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患者男,76岁,血压高6年,心悸3月.胸闷、不能平卧于1990—9—14入院。查体:端坐位、颈静脉怒张,BP22/14kPa(170/100 mmHg)心界向左下扩大,心率62/min,节律不齐,心音强弱不等,未闻及病理性杂音;两肺底可闻及水泡音。肝肋下约3cm,肝颈返流征阳性.双下肢水肿。X 线胸片示“主动脉”型心脏。心电图(图1)示房颤,左室肥厚伴劳损.血钾3.5 mmol/L。血钠134 mmol/L,血钙2.2 mmol/L,血氯102 mmol/L,尿素氮4.0 μmol/L。临床诊断:高血压性心脏病,心房颤动,心功能Ⅳ级。入院后口服巯甲丙脯酸25 mg tid,双氢克尿噻25mg tid,螺内酯20 mg bid.治疗后血压降至正常.胸闷、气急消失可平卧。9-20下午2时30分,胸闷、心慌加剧,不能平卧,大汗淋漓、血压14/6 kPa(100/50mg),心率32/min,律齐.心电图提示:窦室传导,心电轴-54°(图2)。急查血钾为6.6 mmol/L,即停服巯甲丙脯酸,予以克分子乳酸钠100 ml 静脉注射.10%葡萄糖酸钙10ml 缓慢静注.10%葡萄糖500 ml,正规胰岛素16U 静点.吸氧.利尿等综合治疗后.病情渐好转,症状改善。9-21复查血钾为4.3 mmol/L,心电图恢复为窦性心律伴2°Ⅰ型房室传导阻滞(图3)。约24小时后又转为房颤。
Male patient, 76 years old, high blood pressure for 6 years, palpitations March. Chest tightness, can not lie in 1990-9-14 admission. Examination: end sitting, jugular vein engorgement, BP22 / 14kPa (170/100 mmHg) left heart to expand the heart, heart rate 62 / min, irregular rhythm, heart sound intensity range, no smell and pathological murmur; two lungs The end can be heard and blisters sound. Liver ribs about 3cm, liver reflux sign positive .Double lower extremity edema. X-ray showed “aorta” type heart. ECG (Figure 1) shows atrial fibrillation, left ventricular hypertrophy with strain, serum potassium 3.5 mmol / L. Serum sodium 134 mmol / L, blood calcium 2.2 mmol / L, blood chlorine 102 mmol / L, urea nitrogen 4.0 μmol / L. Clinical diagnosis: hypertensive heart disease, atrial fibrillation, cardiac function Ⅳ level. After admission, oral captopril 25 mg tid, hydrochlorothiazide 25 mg tid, spironolactone 20 mg bid. After treatment, blood pressure dropped to normal. 9-20 at 2:30 pm, chest tightness, palpitation increased, can not supine, sweating, blood pressure 14/6 kPa (100 / 50mg), heart rate 32 / min, law Qi. Shaft -54 ° (Figure 2). Rapid check of potassium is 6.6 mmol / L, that is, captopril, to take molecular lactate 100 ml intravenously .10% calcium gluconate 10ml slow intravenous injection .10% glucose 500 ml, regular insulin 16U static point. Oxygen, diuretic and other comprehensive treatment, the disease gradually improved, the symptoms improved. 9-21 review of potassium is 4.3 mmol / L, ECG recovery of sinus rhythm with 2 ° Ⅰ type atrioventricular block (Figure 3). About 24 hours later changed to atrial fibrillation.