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1、NursingTeachingRound护理教学查房CaseReport病例报告买买提·艾山，男，58岁，新疆籍新疆军区副政委。主因发现心脏杂音32年，发作性心悸5年于2007年3月7日入院。PatientMaiMaiTi,male,58year-old,wasborninxinjiang.HewasadmittedtothehospitalonMarch7th2007.Chiefcomplaint:Hehashadcardiacmurmursfor32years,Palpitationfor5years.现病史Pr
2、esentHealthHistory缘于32年前查体发现心脏杂音，患者始终无症状。自5年前经常于劳累或饮酒后感心悸，伴轻度胸闷Thepatienthadcardiacmurmurs32yearsago,buthewasasymptomatic.Hefeltpalpitationafterfatigueoralcoholintake5yearsago,sometimesaccompaniedbychestdiscomfort.现病史PresentHealthHistory无头晕、恶心、呕吐及晕厥,无胸痛休息后可缓解No
3、nauseaandvomiting,chestpain,dizzy,faint.Thesesymptomscanberelievedbyrest.现病史PresentHealthHistory2005年6月动态心电图显示频发多型室性早搏和阵发性室速给予口服胺腆酮治疗超声心动图提示左室流出道压力阶差高,ΔPG＝113mmHgContinuousECGrevelsprematureventricularcontractionsandparoxysmalventriculartachycardiaonJune2006.Or
4、alAmiodaronewasgivenhimtocontrolthem.Echocardiographyshowsleftventriclehypertrophy,leftventricleoutflowwasnarrow.ΔPGis113mmHg.现病史PresentHealthHistory2005年7月明确诊断为肥厚型梗阻性心肌病会诊决定暂时应用β-受体阻滞剂和钙拮抗剂行药物治疗观察血流动力学，如左室流出道压差降低，则继续药物治疗，如左室流出道压力阶差降低不明显，考虑射频消融结合起搏治疗。Hewasdiagn
5、osedasHCM(HypertrophicCardiomyopathy)onJuly2005.Betablockersandcalciumchannelblockerswereused.Thehaemodynamymustbeobserved.既往史PastHealthHistory否认冠心病、糖尿病病史否认肝炎、结核等传染病史否认手术外伤及输血史无药物过敏史DenyhistoryofCAD,diabetesmellitus.DenyhistoryofheritagefamilydiseaseDenyhistory
6、ofsurgicaloperations,injuriesandbloodtransfusion.Nomedicineallergy个人史PersonalHistory：生于原籍，长期居住新疆，到过全国各地否认疫区居住史，否认化学毒物及放射性物质接触史。有吸烟史数十年，已戒烟，偶尔饮酒，无明确规律。已婚，配偶子女均体健大学文化程度Hasneverbeentoepidemicarea,denyhistoryofpoisontouching.Hashistoryofsmokingformanyyears,hehasalr
7、eadyquitsmoking.Drinkingoccasionally.Hiswifeishealthy.Thetwodaughtersarealsohealthy.Bachelordegree.家族史FamilyHistory父母双亡，死因不详家族中无类似疾病患者否认家族遗传病病史Ithasnotbeenfoundsimilardiseaseinhisfamily.Denyhistoryoffamilyheritagedisease.Hisparentsweredied,thereasonhasnotbeencl
8、ear.入院查体physicalexaminationT36.5℃P69次/分，R18次/分BP120/80mmHg发育良好一般情况好，双肺呼吸音清，未闻及干、湿性罗音T:36.5℃,HR:69b/m,R:18t/m,Bp120/80mmHg,DevelopedwellGenerallyspeaking,heisingoodcondition.
