進(jìn)行歸納總結(jié)。 結(jié)果：急性肺栓塞患者其臨床表現(xiàn)與個體解剖學(xué)差異、有無基礎(chǔ)疾病以及機(jī)體心肺代償能力、疾病病理生理學(xué)改變密切相關(guān),千變?nèi)f化。青年人且無基礎(chǔ)心肺疾病者,由于具有較好的機(jī)體代償能力,通常臨床表現(xiàn)不典型,早期可僅表現(xiàn)為咳嗽、咳痰或其他系統(tǒng)非特異性改變,典型的胸痛、胸悶、呼吸困難等癥狀不多見。輔助檢查中以血清酶學(xué)、心肌損傷標(biāo)志物、心電圖、D-二聚體等的改變較為突出,可以出現(xiàn)血清心肌酶、心肌損傷標(biāo)志物水平明顯升高,心電圖表現(xiàn)為一過性、多變性心肌損傷改變,D-二聚體升高明顯。上述改變均與其病理生理學(xué)機(jī)制相關(guān),即栓子的機(jī)械栓塞作用以及神經(jīng)體液因素機(jī)制參與其中,致使肺動脈高壓,繼而造成右心室后負(fù)荷加重,此時右心室與主動脈的脈壓差減小,使得冠狀動脈出現(xiàn)灌注不足表現(xiàn),加之各種體液因子的釋放,引起心肌細(xì)胞的繼發(fā)性病理改變,在臨床上有心血管系統(tǒng)疾病的表現(xiàn),極易造成肺栓塞的誤診及漏診。大面積肺栓塞容易引起血流動力學(xué)急劇改變,若不能及時診治,死亡率很高。若能及時做出正確的診斷,積極給予抗凝、溶栓治療可以極大地降低該病的死亡率,改善預(yù)后。 結(jié)論：青年人無基礎(chǔ)心肺疾病者罹患急性肺栓塞臨床不常見,相關(guān)文獻(xiàn)報道較少,臨床表現(xiàn)不具有典型性,易與心肺其他疾病的臨床表現(xiàn)混淆,故在臨床工作中極易造成誤診或漏診。臨床醫(yī)師應(yīng)提高對該類患者肺栓塞的認(rèn)識和了解,系統(tǒng)掌握特異性輔助檢查結(jié)果,更好的把握疾病的病理生理學(xué)基礎(chǔ),以提高疾病的檢出率和治愈率。
[Abstract]:Objective: to improve the clinicians' understanding of atypical acute pulmonary embolism and early diagnosis cues, to improve the early clinical detection rate and to reduce the misdiagnosis rate. Methods: the clinical data of one case of atypical acute pulmonary embolism were retrospectively analyzed, and the relevant medical literature was searched, and the pathophysiological changes, pathogenesis, clinical manifestations and imaging manifestations of the disease were discussed. Diagnosis and differential diagnosis, and summarized. Results: the clinical manifestations of patients with acute pulmonary embolism were closely related to individual anatomy, whether there were underlying diseases, the ability of cardiopulmonary compensation, and the pathophysiological changes of the disease. In young people with no underlying cardiopulmonary disease, because of their good compensatory ability, the clinical manifestations are usually atypical. In the early stage, they can only show cough, expectoration or other nonspecific changes of the system, typical chest pain, chest tightness. Dyspnea and other symptoms are rare. The changes of serum enzymes, myocardial injury markers, electrocardiogram (ECG) D-dimer and so on were more prominent, and serum myocardial enzymes could appear. The level of myocardial injury markers was significantly increased, and the electrocardiogram was transient. The change of D-dimer was significant in polymorphic myocardial injury. These changes were related to the pathophysiological mechanism, that is, the mechanical embolism of embolus and the involvement of neurohumoral factors, which resulted in pulmonary hypertension and increased right ventricular afterload. At this time, the pressure difference between the right ventricle and the aorta decreases, which makes the coronary artery appear insufficient perfusion, coupled with the release of various humoral factors, which results in the secondary pathological changes of cardiac myocytes, and the clinical manifestations of cardiovascular diseases. It is easy to cause misdiagnosis and missed diagnosis of pulmonary embolism. Large-area pulmonary embolism is easy to cause rapid hemodynamic changes, if not timely diagnosis and treatment, the mortality rate is very high. If correct diagnosis and active anticoagulation can be made, thrombolytic therapy can greatly reduce the mortality and improve the prognosis of the disease. Conclusion: acute pulmonary embolism is uncommon in young people with no underlying cardiopulmonary disease, and the clinical manifestations are not typical and easily confused with the clinical manifestations of other cardiopulmonary diseases. Therefore, it is easy to cause misdiagnosis or missed diagnosis in clinical work. Clinicians should improve their understanding and understanding of pulmonary embolism, systematically master the results of specific auxiliary examinations, and better grasp the pathophysiological basis of the disease so as to improve the detection rate and cure rate of the disease.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2012
【分類號】：R563.5

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