7 个临床经验积累开阔你的思维

2016-11-19 我的加菲肿瘤时间

一位医生的小经验，长期积累，点滴汇总来的，希望对大家有所帮助。1. 鼻塞鼻涕和鼻咽癌患者，50 岁，因鼻塞低热就诊。查血象胸片后以「上呼吸道感染」予以「庆大霉素、病毒唑」静点，2 天后病人诉耳聋，疑为庆大所致，遂改为「氨苄西林」静点，不见好转。TIPS：建议耳鼻喉科检查, 约一周后病人往上级医院确诊为「鼻咽癌」。2.三叉神经痛和颅内出血24 岁患者，诉头痛难忍，敲打桌面，起初以为是三叉神

一位医生的小经验，长期积累，点滴汇总来的，希望对大家有所帮助。

鼻塞鼻涕和鼻咽癌

患者，50 岁，因鼻塞低热就诊。查血象胸片后以「上呼吸道感染」予以「庆大霉素、病毒唑」静点，2 天后病人诉耳聋，疑为庆大所致，遂改为「氨苄西林」静点，不见好转。

TIPS：建议耳鼻喉科检查, 约一周后病人往上级医院确诊为「鼻咽癌」。

三叉神经痛和颅内出血

24 岁患者，诉头痛难忍，敲打桌面，起初以为是三叉神经痛，后做头颅 CT，结果示颅内出血。

主任还说过：「脑血管意外病人少用糖水补液。」脑血管意外患者大脑处于缺氧状态，糖水补进去后，脑细胞在缺氧状态下会增加糖酵解，使乳酸堆积......

腹泻腹痛和肝癌

青年女性，因腹痛、腹泻 2 天就诊，给予补液及左氧氟沙星抗感染。输左氧过程中，患者突然出现四肢僵直、发笑，给予镇静处理后患者仍然会时不时发笑。

入院后因患者家属拒绝交钱，每天予补液治疗、口服黄连素抗感染。但患者仍时有少量腹泻且大小便不能自控，时有发笑、腹痛、四肢僵直发作。

患者有离婚史，考虑癔病予以诱导治疗缓解但腹痛腹泻为止。后来查 B 超有少许腹腔积液，肝脏 B 超是肝脏多发实质性肿块并门静脉栓子形成，AFP ＞ 1000 ng/mL。

最后确诊为原发性肝癌，解释她所有的症状。

术后持续昏迷

40 岁男性，纵隔巨大肿瘤，术前心电图偶发室早。全麻，术中病人一直平稳，手术也很顺利，约 2 个小时搞定关完胸，等待麻醉清醒。

关胸时已停药，过了 30 分钟，患者仍不醒，血氧饱和度 95%～100%，血压正常，心率 120 次/分，仍偶发室早，呼吸机械通气，潮气量 400 mL，睑结膜水肿。

予处理，1 小时后患者仍不清醒，请内科会诊，考虑可能术中挤压肿瘤，瘤栓脱落致脑栓。

主任说：「血气怎么样？」

遂急查：动脉二氧化碳 110。立即加大潮气量，纯氧通气吸入，15 分钟后病人清醒。

TIPS：术中、术后常规查血气，不能因机械通气、吸入纯氧就忽视二氧化碳潴留。

儿童昏迷与营养

13 岁男孩，因 3 天未排大便入院，喝了 2 瓶冰红茶后出现意识模糊、全身瘀斑、颈抗 2 指，血常规 WBC12 左右、血气严重代酸、PH7.29，当时考虑流脑。

后患儿病情加重, 转 ICU 后拟腰穿, 一查血糖 38，因小孩进来饮食不好, 是饥饿性酮症。

心脏病和癌症

患者，70 岁，风湿性心脏病几十年病史，因心悸、气短、恶心 2 小时入院。测血压 120/80 mmhg，心率 145 次/分，全身湿冷，心衰症状及体征不明显。

主任说：「只考虑心脏了，是不是失血休克？」。查腹水征阳性，腹穿抽出不凝血，血压开始下降，剖腹探查：肝癌破裂出血。

胃肠炎与胃出血

患者女，因腹痛腹泻 3 小时就诊。主诉中午在街上买了一碗比较辣的凉面, 可能不太卫生，腹痛、腹泻两次，查体后考虑为急性胃肠炎。嘱患者查血常规，刚走到诊室门口, 忽然说：「我想吐」跟去洗手间一看, 呕吐为咖啡色样胃内容物，诊断为「急性上消化道大出血」。

TIPS：临床上不能过于相信病人讲的诱因，容易误导诊断；通过观察病人的分泌物、排泄物等可协助诊断。

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2017-04-27 1e145228m78(暂无匿称)

学习了，谢谢作者分享!

96 0
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2017-09-09 jiyangfei

#临床经验#

78 0
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2016-11-30 Tulipzyz

是啊，我问的病史就和上级不一样

103 0
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2016-11-20 刘翔翔

谢谢，学习了

91 0
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2016-11-20 小树

学习了，学习！

101 0

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