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病例分析之这只是另一种偏头痛吗? – 译学馆
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病例分析之这只是另一种偏头痛吗?

Just Another Migraine? – Family Medicine | Medical Video

好的 最后一个病例
Okay, last case.
我这里有一位年迈的病人
So I’ve got an older patient here.
我有一位75岁的有一天头痛病史的女士
I’ve got a 75-year-old woman, she has a 1-day history of headache.
好吧 这是我的偏头痛病症之一 她解释到
“Well, It’s just one of my migraines,” She explains.
听起来并不严重 让我们再收集一些信息
Sounds pretty benign, let’s get a little bit more.
她有长期的单侧偏头痛史
So she has a long history of unilateral migraine headaches
以前可以靠
which previously resolved with
大剂量非甾体抗炎药缓解
just a high-dose nonsteroidal anti-inflammatory drugs.
然而 这个偏头痛的症状有些不同
However, the character of this pain is different.
疼痛部位尤其集中在太阳穴
It’s very concentrated over her temple specifically,
实际上一碰就痛
and it’s actually tender to palpation there.
所以 单凭有限的病史
So, just with that limited history alone,
该病人下一步如何处理才最合适
what’s the next best step in the management for this patient?
再次申明 你可以停下来思考一阵
Again, you could pause and think about this for a second.
所以 选项A 仅仅更换她正在使用的非甾体抗炎药
So is it A just change the type of NSAIDs she is taking,
或许就会有所改变
maybe that will make a difference.
或是表明她的想法是对的 可能只是发作性的偏头痛 安抚她的情绪
Just reassurance she’s right, probably just a recurrent migraine,
以及继续使用预期的治疗
and just continue with that expected management
在一段时间内会有一定的疗效
that’s been working for a while.
你开始用一种新药 比如曲坦类药物代替NSAIDs
You initiate maybe a new drug, like a triptan, instead of giving her an NSAID,
对偏头痛可能更有疗效
maybe that’ll be more effective for a migraine headache.
或者选项D 立即送她去实验室
Or D, do we send her to the laboratory immediately
以及开始使用皮质类固醇药物
and we also initiate corticosteroids.
这就是扔给你的一个难题
So this one is to throw you off that
的确 并不是每个急诊治疗的案例
indeed not every case of acute management,
只需要安抚情绪 然后问题就能随时间缓解
just needs reassurance and it will probably resolve with time.
因为这次不同寻常
Because this is unusual.
新型头痛及不同类型的头痛
New headaches and different types of headaches
总是应该亮起警灯
always should raise attention for potential red flags.
这个案例中 你会看到一位75岁女士有着
In this case, you’re seeing unilateral temporal based pain
单侧阵发性头痛 并且触碰时加重
in a 75-year-old woman, with the area actually tender to palpation.
所有证据都指向
All of that is very, very concerning for the diagnosis of
颞动脉炎 很好
temporal arteritis, very good.
并且 颞动脉炎会伴有严重并发症
And so temporal arteritis can have severe complications,
特别是在血栓形成以及急性缺血上有风险
particularly in terms of risk of thrombosis and ischemia immediately.
所以她会失明 会中风发作
So she could lose her vision, she can have a stroke.
因此 迅速进行实验评估比如
Therefore, immediate laboratory evaluation for simple things
红细胞沉降率和全血细胞计数可以评估潜在的颞动脉炎
like a sed rate and a CBC, for the potential for temporal arteritis.
然后 除非你开出皮质类固醇药物的处方 她不能离开
And she should not leave your clinic without a prescription for corticosteroids,
因为应用该类药物
because the application of corticosteriods
能显著降低并发症风险
can dramatically reduce that risk of complications.
所以她需要密切随访 并且立即着手治疗
So she’ll need close follow-up and an initiation of treatment right away.
这只是个例 但在我看来是个很好的例子
So this is just an example, but I thought it was a keen example
告诉你不是每个案例只凭
to give you an idea that not every case can be managed
预期治疗就可以的
just with expected management reassurance.
当然 我想为了执业医考以及病人的感受
But certainly I think, for USMLE exam and the way I think about patient care,
很多时候 答案不是唯一的
the answer many times, it’s not every answer.
所以 诀窍在于注意高危因素
So the trick for you is to watch for high-risk conditions.
那么这些因素都包括什么
Now what do those conditions include?
我认为头痛是一种 所以需要时刻关注
I think headache is a high-risk condition, so always pay attention to it.
胸痛 但通常都是良性的 也是高风险因素
A chest pain, but it’s usually benign, still a high-risk conditions.
出现了新的神经系统症状 患者并非
New neurological symptoms, this isn’t the patient with diabetes for 20 years
有20年糖尿病史以及双足刺痛
who has bilateral tingling in the feet,
但患有单眼失明
but I’m talking about somebody who has monocular blindness
或是左侧面部下垂
or a left facial droop.
出现了新的症状
Something new going on,
那就是线索
that’s a cue.
你应该考虑中风的可能性
You know, think about stroke,
你考虑肿瘤或是其他严重的中枢神经系统疾病
you think about masses or other severe CNS disorders.
或是 经常偶然间发现
Or, and these are often found incidentally,
皮肤或乳房之类的器官内新的病变或是包块
new lesions or masses in organs such as the skin or the breast.
我这有块痣
I’ve got this mole,
看起来它在扩大并且在改变
and yeah it seems to be growing and changing,
接着出血并脱落 然后它又长出来了
then it bleeds and falls off, then it comes back again.
你知道 我第一个担心的就是癌症
You know, the first thing I’m worried about is cancer.
现在 它……会是癌症吗?不太像
Now that’s…is it going to be cancer? unlikely.
但我首先考虑到的依旧是癌症
But the first thing I’m going to worry about is cancer.
并且任何时候都会有人这么认为
And anytime somebody comes in with it.
我摸到了一个 你知道的 那种乳房包块 特别是当她们年龄超过50岁
I feel a new, you know, mass of my breast, particularly if they’re over 50,
以及身为乳腺癌的高危人群
and particularly if they are higher risk for breast cancer
由于家庭遗传或是其他之类的原因
because of a family history or something like that.
这些就是高危因素 我只列出了
These are the high-risk conditions. Just to name a few
一些比较常见的
but some of the more common ones that we see.
这些 应该引起你警觉
Those should, you know, alert you to the fact
你可能需要立即行动起来 进行更彻底的检查
that you might need to really go and perform a more thorough workup here.
你可能从一开始就需要给病人安排深度治疗
You may need to order advanced therapy for this patient right from the get-go,
不是所有情况都可以有待观望
not everything can just be a wait-and-see approach.
希望这些案例对你有价值
So hopefully you found these cases are beneficial.
现在我们将移步至急症护理模块
Now we’ll move into the acute care module,
你会看到这些真实案例会如何上演
and you can see how this plays out with some real cases.
谢谢
Thank you!
继续收看我的课程 或是点击YouTube的播放列表
Continue my course Now! Or check out my YouTube playlist.

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视频概述

临床医生的最大考验就是随机应变及预测未来

听录译者

【MED】小勇

翻译译者

HOUKI

审核员

审核团审核员XD

视频来源

https://www.youtube.com/watch?v=t5l7dj-8BiA

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