投影片 1

Size: px

Start display at page:

Download "投影片 1"

秒琪宣
5 years ago
Views:

1 個案報告 -ARF 指導老師 : 邱豔芬院長學生 : 吳苡璉報告日期 :

2 基本資料 Name:Han Age:83 Gender:Male Medical disease: Hypertension 20 years without medicaine; HD 15 years without medicaine; DM 15 years; Asthma 60~70years; Parkinson s disease 2 years;

3 入院過程 Midnight abdominal pain and nausea with vomitting for three days 華陽 hospital Dx:Metabolic acidosis,acute renal failure with hyperkalemia and anemia r/o UGI bleeding Drug:Jusomin,Tagament,Cefmetazole and primperan 檢查 -renal sonography showed 1)Parenchymal renal disease. 2)Right renal stone.(about 1cm) 3)Kidney size:right-9.9cm,left-9.7cm.

4 入院過程 :00 因家屬意願轉至雙和醫院治療 GCS:E4V5M6 clear but weakness, acutely ill-looking 身上管路 : 外院帶來的 Foley H/L Vital sign: B.P.:132/65mmHg P.R:92 次 / 分 RR:32 次 / 分 B.T.:35.8 C

5 檢驗值 - 血液 WBC /ul1 RBC /ul3. HGB 10.4 g/dl HCT 32.6% MCV 106.9% MCH 34.3 pg MCHC 32.1 g/dl PLT /ul %NEUT 79.0 %LYM 14.0 %MONO 7.0 %EOS 0.0 %BASO 0.0 Infection sourses? ( /ul1) ( /ul3) ( g/dl) anemia ( %) ( %) ( pg) ( g/dl ) ( /ul) ( ) ( ) ( ) ( ) ( ) Infection sourses?

6 檢驗值 - 生化 BUN 63.0mg/dl Creatinine 8.16 mg/dl GOT 34 IU/L GPT 28 IU/L Bilirubin T 0.7 mg/dl Na 143 mmol/l K 6.5 mmol/l Glucose 178 mg/dl Troponin-I ng/ml CKMB 6.1 IU/L CPK 80 U/L 7.0~20.0 mg/d Renal function mg/dl 5-30 IU/L Liver function 5-35 IU/L mg/dl mmol/ mmol/ mg/dl ng/ml IU/L U/L 應是 Acute renal failure 所導致

7 檢驗值 - 生化 Albumin 3.4 g/dl Protein T 5.7 g/dl Uric acid 8.2 mg/dl Cholesterol 137 mg/dl TG 166 mg/dl LDH 240 IU/L ALK-P 59 IU/L r-gt 17 U/L 5-70 P 6.8 mg/dl Ca 7.4 mg/dl

8 檢驗值 -gas Blood gas PH PCO PO thb 10.9 O2Hb 96.9 so2 97.8% COHB 0.40% MetHb 0.50 HCO3 1.7 mmol/l ABEc VBG Metabolic acidosis

9 檢驗值 -urine SP.Gr PH 5.0 Protein 1+ Sugar 2+ Ketone 2+ Bilirubin - Occult Blood 2+ Nitrite - Urobilinogen 0.0 RBC 3-5 WBC 0-2 Eithel 0-2 Bacteria1 +.Colour YEL 可能由代謝性酸血症所引起

10 檢驗值 - stool Consistency Soft Color Brown Occult Blood 4+ Parasite Not Found WBC Not Found Mucus --

11 1.CXR analysis: Enlargement of heart. Tortuous aorta Increased pulmonary vascularity. Scoliosis of spine.

2.Abdomen+ plevis CT 7/9 Right renal stones; a suspicious tiny left renal stone; bilateral renal parechymal thinning; No hydronephrosis. No ascites; no extraluminal free air.

12 2.Abdomen+ plevis CT 7/9 Right renal stones; a suspicious tiny left renal stone; bilateral renal parechymal thinning; No hydronephrosis. No ascites; no extraluminal free air. s/p urinary catheterization. No remarkable finding in the liver, spleen, pancreas, gallbladder, and bilateral adrenal glands. Suspicious mild hiatal hernia of stomach. S/P internal fixation at left femur.

13 3.EKG:7/9 RBBB,sinus tachycardia

14 Problem list 1 Mr.Han 之 ARF 是如何診斷的? 2 屬於何種 ARF? 3 ARF 的治療有哪些? 4 除了 ARF, 有哪些問題? (1)anemia OB:4+ (2)Infection? (3)Electrolyte imbalance

15 1 Mr.Han 之 ARF 是如何診斷的?

16 1 Mr.Han 之 ARF 是如何診斷的? ARF 的臨床表徵 - 常見的實驗室檢驗異常 : 短時間內 BUN 上升 20~100mg/dl Cr 上升 1~5mg/dl 低鈉血症代謝性酸中毒高鉀血症 K:6.5 mmol/l Ca 7.4 mg/dl 低鈣血症高尿酸血症 Uric acid 8.2 mg/dl BUN:63.0mg/dl Creatinine:8.16 mg/d PH:6.746,PCO2:12.6, HCO3 1.7 mmol/l

17 2 屬於何種 ARF?

18 Acute renal disease Acute renal failure Prerenal Intrinsic Postrenal (obstruction) Tubular Glomerular Vascular ATN Interstitial Glomerulonephritis Vasculitis nephritis Ischemia Toxic

19 Prereanl disease he suffered from abdominal pain and nausea with vomitting for three day True volume depletion due to gastrointestinal, renal, or third-space losses Congestive heart failure or valvular heart disease Hepatorenal syndrome in advanced hepatic cirrhosis Use of a nonsteroidal antiinflammatory drug in certain clinical settings Shock due to fluid loss,sepsis.or cardiac failurefrequently progresses to acute tubular necrosis Madopar-HBS(125) Novonorm Blopress Plav

20 Intrinsic renal disease 1 急性腎小管壞死 (1) 缺血性起因於腎臟的灌流不足, 而當灌流不足, 持續且嚴重時, 可發生在與腎前因素引起的氮血症有關之任何狀況 (2) 腎毒性外生性毒素顯影劑具腎毒性的抗生素具腎毒性之抗腫瘤藥物重金屬 ( 鉛汞 ) 有機溶劑內生性毒素橫紋肌溶解症 ( 肌蛋白 ) 溶血 ( 血紅素 ) 腫瘤溶解症候群骨隨瘤高血鈣

21 Intrinsic renal disease 2 急性腎小球腎炎: 鏈球菌感染後腎小球腎炎快速進行性腎小球腎炎全身性紅斑性狼瘡 3 惡性高血壓皮質壞死血管炎腎動脈阻塞 4 間質性腎炎 5 其他: 尿酸腎病變高鈣血症

22 Distinction between Prerenal Disease and Acute Tubular Necrosis Test Favors Prerenal Disease Favors ATN BUN-to-PCr ratio >20: :1 Urinalysis Normal or near normal with Many granular casts with few cells or casts; hyaline casts renal tubular epithelial may be seen but are not abnormal and epithelial cell casts Urine sodium <25 meq/l >40 meq/l FENa < 1% >2 % FE Na= U Na P Cr 100 P Na U Cr Urine osmolality > 500 mosm/kg mosm/kg

23 FENa FENa = Na + excreted 100 = U Na V 100 Na + filtered P Na Ucr V = U Na P Cr 100 P Na U Cr U= 尿液,P= 血漿,V= 體積 P Cr

24 Urinary tract obstruction 1 輸尿管阻塞 ( 例如血塊鈣化石外來壓迫 ) 2 膀胱出口阻塞 ( 例如攝護腺肥大腫瘤 )

25 Urinalysis Urine Red cells red cell casts, and proteinuria glomerulonephritis or vasculitis. Protein 1+ White cells and white cell casts with or without some red cells a clearly positive sulfosalicylic acid test points muddy-brown granular casts with epithelial cells and epithelial cell casts normal urinalysis acute interstitial nephritis myeloma kidneysince the immunoglobulin light chains are not detected by the dipstick. acute tubular necrosis seen in prerenal disease, but may also occur in about 10% to 15% of cases of acute tubular necrosis and with urinary tract obstruction.

26 3.ARF 之治療方法?

27 急性腎小管處理原則急性腎小管壞死的恢復是自發性的, 處理方面是支持性的並根據以下幾點原則 : 限制水鈉鉀與磷的攝取限制蛋白質的攝取以減少尿素的生成使用利尿劑控制體液過剩給予 NaHCO3 以矯正酸血症調整依賴腎臟代謝之藥物劑量如果保守性處理不足以維持溶質與水的平衡時, 應進行透析

28 ARF 之治療使用利尿劑控制體液過剩 7/9 Lasix 2amp 高劑量的 Loop 利尿劑需用於急性腎衰竭? Samuel Shem's novel House of God 支持以下公式 : 年齡 + 血液尿素氮 =Lasix 劑量 Furosemide 與其他 loop 類的利尿劑作用於亨氏環上行支腎小管細胞的管腔面過度的利尿可能造成體液缺乏與腎臟的灌流過低, 增加造成傷害的機會

29 ARF 之治療在 ARF, 腎- 劑量的 dopamine 如何改善尿液排出? 即使低劑量的 dopamine 也會導致心搏過快心律不整或心肌缺氧因為它的注射腎 - 劑量 (1~3 ug/kg/min) 的 dopamine α- 腎上腺作用, 肢端的缺血可能會發在處理寡尿性病人時已被廣為利用生腸道缺血, 雖不常見, 但可能造成細菌或細菌的產物穿過腸道注射腎 - 劑量的 dopamine 可經由直接的腎小管作用增加尿液排出也可幫忙腎小管傳送利尿劑與阻斷醛固酮在遠端腎小管的留鹽作用

30 ARF 之治療給予 NaHCO3 以矯正酸血症 7/9 Rolikan 7% (sod.bicarbonate) 3 amp 如果保守性處理不足以維持溶質與水的平衡時, 應進行透析 7/9 HD 治療目標 : 體液 - 體積狀況正常化矯正電解質的平衡與控制尿毒

31 4 除了 ARF, 有哪些問題?

32 4 除了 ARF, 有哪些問題? (1) abdominal pain OB:4+ (2)Infection? (3)Electrolyte imbalance

33 (1) abdominal pain 7/9 Abdomen+ plevis CT 7/10 KUB 7/16 Endoscopy:7/16 Gastric ulcer with recent bleeding. Erosive gastritis.

34 (2)Infection? 7/9 WBC /ul1 %NEUT 79.0 Empirical antibiotic with rocephen 7/15 WBC /ul1

35 (3) Electrolyte imbalance Hyperkalemia 7/9 16:15 K:6.5 mmol/l Kalimate5g/ Sachet 3pk Glucose 50% 2PC +RI 8U Bricanyl nebulizing 1amp INH 7/9 23:48 K:4.0 mmol/l P 6.8 mg/dl Ca 7.4 mg/dl

針灸治療頭痛301例分析

針灸治療頭痛301例分析乾眼症病例報告曹永昌台北市中興醫院中醫科主任台北市中醫師公會常務理事摘要三現病史以辨證論治法取杞菊地黃丸滋腎明目湯黃蓮解毒丸加減, 於一個月內治療病史四年之乾眼症病例的成功案例一基本資料姓名 : 彭吉性別 : 男