【医学生物】联合病例讨论.ppt

聯合病例討論Present：PGY王又德Supervisor：鍾焜明醫師1业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友PatientprofilenName：李高X春nGender：femalenAge：78y/onTriage：1nTime：97/07/27pmnBP：193/105T/P/R：36.1/88/12Charter：cantwalk,onbedOximeter：82%2业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友ChiefcomplaintnChesttightnesswithshortofbreathtonight3业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友PresentillnessnThis78yearoldfemalepresentedtoEDforChesttightnesswithshortofbreath.nChesttightnesswaspressure-likewithoutradiation.Butshefeltcoldsweating.nOrthopneaanddyspneaonexertionwasalsomentioned.nProductivecoughwithyellowishsputumwasnoted.nHerfamilydeniedthatshehadrecentlyfeverandchills.nBesides,shefoundprogressiveyellowishskininrecent2weeks.Shedeniedabdominalpain,vomitinganddiarrhea.4业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友PasthistorynDenieddiabetesmellitusnHypertensionformanyyearsnAMIwithrespiratoryfailureon95/06nESRDonH/D(QW2.4.6)forabout2yearnCongestiveheartfaliureNYHAclassIIInHCVD5业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友PasthistorynSurgicalhistory:a.Appendectomyformanyyearsagob.A-VshuntnSmoking:deniednAlcohol:deniednMedications:Sigmart,Mucaine,Hematon,Cofsoline-codeineSorbitrate,Inderal,Ticlid,Alinamin-F,Zyrtec,Gascon6业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友FamilyhistorynNofamilyhistoryofdiabetesmellitus,hypertensionormalignancy.7业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友PhysicalexaminationnVitalsign：BP：193/105T/P/R：36.1/88/12nCons.：alert,E4V5M6nHEENT：Conjunctivae：notanemicSclera：ictericNeck：supplenChest：symmetricalexpansionwheezing and ralesRHB,nomurmur8业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友PhysicalexaminationnAbdomen：soft,notenderness,noreboundingpainnoMurphysignnExtremity：warm,freelymovable,nopittingedema,nodeformity,nolossofpulsation9业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友Firstimpression1.Pulmonaryedema(suspectCHFrelatedorinfectionrelated)2.Jaundice,susp.obstructivejaundice10业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友PlannOnNRMmask,monitornBloodroutinenCXR,EKG11业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友12业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友CXR13业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友CXRSupinechestfilmshows:nMixedalveolarandinterstitialinfiltrationoverbothlungs,probablypulmonaryedemaorinfectious/inflammatoryprocess.nElevationofRthemidiaphragmnTortuousaorticarchwithintimalcalcification.nBorderlinecardiomegaly.nDJDofthespine.14业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友PlannConsultnephrologistforemergencyHDnArrangeabdominalCT15业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友16业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友17业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友18业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友19业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友20业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友21业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友22业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友23业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友24业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友25业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友26业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友27业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友28业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友29业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友30业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友31业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友32业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友33业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友34业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友AbdominalCTnThe gallbladder is contracted without stone.No dilatation of biliary tree.No obvious radiopaque stone in bile ducts.nAtrophyofbothkidneys,ESRDisconsidered.Noremarkablefindingsoverliver,spleen,pancreas,adrenalglands.Nodilatedbowelloopsorthickeningofbowelwall.Noascites.NoenlargedLNs.Nodestructivebonelesion.Nodilatedbiliarytree.Novisibleintraperitonealfreeair.Noacuteappendicitisordiverticulitis.Smallamountofbilateralpleuraleffusion.nIMP:1.Bilateralpleuraleffusion.n2.ESRDwithatrophickidneys.35业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友SecondaryimpressionnPulmonaryedemanJaundice,causeunknownAssociatedimpressionnCADnHTNnESRD36业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友HospitalizationnVirushepatitissurveyonJuly17r/oautoimmunehepatitis37业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友Hospitalization(07/30)38业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友ConsultGImannReviewdrughistory(newdrugduringtheprevious3Mbeforesymptoms).nConsiderliverbiopsyifnocontra-indication.nGiveUrso,Silymarinassymptomatictreatments.39业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友DruglistnSigmart,Mucaine,Zyrtec,Gascon,Alinamin-FnHematonnCofsoline-codeinenSorbitrate,Inderal,Ticlid40业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友41业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友42业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友43业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友Jaundice44业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友IntroductionnClinicaljaundiceisusuallynotevidentuntiltheserumbilirubinconcentrationrisesabove2.5mg/dL.Fourbilemetabolism：nOverproductionofhemeproductsnFailureofthehepatocytetotakeupthebilirubinnFailureofthehepatocytetoconjugateorexcretebilirubinnObstructionofbiliaryexcretionintotheintestine.45业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友46业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友Marx:RosensEmergencyMedicine:ConceptsandClinicalPractice,6thed.47业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友48业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友49业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友AutoimmunehepatitisnAutoimmunehepatitis(AIH)isanunresolvinginflammationoftheliverofunknowncause.nItischaracterizedbythepresenceofinterfacehepatitisonhistologicexamination,hypergammaglobulinemia,andautoantibodies.nDiagnosisrequirestheexclusionofotherchronicliverdiseases.Feldman:Sleisenger&FordtransGastrointestinalandLiverDisease,8thed.50业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友Autoimmunehepatitis51业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友Autoimmunehepatitis52业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友Autoimmunehepatitis53业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友Autoimmunehepatitis54业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友Autoimmunehepatitis55业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友Drugsandtheliver:Patternsofhepatotoxicity56业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友IntroductionnDrug-inducedhepaticinjurya.2to5%ofhospitalizationsforjaundiceb.10%ofcasesofhepatitisinalladultsc.morethan40%ofcasesinadultsolderthan50.nIncreaseinALT,alkaline phosphatase,or bilirubin levelstomorethantwicetheupperlimitofnormal.nAmongpatientsadmittedtothehospitalfordrug-inducedliverdiseases,themortalityrateisapproximately10%.57业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友IntroductionnAsymptomaticmildbiochemicalabnormalitiestoanacuteillnesswithjaundicethatresemblesviralhepatitisnChronichistologicinflammatorychangesandaclinicalsyndromeresemblingautoimmunehepatitisnEndothelialdamageorthrombosisleadingtovascularcomplicationssuchasveno-occlusivediseaseorBudd-Chiarisyndrome.58业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友IntroductionnWithdrawaloftheoffendingdrugreversaloftheinjury.nSometypesoftoxicitymaybeaprogressivecoursefibrosisorcirrhosis(discontinuationofthedrug)59业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友SubclinicalnAntibioticsnAntidepressantsnAntihyperlipidemicsnSulfonamidesnSalicylatesnSulfonylureasnQuinidineproduceasymptomaticelevationinserumaminotransferasesinfewerthan5percentofindividuals.60业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友AcutehepaticinjurynCytotoxica.ALT2timesb.ALT/alkalinephosphataseratio5Druglist：Penytoin,Methyldopa,Isoniazid,Diclofenac,AspirinnMortalityrate：10%nFulminanthepaticfailuredevelops,mortalityratesof80%ormore61业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友AcutehepaticinjurynCholestatica.alkalinephosphatase2timesb.ALT/alkalinephosphataseratio2Druglist：Chlorpromazine,Nafcillin,trimethoprim-sulfamethoxazole,Rifampin,Erythromycinestolate,Captopril,Estradiol,Amiodarone62业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友AcutehepaticinjurynMixedpatterns2ALT/alkalinephosphataseratio5Druglist：phenytoinnSteatosisAcutefattydegenerationDruglist：High-doseintravenoustetracyclineandamidaroneOtherdrugs：Camphor,cocaine,piroxicam,tolmetin,valproicacid,theantiretroviralagentsAZT,stavudine,ddl63业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友ChronichepaticinjurynChronichepatitisa.Autoimmune-likeMethyldopa,minocycline,nitrofurantoin,diclofenac,fenofirbrate,papaverine,phenytoin,PTU,germander,andecstasy.b.Viralhepatitis-likephenytoin,dihydralazine,andticrynafen64业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友ChronichepaticinjurynSteatosisDiethylstilbestrol,glucocorticoids,griseofulvin,MTX,nifedipine,tamoxifen,TPN,mercury,ethanolnonalcoholicfattyliverdiseasenChroniccholestasisnBiliarysclerosis65业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友OthersnVenoocclusivediseasea.Hepaticveinthrombosisb.VenoocclusivediseasenGranulomatousdiseasenNeoplasia66业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友67业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友OurpatientnTiclopidineandclopidogrelareantiplateletagentsthathavebeenincriminatedinatleastonecaseofmicrovesicularsteatosisandinanotherofcholestatichepatitis Gastroenterol Clin Biol1999;23:151.68业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友DiagnosisKeyelementsforattributingliverinjurytoadrugincludenExposuremustprecedetheonsetofliverinjury(althoughthelatentperiodishighlyvariable)nUnderlyingliverdiseaseshouldbesoughtnInjurymayimprovewhenthedrugisstoppednLiverinjurymayhaverecurredmorerapidlyandseverelyafterrepeatedexposure.69业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友TREATMENTnThemaintreatmentfordrug-inducedhepatotoxicityiswithdrawalofthedrug.nAnexceptionistheuseofn-acetylcysteineforacetaminophentoxicity.nCorticosteroidsareofunprovenbenefitformostformsofdrughepatotoxicity,althoughtheymayhavearolefortreatingpatientswithhypersensitivityreactions70业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友Thanksforyourattention71业精于勤荒于嬉行成于思毁于随【医学生物PPT，欢迎收藏分享】豆丁网友