急診醫(yī)學專業(yè)英語

精品文檔精品文檔..大連醫(yī)科大學碩士研究生試卷2010年級專業(yè)外語試卷學號 姓名一二三四五總分一二三四五總分分數(shù)英譯漢：EmergencyDiagnosisandAssessmentofICHandItsCausesRapidrecognitionanddiagnosisofICHareessentialbecauseofitsfrequentlyrapidprogressionduringthefirstseveralhours.Theclassicclinicalpresentationincludestheonsetofasuddenfocalneurologicaldeficitwhilethepatientisactive,whichprogressesoverminutestohours.Thissmoothsymptomaticprogressionofafocaldeficitoverafew hoursisuncommoninischemicstrokeandrareinsubarachnoidhemorrhage.HeadacheismorecommonwithICHthanwithischemicstroke,althoughlesscommonthaninsubarachnoidhemorrhage.VomitingismorecommonwithICHthanwitheitherischemicstrokeorsubarachnoidhemorrhage.Increasedbloodpressureandimpairedlevelofconsciousnessarecommon.However,clinicalpresentationalone,althoughhelpful,isinsufficienttoreliablydifferentiateICHfromotherstrokesubtypes.TheearlyriskofneurologicaldeteriorationandcardiopulmonaryinstabilityinICHishigh.IdentificationofprognosticindicatorsduringthefirstseveralhoursisveryimportantforplanningthelevelofcareinpatientswithICH.ThevolumeofICHandgradeontheGlasgowComaScale(GCS)onadmissionarethemostpowerfulpredictorsofdeathby30days.Hydrocephaluswasanindependentindicatorof30-daydeathinanotherstudy.Conversely,corticallocation,mildneurologicaldysfunction,andlowfibrinogenlevelshavebeenassociatedwithgoodoutcomesinmediumtolargeICH.BecauseofthedifficultyindifferentiatingICHfromischemicstrokebyclinicalmeasures,emergencymedicinepersonneltriageandtransportpatientswithICHandischemicstroketohospitalssimilarly.Asdescribedbelow,patientswithICHoftenhavegreaterneurologicalinstabilityandriskofveryearlyneurologicaldeteriorationthandopatientswithischemicstrokeandwillhaveagreaterneedforneurocriticalcare,monitoringofincreasedintracranialpressure(ICP),andevenneurosurgicalintervention.Thislevelofcaremayexceedthatavailableatsomehospitals,eventhosethatmeetthecriteriaforprimarystrokecenters.Thus,eachhospitalthatevaluatesandtreatsstrokepatientsshoulddeterminewhethertheinstitutionhastheinfrastructureandphysiciansupporttomanagepatientswithmoderate-sizedorlargeICHsorhasaplantotransferthesepatientstoatertiaryhospitalwiththeappropriateresources.InitialclinicaldiagnosticevaluationofICHatthehospitalinvolvesassessmentofthepatpresentingsymptomsandassociatedactivitiesatonset,timeofstrokeonset,age,andotherriskfactors.Thepatientorwitnessesarequestionedabouttrauma;hypertension;priorischemicstroke,diabetesmellitus,smoking,useofalcoholandprescription,over-thecounter,orrecreationaldrugssuchascocaine;useofwarfarinandaspirinorotherantithrombotictherapy;andhematologicdisordersorothermedicaldisordersthatpredisposetobleeding,suchassevereliverdisease.Thephysicalexaminationfocusesonlevelofconsciousnessanddegreeofneurologicaldeficitafterassessmentofairway,breathing,circulation,andvitalsigns.Inseveralretrospectivestudies,elevatedsystolicbloodpressure_160mmHgonadmissionhasbeenassociatedwithgrowthofthehematoma,butthishasnotbeendemonstratedinprospectivestudiesofICHgrowth.Fever_37.5°Cthatpersistsfor_24hoursisfoundin83%ofpatientswithpooroutcomesandcorrelateswithventricularextensionofthehemorrhage.Brainimagingisacrucialpartoftheemergentevaluation.Computedtomography(CT)andmagneticresonancescansshowequalabilitytoidentifythepresenceofacuteICH,itssizeandlocation,andhematomaenlargement.Deephemorrhagesinhypertensivepatientsareoftenduehypertension,whereaslobarhemorrhagesinnonhypertensiveelderlypatientsareoftenduecerebralamyloidangiopathy;however,asubstantialnumberoflobarhemorrhagesinhypertensivepatientsmaybeduetohypertension,andbothdeepandsuperficialhemorrhagesmaybecausedbyvascularabnormalitiesandothernonhypertensivecauses.CTmaybesuperioratdemonstratingassociatedventricularextension,whereasmagneticresonanceimaging(MRI)issuperioratdetectingunderlyingstructurallesionsanddelineatingtheamountofperihematomaledemaandherniation.ACTscanwithcontrastmayidentifyanassociatedaneurysm,arteriovenousmalformation,ortumor.CTangiographymayprovideadditionaldetailinpatientswithsuspectedaneurysmorarteriovenousmalformation.CThasalsoclarifiedthenaturalhistoryofICH.OneprospectivestudyofspontaneousICHinthemid-1990sdemonstratedthatanincreaseinvolumeof_33%isdetectableonrepeatedCTexaminationin38%ofpatientsinitiallyscannedwithin3hoursafteronset.IntwothirdsofcaseswithgrowthinvolumeofICH,thisincreasewasevidentwithin1hour.GrowthofthevolumeofICHwasassociatedwithearlyneurologicaldeterioration.Hematomagrowthisassociatedwithanearly5-foldincreaseinclinicaldeterioration,pooroutcome,anddeath.ThelobarlocationofICHincreasestheriskoflong-termrecurrencebyafactorof3.8.MRIperformsaswellasCTinidentifyingICH.Inonemulticenterstudyofacutestrokewithin6hoursofonset, gradient-echoMRIwasasaccurateasCTfortheidentificationofacutehemorrhageandmoreaccurateforidentificationofchronichemorrhage. Inanotherunder-6-hourmulticenterdiagnostictrial,MRIshowedequivalentperformancetoCTinICHidentification.MRIisalsosuperiortoCTfortheidentificationofassociatedvascularmalformations,especiallycavernoma.MRI,however,isnotaspracticalasCTforallpresentingpatients.OnestudyfoundthatMRIwasnotfeasiblein20%ofacutestrokepatientsbecauseofcontraindicationstoMRIorimpairedconsciousness,hemodynamiccompromise,vomiting,oragitation.OfthepatientswithacutestrokeineligibleforMRI,73%hadanICH.Indicationsforcatheterangiographyincludesubarachnoidhemorrhage,abnormalcalcifications,obviousvascularabnormalities,andbloodinunusuallocations,suchasthesylvianfissure.Angiographymayalsobeindicatedinpatientswithnoobviouscauseofbleeding,suchasthosesubjectswithisolatedIVH.Theyieldofangiographydeclinesinelderlypatientswithhypertensionandadeephematoma.Thetimingoftheangiogrambalancestheneedforadiagnosiswiththeconditionofthepatientandthepotentialtimingofanysurgicalintervention.Acriticallyillpatientwithhemorrhageandherniationmayrequireurgentsurgerybeforeangiography, whereasstablepatientwithimagingfeaturesofananeurysmorarteriovenousmalformationshouldundergoangiographybeforeanyintervention.RoutinelaboratorytestsperformedinpatientswithICHincludecompletebloodcount;electrolytes;bloodureanitrogenandcreatinine;glucose;electrocardiogram;chestradiography;prothrombintimeorinternationalnormalizedratio (INR);andactivatedpartialthromboplastintime.Atoxicologyscreeninyoungormiddle-agedpersonstoruleoutcocaineuseandapregnancytestinawomanofchildbearingageshouldalsobeobtained. ElevatedserumglucoseislikelyaresponsetothestressandseverityofICHandisamarkerfordeath,withanoddsratio(OR)of1.2.Warfarinuse,reflectedinanelevatedprothrombintimeorINR,isariskfactorforhematomaexpansion(OR6.2),withexpansioncontinuinglongerthaninpatientsnottakingwarfarin.RecentstudieshaveidentifiedserummarkersthataddtotheprognosticevaluationofICHandmayprovidecluestoitspathophysiology.Earlyneurologicaldeteriorationinonestudywasassociatedwithatemperature_37.5°C,elevated