不典型急性肺栓塞1例报告及早期诊断线索回顾性分析

发布时间：2018-05-27 18:41

本文选题：肺栓塞 + 右心功能不全　；参考：《山东大学》2012年硕士论文

【摘要】：目的：提高临床医师对不典型急性肺栓塞及早期诊断线索的认识,提高早期临床检出率,降低误诊率。方法：对1例不典型急性肺栓塞的临床病例资料进行回顾分析,检索相关医学文献,深入探讨该类疾病的病理生理学改变、发病机制、临床表现、影像学表现、诊断及鉴别诊断,并进行归纳总结。结果：急性肺栓塞患者其临床表现与个体解剖学差异、有无基础疾病以及机体心肺代偿能力、疾病病理生理学改变密切相关,千变万化。青年人且无基础心肺疾病者,由于具有较好的机体代偿能力,通常临床表现不典型,早期可仅表现为咳嗽、咳痰或其他系统非特异性改变,典型的胸痛、胸闷、呼吸困难等症状不多见。辅助检查中以血清酶学、心肌损伤标志物、心电图、D-二聚体等的改变较为突出,可以出现血清心肌酶、心肌损伤标志物水平明显升高,心电图表现为一过性、多变性心肌损伤改变,D-二聚体升高明显。上述改变均与其病理生理学机制相关,即栓子的机械栓塞作用以及神经体液因素机制参与其中,致使肺动脉高压,继而造成右心室后负荷加重,此时右心室与主动脉的脉压差减小,使得冠状动脉出现灌注不足表现,加之各种体液因子的释放,引起心肌细胞的继发性病理改变,在临床上有心血管系统疾病的表现,极易造成肺栓塞的误诊及漏诊。大面积肺栓塞容易引起血流动力学急剧改变,若不能及时诊治,死亡率很高。若能及时做出正确的诊断,积极给予抗凝、溶栓治疗可以极大地降低该病的死亡率,改善预后。结论：青年人无基础心肺疾病者罹患急性肺栓塞临床不常见,相关文献报道较少,临床表现不具有典型性,易与心肺其他疾病的临床表现混淆,故在临床工作中极易造成误诊或漏诊。临床医师应提高对该类患者肺栓塞的认识和了解,系统掌握特异性辅助检查结果,更好的把握疾病的病理生理学基础,以提高疾病的检出率和治愈率。
[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.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R563.5

【参考文献】