般内科病例联合讨论课件

般內科病例聯合討論 PGY 洪啟偉/VS 黃信凱 980403 Patient Profile Chart No. : 13723785, 吳X進 Age: 56 y/o Gender: male Date of admission: 2009/03/06 Hx of 1) CHF, Fc III HCVD related 2) hypertension for 10+ years 3) Gangrenous cholecystitis s/p cholecystectomy 4) BPH Chief complaint Short of breath for 1 month and aggregated in recent two days Present illness CHF, Fc III HCVD related and hypertension for 10+ years lost regular medical control for one month suffered from S.O.B, orthropnea, PND With bil. lower legs pitting edema denied decrease urine output, dysuria, Chest tightness character: heavy compression persisted all day long no abd. pain Cough with sputum for 1 month white aggregated in recent two days denied asthma hx, no fever Shortness of breath L: Q: rapid, shallow breathing Q: persistently O: progression after discontinue of medication P: E: exercise R: rest A: orthopnea、PND、 chest tightness、 urine output decrease(-) Past Medical History 1. Medical history: Hypertension -(+) Diabetes mellitus -(-) Chronic hepatitis B-(-) Chronic hepatitis C-(-) 2. Surgical history: Gangrenous cholecystitis s/p cholecystectomy 3. Drug allergy: No known allergy Personal History Smoking: (+) 2 ppd/daily Drinking: social drinking Betel nuts use: denied History of oversea travel: denied History of contact with animals or sick people: denied Physical exam Vital sign: T: 36.3 P: 75 R:18 BP: 102/78 Conscious level: clear HEENT: Eyes: conjunctiva not pale, sclera not icteria Neck: Supple, Jugular venous engorgement(-), no lymphadenopathy No thyroid enlargement Chest & Lungs: Symmetrical expansion, Breathing sound: moist rales and diminish over right chest region Physical exam Heart: HS: Regular heat beat Abdomen: fullness and distension tenderness(-), rebounding pain(-) Liver/spleen: palpable(-)/(-) Normal active bowel sounds, No abdominal bruit Extremities: Freely movable, Pitting edema(+) Exam CBC/DC, e-, Cardiac enzyme BUN/Cr, GOT/GPT CXR EKG LAB CXR EKG APC Sinus tachycardia First degree AV block Non-specific ST-T changes Impression Congestive heart failure with bilateral pulmonary congestion Admission Coarse 核醫 CXR Abdominal echo 3/63/73/83/93/103/113/12 Admission Cardiac Echo At ward Laxis 1 amp q12h+ aldactone 1#qd Water restriction 1200cc/day Check BW Cardiac echo 1. Dilated LA, LV, RA, RV. 2. Severe eccentric MR, moderate TR. 3. Poor LV global performance. Abdominal echo abdominal distension- r/o 1. CHF related ascites 2. cirrhosis 3. tumor growth * Hepatic cyst * Bil. pleural effusion * Ascites, small amount CXR 3/9 Cough with pinkish frothy sputum + Acertil 0.5# qd, Dilatrend 0.5# bid Ventricle Ejection Fraction and Wall Motion Study LVEF (%) - 18 LV peak filling rate (EDC/S) - 1.06 LV time from systole to peak filling (msec) - 100 RVEF (%) - 23 RV peak filling rate (EDC/S) - 0.86 RV time from systole to peak filling (msec) - 600 DISCUSSION 心衰竭之定義 心臟機能暫時性或永久行下降造成心輸 出量不足以達到需求時，它是一種症候 群；而不是種疾病。 心臟衰竭的分類 收縮性心衰竭systole或舒張性心衰竭diastole 低輸出性low cardiac output 心衰竭或高輸出性心衰竭 high cardiac output 急性acute 心衰竭或慢性心衰竭 chronic 右側right 心衰竭或左側left 心衰竭 前向式forward 心衰竭或後向式backward心衰竭 鹽salt或水water 堆積造成的心衰竭 鬱血性心臟衰竭診斷之Framingham Criteria 主要準則 陣發性夜間呼吸困難 paroxysmal nocturnal dyspnea 頸靜脈擴張 Neck vein distention 肺部鑼音 Rales 心臟擴大 cardiomegaly 急性肺水腫 Acute pulmonary edema 心臟奔馬音 S3 gallop 中心靜脈壓升高 Increased venous pressure 16cm H2O Positive hepatojugular reflux 次要準則 踝部浮腫 Extremity edema 夜間咳嗽 Night cough 勞動性呼吸困難 Dyspnea on exertion 肝腫大 hepatomegaly 胸膜積水 Pleural effusion 肺活量減少三分之 心跳過速 tachycardia 120 /min 診斷條件 : 二項主要準則 或項主要準則加上二項次要準則 慢性心臟衰竭機能評估-NYHA 1. 病人有心臟病，但未使體力活動受到限制，平常的體力 活動不致引起疲乏、心悸、呼吸困難、或心絞痛。 2. 病人有心臟病使其體力活動受到輕微限制，休息時覺得 舒適，但平常的體力活動會引起疲乏、心悸、呼吸困難或 心絞痛。 3. 病人有心臟病使其體力活動受到明顯限制，休息時 覺得 舒適，但低於平常的體力活動或引起疲乏、心悸、呼吸困 難或心絞痛。 4.病人有心臟病使其無法從事任何體力活動而不引起症狀 ，就是休息時也可能出現心臟機能不足的症狀或心絞痛， 從事任何活動的話，不舒服的程度就或加重。 心臟衰竭的促發或加重因素Predisposing factor 需求增加： 貧血、發燒、感染、食鹽攝食增加、環境 溫度升高、呼吸衰竭、腎衰竭、肝衰竭、甲狀腺機能 亢進、動靜脈瘻管、情緒壓力、懷孕、肥胖 心臟血管疾病 心律不整 高血壓控制不良 藥物：NSAID 、 鈣離子阻斷劑、 類固醇、 酒精、 Doxorubicin 體液過量 肺栓塞 飲食或藥物控制不良 心衰竭之病因 心室壓力負荷過重(pressure overloading ) 高血壓 , 主動脈瓣狹窄 心室容積負荷過重(volume overloading) 二尖瓣閉鎖不全 , 主動脈瓣閉鎖不全 心肌無力收縮(impaired contractility) 心肌缺氧 , 心肌梗塞 , 心肌病(diated cardiomyopathy) 診斷和評估心衰竭之方法 理學檢查 X光攝影 心電圖 心超音波圖 心臟核醫攝影 心導管和冠狀動脈攝影 Pathophysiology of Chronic Heart Failure Phase I:the initial response to myocardial injury Phase II: the development of heart failure Phase III: the progression of heart failure Pharmacologic Agents for CHF Diuretics Digitalis Vasodilators ACE inhibitors AT1 receptor blockers Beta-blockers STAGES OF HF Stage A High risk for HF, without structural heart disease or symptoms Stage B Heart disease with asymptomatic left ventricular dysfunction Stage C Prior or current symptoms of HF Stage D Refractory end stage HF Management of Heart Failure Patients with class A heart failure Control of risk factors HTN DM lipids Modifications of lifestyle Moderate sodium restriction Weight monitoring Adherence to medication schedules Moderation of alcohol intake Scheduled exercise program Stage B,C, or D HF with or without Symptoms ACEI For asymptomatic high risk patients with DM or vascular disease and no history of heart failure (reduction in the rates of death, MI, and stroke) For patients with MI, improvements in Survival, the rate of hospitalization, symptoms, cardiac performance, neurohomonal levels, and reverse remodeling ARB (lorsartan) For heart failure in patients with DM and neuropathy (delay the first hospitalization) Should not be used as first line Used in patients who cant tolerate ACEI (severe cough or angioedema) Improvements in cardiovascular morbidity and survival, decrease in the incidence of new-onset DM -blockers To counteract the harmful effects of sympathetic nervous system Improvements in survival, morbidity, ejection fraction, remodeling, quality of life, the rate of hospitalization and the incidence of sudden death Used in stable condition Additional therapy for symptomatic patients with stage C or D heart failure Spironolactone An aldosterone anatagonist Aldosterone Stimulation by angiotensin II and decrease in the hepatic clearance Stimulates the retention of salt, myocardial hypertrophy, and potassium excretion Decrease in collagen synthesis Diuretics Mainstay for controlling symptoms of congestion Thiazide or loop diuretics, or both Digoxin No different in mortality Decreasing in the rates of worsening heart failure and hospitalization Low serum concentration( 0.09ng/ml) Revascularization and surgical therapy Catheter-based or a surgical approach Improves ischemic symptoms, cardiac performance, and reduces the risk of sudden death The End Thanks for your attention Assessment Findings of Acute Pulmonary Edema Severe dyspnea and orthopnea Pallor Tachycardia Expectoration of large amounts of blood-tinged, frothy sputum Wheezing and crackles on auscultation Bubbling respirations Acute anxiety, apprehension, restlessness Profuse sweating Cold, clammy skin Cyanosis Nasal flaring Use of accessory breathing muscles Tachypnea Hypocapnia, evidenced by muscle cramps, weakness, dizziness and paresthesias The patient has hypotension: when i