生理病案讨论

生理学病案讨论

（供临床医学、口腔医学、基础医学等专业使用）

四川大学华西基础医学与法医学院生理教研室

2008年9月

第一章细胞生理

Clinical Case 1

A 48-year-old women with insulin dependent diabetes mellitus reports to her physician that she is experiencing severe muscle weakness. She is being treated for hypertension with propranolo, a β-adrenergic blocking agent. He physician immediately order blood studies, which reveal a serum [K+] of 6.5mEq/L (normal,4.5mEq/L) and elevaled BUN (blood urea nitrogen). The physician tapers off the dosage of propranolol ,with eventual discontinuation of the drug. He adjusts her insulin dosage. Within a few days, the patient’s serum [K+] has decreased to 4.7 5mEq/L, and she reports that her muscle strength has returned to normal. Question: Why does hyperkalemia cause muscle weakness？

Clinical Case 2

An 18-year-old college woman comes to the student health service complaining of progressive weakness. She reports that occassionally her eyelids “drop” and that she tires easily, even when completing ordinary daily tasks such as brushing her hair. She has fallen several times while climing a flight of stairs. These symptoms improve with rest. The physician orders blood studies, which reveal elevated of antibodies to ACh receptors. Nerve stimulation studies show decreased responsiveness of skeletal muscle upon repeated stimulations. The women is diagnosed with myasthenia gravis and is treated with drug pyridostigmine. After treatment, she reports a return of muscle strength.

Please explain her progressive weakness based on the clinical studies.

第四章循环系统

病案摘要：

张XX，男，56岁

主诉：因反复头昏头痛15年，加重半年伴视物模糊一天入院。

病史：患者15年前无明显诱因出现轻度头昏头痛，尤以午后及情绪激动后为著。休息后可缓解。未加重视。以后，上述症状反复出现并逐年加重。去年体检时发现血压高，约220／110mmHg，服“降压灵”后，症状有所减轻。近半年

来，因工作繁忙，头痛明显加重，昨日因情绪激动后出现视物模糊，遂来院诊治，门诊以高血压之诊断收入。

体检：血压250／120mmHg，脉搏98次／分，呼吸20次／分，面色红润，神志清楚。双侧瞳孔等大等圆，对光反射灵敏。眼底检查：动脉呈银丝状，动静脉交叉压迹明显，左眼底可见散在出血及渗出物。肺部检查无异常。心尖搏动位于第5肋间左锁骨中线外1．5cm，心界向左下方扩大，心音有力，心率98次／分，律齐，心尖处可闻及吹风样收缩期杂音，主动脉瓣区第二心音增强。余各瓣膜听诊区未闻及异常心音及杂音。

讨论内容：

1. 该患者的可能诊断是什么？

高血压

2. 引起或加重高血压的可能因素是什么？

由于情绪激动，工作繁忙引起神经的紧张性增高，肾上腺素、去钾肾上腺素分泌增多，缩血管神经兴奋

3. 血压升高对心脏功能有何影响?

血压升高，会增加心脏的后负荷，使得心脏的等容收缩期延长和射血期缩短，射血期心室肌缩短的程度和速度都减小，射血速度减慢，搏出量减少。心室肌会出现代偿性肥厚。同时，高血压可加速冠状脉硬化的形成和发展，增加心脏的重量，使心肌氧供需平衡发生失调，导致心绞痛甚至心肌梗塞。高血压心脏病的主要死亡原因为心肌梗塞和心力衰竭。

4. 如果高血压得不到控制，还可能有哪些脏器受累，为什么？

一、心脏：高血压会增大人体外周动脉的阻力，使左心室的射血负荷加重，导致心脏需要以更大的压力把血液输送到人体的各个器官。心脏如此长期加大负荷地进行工作，会使左心室变得肥厚、扩张，最终可导致心脏因不堪重负而发生心力衰竭。

二、脑：由于脑血管比较薄弱(发生动脉硬化的脑小动脉尤为脆弱)，因此一旦血压发生波动，脑血管极易破裂出血(出血常发生在内囊或基底结处)，造成脑卒。

三、肾脏：高血压可使流经肾小球的血液增多，也可引起肾细小动脉硬化，导致肾功能迅速减退，使患者出现尿频、夜尿增多等症状。做尿常规检查时可见其尿液中有蛋白质、红细胞和管型(蛋白质凝聚在肾小管腔中所形成的一种圆柱状物