《联合病例讨论》PPT课件.ppt

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 1 聯合病例討論 Present PGY王又德Supervisor 鍾焜明醫師 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 2 Patientprofile Name 李高X春Gender femaleAge 78y oTriage 1Time 97 07 27pmBP 193 105T P R 36 1 88 12Charter can twalk onbedOximeter 82 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 3 Chiefcomplaint Chesttightnesswithshortofbreathtonight 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 4 Presentillness This78yearoldfemalepresentedtoEDforChesttightnesswithshortofbreath Chesttightnesswaspressure likewithoutradiation Butshefeltcoldsweating Orthopneaanddyspneaonexertionwasalsomentioned Productivecoughwithyellowishsputumwasnoted Herfamilydeniedthatshehadrecentlyfeverandchills Besides shefoundprogressiveyellowishskininrecent2weeks Shedeniedabdominalpain vomitinganddiarrhea 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 5 Pasthistory DenieddiabetesmellitusHypertensionformanyyearsAMIwithrespiratoryfailureon95 06ESRDonH D QW2 4 6 forabout2yearCongestiveheartfaliureNYHAclassIIIHCVD 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 6 Pasthistory Surgicalhistory a Appendectomyformanyyearsagob A VshuntSmoking deniedAlcohol deniedMedications Sigmart Mucaine Hematon Cofsoline codeineSorbitrate Inderal Ticlid Alinamin F Zyrtec Gascon 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 7 Familyhistory Nofamilyhistoryofdiabetesmellitus hypertensionormalignancy 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 8 Physicalexamination Vitalsign BP 193 105T P R 36 1 88 12Cons alert E4V5M6HEENT Conjunctivae notanemicSclera ictericNeck suppleChest symmetricalexpansionwheezingandralesRHB nomurmur 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 9 Physicalexamination Abdomen soft notenderness noreboundingpainnoMurphysignExtremity warm freelymovable nopittingedema nodeformity nolossofpulsation 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 10 Firstimpression 1 Pulmonaryedema suspectCHFrelatedorinfectionrelated 2 Jaundice susp obstructivejaundice 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 11 Plan OnNRMmask monitorBloodroutineCXR EKG 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 13 CXR 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 14 CXR Supinechestfilmshows Mixedalveolarandinterstitialinfiltrationoverbothlungs probablypulmonaryedemaorinfectious inflammatoryprocess ElevationofRthemidiaphragmTortuousaorticarchwithintimalcalcification Borderlinecardiomegaly DJDofthespine 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 15 Plan ConsultnephrologistforemergencyHDArrangeabdominalCT 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 35 AbdominalCT Thegallbladderiscontractedwithoutstone Nodilatationofbiliarytree Noobviousradiopaquestoneinbileducts Atrophyofbothkidneys ESRDisconsidered Noremarkablefindingsoverliver spleen pancreas adrenalglands Nodilatedbowelloopsorthickeningofbowelwall Noascites NoenlargedLNs Nodestructivebonelesion Nodilatedbiliarytree Novisibleintraperitonealfreeair Noacuteappendicitisordiverticulitis Smallamountofbilateralpleuraleffusion IMP 1 Bilateralpleuraleffusion 2 ESRDwithatrophickidneys 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 36 Secondaryimpression PulmonaryedemaJaundice causeunknownAssociatedimpressionCADHTNESRD 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 37 Hospitalization VirushepatitissurveyonJuly17 r oautoimmunehepatitis 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 38 Hospitalization 07 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 39 ConsultGIman Reviewdrughistory newdrugduringtheprevious3Mbeforesymptoms Considerliverbiopsyifnocontra indication GiveUrso Silymarinassymptomatictreatments 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 40 Druglist Sigmart Mucaine Zyrtec Gascon Alinamin FHematonCofsoline codeineSorbitrate Inderal Ticlid 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 44 Jaundice 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 45 Introduction Clinicaljaundiceisusuallynotevidentuntiltheserumbilirubinconcentrationrisesabove2 5mg dL Fourbilemetabolism OverproductionofhemeproductsFailureofthehepatocytetotakeupthebilirubinFailureofthehepatocytetoconjugateorexcretebilirubinObstructionofbiliaryexcretionintotheintestine 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 47 Marx Rosen sEmergencyMedicine ConceptsandClinicalPractice 6thed 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 50 Autoimmunehepatitis Autoimmunehepatitis AIH isanunresolvinginflammationoftheliverofunknowncause Itischaracterizedbythepresenceofinterfacehepatitisonhistologicexamination hypergammaglobulinemia andautoantibodies Diagnosisrequirestheexclusionofotherchronicliverdiseases Feldman Sleisenger Fordtran sGastrointestinalandLiverDisease 8thed 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 51 Autoimmunehepatitis 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 52 Autoimmunehepatitis 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 53 Autoimmunehepatitis 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 54 Autoimmunehepatitis 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 55 Autoimmunehepatitis 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 56 Drugsandtheliver Patternsofhepatotoxicity 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 57 Introduction Drug inducedhepaticinjurya 2to5 ofhospitalizationsforjaundiceb 10 ofcasesofhepatitisinalladultsc morethan40 ofcasesinadultsolderthan50 IncreaseinALT alkalinephosphatase orbilirubinlevelstomorethantwicetheupperlimitofnormal Amongpatientsadmittedtothehospitalfordrug inducedliverdiseases themortalityrateisapproximately10 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 58 Introduction AsymptomaticmildbiochemicalabnormalitiestoanacuteillnesswithjaundicethatresemblesviralhepatitisChronichistologicinflammatorychangesandaclinicalsyndromeresemblingautoimmunehepatitisEndothelialdamageorthrombosisleadingtovascularcomplicationssuchasveno occlusivediseaseorBudd Chiarisyndrome 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 59 Introduction Withdrawaloftheoffendingdrug reversaloftheinjury Sometypesoftoxicitymaybeaprogressivecourse fibrosisorcirrhosis discontinuationofthedrug 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 60 Subclinical AntibioticsAntidepressantsAntihyperlipidemicsSulfonamidesSalicylatesSulfonylureasQuinidineproduceasymptomaticelevationinserumaminotransferasesinfewerthan5percentofindividuals 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 61 Acutehepaticinjury Cytotoxica ALT 2timesb ALT alkalinephosphataseratio 5Druglist Penytoin Methyldopa Isoniazid Diclofenac AspirinMortalityrate 10 Fulminanthepaticfailuredevelops mortalityratesof80 ormore 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 62 Acutehepaticinjury Cholestatica alkalinephosphatase 2timesb ALT alkalinephosphataseratio 2Druglist Chlorpromazine Nafcillin trimethoprim sulfamethoxazole Rifampin Erythromycinestolate Captopril Estradiol Amiodarone 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 63 Acutehepaticinjury Mixedpatterns2 ALT alkalinephosphataseratio 5Druglist phenytoinSteatosisAcutefattydegenerationDruglist High doseintravenoustetracyclineandamidaroneOtherdrugs Camphor cocaine piroxicam tolmetin valproicacid theantiretroviralagentsAZT stavudine ddl 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 64 Chronichepaticinjury Chronichepatitisa Autoimmune likeMethyldopa minocycline nitrofurantoin diclofenac fenofirbrate papaverine phenytoin PTU germander andecstasy b Viralhepatitis likephenytoin dihydralazine andticrynafen 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 65 Chronichepaticinjury SteatosisDiethylstilbestrol glucocorticoids griseofulvin MTX nifedipine tamoxifen TPN mercury ethanol nonalcoholicfattyliverdiseaseChroniccholestasisBiliarysclerosis 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 66 Others Venoocclusivediseasea Hepaticveinthrombosisb VenoocclusivediseaseGranulomatousdiseaseNeoplasia 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