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Chest discomfort, 電生理　舒張期：受損到正常　收縮期：正常到受損圖片3, STEMI與NSTEMI之診斷:心肌酵素、 …

- - - - symptom
        
        burning(火燒心的感覺)
        
        relieved by sitting up
        
        因為坐起之後胃酸會因重力流在胃部
        而不會進入食道因而緩解症狀
        
        dysphagia
        
        食道因為發炎與疼痛而難以吞嚥
      - risk factor
        
        DM
        
        自律神經病變
        
        Coffee, chocolate
        
        甜食促進胃酸分泌；咖啡因使食道肌肉張力下降
        
        obesity
        
        胃部壓力增加，自律神經失調
      - reason
        
        GRED
        
        反覆的胃食道逆流造成食道損傷進而導致reflux esophagitis
    - - 胃跟食道交裂傷
        
        Mallory-Weiss tears
      - 遠端食道破裂，並造成mediastinitis
        
        Boerhaave syndrome
    - - reason
        
        慢性GRED
        
        食道的squamous mucosa出現
        對胃酸較有抗性的intestinal metaplasia
      - symptom
        
        trouble swallowing (dysphagia)
        
        vomiting blood (hematemesis)
        
        pain under the sternum(胃食道交界處)
        
        frequent and longstanding heartburn
        
        eating is painful (odynophagia)
  - - - Reason
        
        Stress ulcers
        
        胃血液供應不正常
        
        Curling ulcers
        
        於十二指腸近端產生潰瘍
        
        Cushing ulcers
        
        頭部外傷或腦部腫瘤造成的顱內壓上升所致的潰瘍
        
        NSAIDs等止痛藥
        
        alcohol
      - Symptom
        
        sharp, stabbing, or burning pain
        in the upper-center or upper-left abdomen
        
        often radiates to the back
        
        bloating and nausea
        
        vomit may be clear, yellow, or green
        
        嚴重才會出現
        
        shortness of breath
        
        chest pain
        
        vomit that contains blood
        
        severe stomach pain
        
        foul-smelling bowel movements
    - - Reason
        
        Helicobacter Pylori： G(-)的螺旋桿菌
      - Symptom
        
        似急性胃炎(要到非常嚴重才會胸痛)
        
        上皮內有neutrophil 和上皮下有plasma cell
        
        誘導黏膜層淋巴組織　
        （mucosa associated lymphoid tissue，MALT）的產生
    - - Reason
        
        抗體攻擊 body 與 fundus 黏膜上的 parietal cell 及 intrinsic factor
        
        與Hypergastrinemia（高胃泌素血症）有關
      - Symptom
        
        serum pepsinogen I 的濃度降低
        
        因為chief cell 被破壞
        
        antral endocrine cell增生
        
        Vitamin B12 不足
        
        在胃體（body）和胃底（fundus）可見產酸的粘膜有瀰漫性損傷
        
        achlorhydria
        
        很嚴重才會胸痛
  - - - 超過70%的PUD病患有感染H. pylori，但感染H. pylori的病患只有不到20%發展出PUD
      - frequent use of aspirin (Bayer), ibuprofen (Advil), and other anti-inflammatory drugs
      - smoking
      - drinking too much alcohol
      - stomach cancer
    - - 最常發生在gastric antrum和duodenum之第一段
      - burning abdominal pain
        
        extends from the navel to the chest
        pain range from mild to severe
      - changes in appetite
      - nausea
      - vomiting
  - - - Unknown
        
        Many doctors believe：a disruption of the nerve activity that coordinates the swallowing action of the esophagus.
    - - Squeezing pain in your chest.
        
        may spread outward to the arms, back, neck, or jaw
      - The feeling that an object is stuck in your throat
      - difficulty or inability to swallow
      - regurgitation
- - - - 神經缺血
        
        spinal infaction
        
        medullary artery
        
        粥狀硬化
        
        被壓迫
        
        使供血異常
      - 神經受壓迫
        
        tumors
        
        壓迫
        
        cervical myelopathy
        
        Pathologic Reflexes
        
        Hyperreflexia
        
        Spasticity
        
        壓迫、過度刺激
        
        頸椎間盤問題
        
        老化外傷姿勢不良
        造成肌腱緊繃發炎
        
        纖維環破裂髓核突出
        
        壓迫
        
        脊隨神經核 C4~C8
        
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  - - - 肌肉運動範圍過大
      - 強度過強、疲勞（健身胸大肌斷裂）
        
        臨床特點
        
        位置
        
        損傷處
        
        動作
        
        使疼痛加劇、重現
        
        叩診
        
        使疼痛加劇、重現
        
        職業活動
        
        健身、搬運工
        
        明顯外傷
      - 創傷
      - 突然猛烈（打噴嚏）
  - - - Varicella Zoster Virus
        
        第一次水痘，第二次皮蛇
        
        少數造成 viral pericaditis（見心臟區）
        
        潛伏於顱神經
        背根神經節
        
        老化
        免疫力下降
        
        （沿皮節爆發）帶狀皰疹
        
        分佈：頭、頸、胸
        
        多單側
        
        燒灼刺痛感，一般隨皮膚症狀消失
        
        病程
        
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        免疫力極弱
        
        散布性帶狀皰疹
        
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  - - - injury
        strain
        arthritis
        infection
        tumors
    - - 因上述原因產生發炎、腫脹
        
        壓痛
        
        多集中在胸骨附近
        
        拉扯運動會加劇
      - 軟骨連帶硬骨發炎
        
        Tietze syndrome
        
        cause
        
        Metastasis
        
        infection
        
        靜脈注射藥癮
        
        胸壁受損
        
        location
        
        多在第二三肋與胸骨交界
    - - 因為多與感染、腫瘤相關
        
        血液檢查：發炎指數、菌相、癌症因子
        
        影像學：看是否有腫瘤
- - - - 廣泛性ST elevation
  - - - Coronary
        artery
        disease
        
        risk factor
        
        Hyperlipidemia
        
        冠心狹窄
        
        Atherosclerosis
        
        DM
        
        血管慢性發炎
        
        smoking
        
        尼古丁加速動脈硬化，
        讓血液黏稠、血管缺乏彈性
        
        Hypertension
        
        堵塞<70%
        
        無症狀
        
        堵塞>70%
        
        incomplete myocardial necrosis
        (cardiac enzymes can be detected)
        
        NSTEMI
        
        T wave invert (可能)
        
        absence of myocardial injury
        (no cardiac enzymes)
        
        Unstable angina
        
        ST depression
        
        T wave invert( 可能)
        
        complete myocardial necrosis
        (cardiac enzymes can be detected)
        
        STEMI
        
        舒張期電流遠離導極（藍箭頭）－心電圖下降；
        收縮期電流接近導極（紅箭頭）－心電圖上升
        
        方向性ST elevation
        
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        對側出現reciprocal change
        
        側邊導極有ST depression
        
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        前方導極也有ST depression
        
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        可能有LBBB
        
        非急性發作
        
        Stable angina
        
        運動才痛
        
        symptom
        
        pressure, tightness
        
        retrosternal pain
        
        cold sweating
        
        內分泌失調，毛孔擴張
        
        dyspnea, nausea
        
        心輸出下降造成缺氧
        
        硝化甘油可緩解
        
        preload下降，管腔上升，流量上升
- - - - reason
        
        deep vein thrombosis travelling to lung
        
        large
        
        distention of the pulmonary artery
        
        right ventricular wall stress
        
        subendocardial ischemia related to acute pulmonary hypertension
        
        sign
        
        right heart failure
        
        small
        
        involvement of the pleural surface of the adjacent lung
      - diagnosis
        
        血液診斷
        
        PaO2下降&D-dimer上升
        
        ECG
        
        T波和ST段改變或P波和QRS波型改變
        
        肺動脈血管攝影
        
        invasive, 最後診斷依據
        
        CXR
        
        Westermark sign & Hamptom hump
      - symptom
        
        側邊感受到重物或壓力
    - - primary spontaneous
        
        risk factor
        
        male, Marfan syndrome, smoking, family history
      - secondary spontaneous
        
        with underlying lung disease
      - tension
        
        trapped intrathoracic air precipitating hemodynamic collapse
    - - inflammation of pleura
        
        knifelike pain
        
        worsened by inspiration or cough
- - - - anterior chest pain(ascending aorta)
        back pain(descending aorta)
      - sudden onset
      - tearing
        non-pleuritic
    - - normal, but present CWR
        
        其他器官有問題擠壓到心臟而出現偏轉
    - - hypertension
        (common in elderly)
        
        對血管壁造成長期壓力
        vasa vasorum 的內皮細胞受損
        hyaline跑到血管壁内沉積 (hyaline arteriolosclerosis)
        管壁增厚，管徑變小，主動脈中膜缺血，管壁萎縮
      - Genetic disease
        (Marfan syndrome, Ehler-Danlos syndrome)
        
        結締組織病變
        
        血管壁結構弱化
        
        主動脈管壁剝離
        形成假腔
        
        假腔血液影響血管
        
        下游
        
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        上游
        
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- - - - 心理上的問題轉化為身體上的症狀，
        但在生理上卻又找不出病因的心理疾病
        
        需反覆發生且容易合併疑病症
    - - 心理因素懷疑自己有病
    - - 會合併頭痛、冒冷汗、手腳指麻痺