1、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
2、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.nHerfamilydeniedthatshehadre
3、centlyfeverandchills.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)forabout2yearnCongestiveheartfaliu
4、reNYHAclassIIInHCVD5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Familyhist
5、orynNofamilyhistoryofdiabetesmellitus,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【
6、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.obstructivejau
7、ndice10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,probablypulmonaryedemaorin
8、fectious/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】
9、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
10、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
11、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.Nodilatedbowelloopsor
12、thickeningofbowelwall.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Secondar
13、yimpressionnPulmonaryedemanJaundice,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ConsultGImannReviewdrug
14、history(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
15、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:nOverproductionofhe
16、meproductsnFailureofthehepatocytetotakeupthebilirubinnFailureofthehepatocytetoconjugateorexcretebilirubinnObstructionofbiliaryexcretionintotheintestine.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
17、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,andautoanti
18、bodies.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
19、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%of
20、casesofhepatitisinalladultsc.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Introd
21、uctionnAsymptomaticmildbiochemicalabnormalitiestoanacuteillnesswithjaundicethatresemblesviralhepatitisnChronichistologicinflammatorychangesandaclinicalsyndromeresemblingautoimmunehepatitisnEndothelialdamageorthrombosisleadingtovascularcomplicationssuchasveno-occlusivediseaseorBudd-Chiarisyndrome.58业
22、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SubclinicalnAntibioticsnAntidepressantsnAntihyperlipidemicsnSulfonamidesnSalicylat
23、esnSulfonylureasnQuinidineproduceasymptomaticelevationinserumaminotransferasesinfewerthan5percentofindividuals.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%nFulmina
24、nthepaticfailuredevelops,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
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AcutehepaticinjurynMixedpatterns2ALT/alkalinephosphataseratio5Druglist:phenytoinnSteatosisAcutefattydegenerationDruglist:High-doseintravenoustetracyclineandamidaroneOtherdrugs:Camphor,cocaine,piroxicam,tolmetin,valproicacid,theantiretroviralagentsAZT,stavudine,ddl63
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Chronichep
27、aticinjurynSteatosisDiethylstilbestrol,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.VenoocclusivediseasenGranulomatousd
28、iseasenNeoplasia66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
29、物PPT,欢迎收藏分享】豆丁网友DiagnosisKeyelementsforattributingliverinjurytoadrugincludenExposuremustprecedetheonsetofliverinjury(althoughthelatentperiodishighlyvariable)nUnderlyingliverdiseaseshouldbesoughtnInjurymayimprovewhenthedrugisstoppednLiverinjurymayhaverecurredmorerapidlyandseverelyafterrepeatedexposur
30、e.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
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