壹生资讯-『Day1』这例高血压为何难治？如果诊治前有一段“冷静期”……

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『Day1』这例高血压为何难治？如果诊治前有一段“冷静期”……

2020-08-03作者：论坛报心血管活动

高血压病例

万事不能轻易下决定，离婚都有了“冷静期”！

那么，在给病人开检查、作诊断、处方治疗药物前，是否也需要一个“冷静期”？

专家在这个“冷静期”都会想些什么？

看看这个病例：

患者，男性，53岁，蒙古族。

主因发现高血压16年，胸闷5年，血压“不易控制”2年就诊。患者16年前因头晕发现高血压，血压最高达210/120 mmHg，不伴有头痛，无明显心悸、气短、胸闷及胸痛，无明显双下肢水肿，无明显尿量、尿色变化，在当地医院以“高血压”给予硝苯地平及普萘洛尔治疗，血压控制不良。

10年前因血压控制不佳来北京住院诊治，诊为“多发性大动脉炎，继发性高血压”，先后行“双侧锁骨下动脉旁路移植术”及“右侧股动脉血管瘤切除及旁路移植术”，术后长期不规律服用泼尼松及免疫抑制剂。术后血压仍波动较大，服用硝苯地平缓释片、依那普利及氢氯噻嗪等，双上臂血压不易测出。因“大动脉炎”间断口服泼尼松治疗。

5年前患者出现活动后胸闷、气短，多于快走及爬楼梯时出现，休息后可缓解，当地医院心电图显示陈旧性心肌梗死；超声心动图提示左心室心尖部及室间隔中、下段节段性室壁运动障碍，左心房扩大，舒张功能不全。诊断为“冠状动脉粥样硬化性心脏病，陈旧性心肌梗死”，给予药物治疗（美托洛尔、依那普利、硝苯地平缓释片及氢氯噻嗪）。自觉胸闷、气短时有发生，运动耐量逐渐下降，双下肢轻度水肿。

近2年头晕、头痛发作较频繁，不伴有肢体活动障碍。活动后胸闷、气短，无胸痛，夜间平卧休息，有夜间胸闷发生，无须坐起即可逐渐缓解，双下肢水肿，尿量无明显变化，食欲及大便正常。

患者否认既往糖尿病、慢性呼吸道炎症及传染病病史。吸烟30年，每天20支。否认酗酒史。

母亲患有高血压。

下一步：体检和辅助检查……

停！

冷静一下，请投票作出你的思考和选择：

（明日公布陈源源教授对病史资料的思考，敬请期待！）

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