《老城的话去一初中》PPT课件 26页

风湿性关节炎的演变史05基础医学班第三小组孙琳琳何金龙张易雄安宇刘忱2008-11-27病例三\n病例分析心力衰竭机制\n病例分析病情发展过程风湿性心脏病左心衰竭右心衰竭早期全心衰竭病例分析小结\n第一期幼年时反复扁桃体发炎，6岁扁桃体摘除。曾出现膝关节肿痛，血沉增快。诊断：风湿性关节炎15岁，劳累后胸闷，心悸，二尖瓣舒张期杂音。休息，自服中药后好转。诊断：风湿性心脏病，二尖瓣狭窄\n\n第二期28岁，妊娠6个月，胸闷和心悸的症状加重，伴乏力、气促、夜间喘憋、不能平卧，无少尿和双下肢浮肿。超声心动图显示左心房扩大，左室射血分数53％。39岁，因感冒导致胸闷、心悸和乏力加重。仅可步行500～600米，上楼时气喘加剧。血压达150/90mmHg，心房扑动，左心房增大，二尖瓣轻度狭窄，左室舒张功能减低，左室射血分数47%。\n心房扑动：心房异位节律点频率超过阵发性房性心动过速。当心房异位起搏点频率达250-350次/分时，心房收缩快而协调为心房扑动。\n第三期停用地高辛5天，发生心慌气短，伴喘憋，一次只能系一只鞋的鞋带，夜间患者喘憋明显，不能平卧，坐位入睡。查体体检化验检查诊断：房性心动过速，风湿性心脏病，心衰改变。中度二尖瓣狭窄伴轻度关闭不全、轻度主动脉瓣关闭不全、左室收缩功能减低，左室射血分数39%，主动脉和肺动脉增宽，轻度肺动脉高压。\n体检体温36.4℃，脉搏132次/分，呼吸24次/分，血压150/80mmHg二尖瓣面容：两颧及口唇紫红双肺呼吸音粗，双下肺可闻中小水泡音：肺水肿心尖部舒张期隆隆样杂音：左心房代偿性肥大，血液快速通过二尖瓣，并引起漩涡和振动双下肢轻度凹陷性水肿：静脉轻度淤血，提示有右心衰竭\n化验检查K+：2.8mmol/L，Na+：122mmol/L，Cl-：95mmol/L：离子浓度全部降低，低渗性水过多，水潴留较多动脉血pH：7.32，PaCO2：37mmHg，BE：－9.6mmol/L，血清HCO3-：18.2mmol/L：呼吸性酸中毒\n第四期45岁,受凉后喘憋加重，不能自行行走，夜间坐位入睡，伴咳血痰，暗红色为主，偶有鲜红色血痰。查体诊断风湿性心脏病；二尖瓣狭窄合并关闭不全，主动脉瓣关闭不全，三尖瓣关闭不全；心律失常：心房颤动、完全性右束支传导阻滞；慢性充血性心力衰竭。\n体检体温37.6℃，血压150/70mmHg，脉搏64次/分，呼吸33次/分，口唇发绀,颈静脉怒张。双肺可闻及满肺哮鸣音及少量细湿罗音。心尖部闻及III级收缩期杂音，舒张期隆隆样杂音。双下肢凹陷性水肿。\n\n病例分析小结从风湿性关节炎到心力衰竭第四阶段中-重度二尖瓣狭窄合并关闭不全，联合瓣膜病，全心衰第三阶段中度二尖瓣狭窄伴关闭不全，右心衰早期第一阶段风湿性心脏病第二阶段二尖瓣轻度狭窄，左心衰\n风湿性关节炎扁桃体炎风湿性心脏病，二尖瓣狭窄左心衰二尖瓣狭窄伴关闭不全，主动脉瓣关闭不全左心肥大，收缩功能降低射血分数下降主动脉和肺动脉增宽，肺动脉高压。\n左心衰肺水肿心律失常瓣膜关闭不全合并狭窄酸中毒静脉淤血炎症……二尖瓣面容腹水下肢水肿缺氧表现结果全心衰竭！右心衰\nMechanisms心肌收缩力降低1心肌舒张性能异常2心脏各部分舒缩活动不协调3为什么会出现这些病理变化呢？\n1心肌收缩力降低心肌收缩力降低心肌能量代谢障碍碍1心肌能量生成障碍2心肌储能减少3能量利用障碍兴奋—收缩偶联障碍1肌浆网Ca++转运功能障碍2胞外Ca++内流障碍3肌钙蛋白与Ca++结合障碍1心肌细胞数量减少2心肌结构改变3心室扩张细胞机制\n细胞机制心肌细胞数量减少心肌细胞坏死心肌细胞凋亡心肌结构改变肌丝滑行阻力增大纤维化心室扩张室壁应力增加\n能量机制心肌能量生成障心肌缺血ATP生成减少心肌储能减少心肌肥大，耗能增加，储能形式CP含量降低能量利用障碍肌球蛋白头部Ca2+-Mg2+-ATP酶活性降低\n兴奋-收缩耦联机制肌浆网Ca2+转运功能障碍胞外Ca2+内流障碍肌钙蛋白与Ca2+结合障碍\n2心肌舒张性能异常心肌舒张性能异常心室舒张势能降低心室顺应性下降钙离子复位延缓肌球-肌动蛋白复合体解离障碍\n心脏各部分舒缩活动不协调病变区与非病变区兴奋性、自律性、传导性、收缩性方面发生差异舒缩活动协调性下降最终累及全心心输出量下降\n机制小结心肌兴奋-收缩耦联障碍心肌细胞凋亡坏死心肌能量代谢紊乱钙离子复位延缓肌球-肌动蛋白复合体解离障碍心肌顺应性降低心室舒张势能减弱心律失常心肌收缩性减弱心脏各部位舒缩活动不协调性心肌舒张功能异常心力衰竭\nThankYou！\nYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)vkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8C0z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQJ7F4C1z)w&s!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x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