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夏满
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1 CV Symptomatology 洪瑞松教授 Jui-Sung Hung, MD, FACC, FAHA

Cardiovascular System Structure and Function Electrical ( 電氣 ) ( 構造及功能 ) Mechanical ( 機械 ) *Close interactions Perfusion ( 灌流 ) Neuro-humoral regulations Autonomic nervous system

2 Cardiovascular System Structure and Function Electrical ( 電氣 ) ( 構造及功能 ) Mechanical ( 機械 ) *Close interactions Perfusion ( 灌流 ) Neuro-humoral regulations Autonomic nervous system Endocrine-humoral catecholamines, RAS, natriuretic peptides, endothelin etc. 問題之剖析診斷方法 (Means) 1. 病史 (history) 2. 理學檢查 (physical Exam) 3. 實驗室檢查 (laboratory tests) Proper ( 適當性 ) Timely ( 適時性 ) * 緊密的互動

3 心臟血管病之症狀表現心臟病患不一定有症狀若有症狀, 基於病態生理學或依其特性, 諸多症狀可歸納以下 6 大類 : 1) 肺充血 (pulmonary venous congestion) 之症狀 2) 全身性充血 (systemic venous congestion) 之症狀 3) 低心輸出量 (low cardiac output) 之症狀 4) 不適感 / 痛 (distress, discomfort/pain) Mechanical 5) 心悸 (palpitation) 6) 其他 (miscellaneous) Electrical Perfusion [ 註 ] 1) 3) 屬於心衰竭之表現症狀為主觀之感覺而沒有特異性 ( 或專一性 ), 所以需作詳細而有系統的分析

4 1) 肺靜脈充血 (Pulmonary Venous Congestion) 機轉 : 肺充血在病理學上屬於心因性肺水腫, 其因肺靜脈 / 毛細管靜水壓力 (hydrostatic pressure) 上昇, 而導致水 / 鈉離子由毛細管內滲出於肺間質組織而引起 (Cardiogenic pulmonary edema) 症狀 : 常見的為呼吸困難 (dyspnea) : 症狀有輕到重分別是 : exertional dyspnea, dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea, trepopnea 最嚴重者為 acute pulmonary edema ( 呼吸短促外尚有 cyanosis 及 pink frothy sputum) 註呼吸困難之表現不一定依輕重之次序出現少見的有 cough wheezing (cardiac asthma) 及 hemoptysis; 典型的 cough 特徵為乾咳, 躺下去會咳, 坐起來則改善 ( 與 orthopnea 機轉同 ); 註但肺充血常因感冒而引發, 而會有痰

5 Trepopnea Definition: Dyspnea, sensed while lying on one side but not on the other. Mechanism 1) Unilateral lung disease (one lung, or one major bronchus) Patients Prefer to lie on the opposite side of the diseased lung as the gravitation increases perfusion of the lower lung. Increased perfusion in diseased lung would increase shunting and hypoxemia, resulting in worsening dyspnea. To maximize function of the healthier lung, the patient is best to lie on the side of the healthier lung (good side down), so that it receives adequate perfusion. 2) Chronic heart failure Patients prefer to lie mostly on the left side (heart side down), to enable a better blood return, whereby CO is augmented

6 Platypnea Platypnea is due to either hepatopulmonary syndrome or an anatomical cardiovascular defect increasing positional rightto-left shunting (blood flow from the right to the left part of the circulatory system). These defects include rare syndromes in which 1) the venous blood from the liver does not pass Through the lungs, or 2) if venous blood from the portal circulation Reaches the inferior vena cava without passing through the liver ( type 1). Insufficiency of abdominal muscles causes lower diaphragm position and dyspnea. In clinostatism, abdominal organs push the diaphragm in its normal, upper position, reducing the respiratory effort. - Google

7 2) 全身靜脈充血 (Systemic Venous Congestion) 機轉 : 因右心房壓上昇, 繼而 systemic veins 之靜水壓力上昇, 而導致水 / 鈉由毛細管內滲出於全身間質組織症狀 : 常見者為 1) 下肢浮腫 (pitting edema) 及 2) 肝充血 (congested liver) 肝充血之表現 : 其特徵為運動時因右心房壓 ( 繼而肝靜脈壓 ) 上升, 造成上腹或右上腹部脹痛感出現或加劇必需與狹心症作鑑別 1) 與腳浮腫之正向關係 ( 浮腫加劇則肝充血之症狀更明顯, 反之浮腫減輕 ( 如利尿後 ) 則肝充下肢血症狀改善 : 2) 狹心症一般不合併腳浮腫嚴重者為 GI congestion (anorexia nausea vomiting constipation) ascites anasarca and GI bleeding (ischemic colitis mensenteric thrombembolism) 之表現 ; Renal vein thrombosis, nephrotic syndrome

8 Abdominal Pain and/or GI Bleeding* Acute coronary syndrome Superior mesenteric syndrome Congestive liver* ischemic colitis* AF with Mesenteric embolism Severe mesenteric arteriosclerosis Aneurysm rupture* Aortic dissection* Mesenteric venous thrombosis * Risk factors : CAD AF CHF Drugs: NSAID, anti-platelets, anticoagulants NS Ischemic Colitis* Risk

9 3) 低心輸出量 (Low Cardiac Output) 1. 急性 (Acute) 不可逆 (irreversible): Death ( 非症狀 ) 可逆 (reversible): dizziness syncope 2. 非急性 (Non-acute) Easy fatigability ( 疲倦 ),weakness Hypotension 及 shock 之表現 ( 包括 symptoms of increased sympathetic tone)

10 頭暈頭昏走路不穩洪祖培教授以頭暈或頭昏 (giddiness,dizziness) 就醫的病人為例, 必須詳細問病史或誘以了解究竟屬於下列那一種 : 1) 病人覺得頭暈 (light-headed) 頭飄浮感 (floating) 昏沈 (hazy) 朦朧 (groggy) 不清晰 (blurred) 霧煞煞 (misty) ; 但病人看得事物不會旋轉也没有眩暈感 ; 可能含有噁心但不會嘔吐, 不影響聴力, 也不會喪失意識此感覺有如健康的人在空氣稀薄氣壓低的高地, 感覺頭昏沈不舒服後, 經移到低處, 給予氧氣後即恢復 ; 在人多的密閉空間或場所, 離開密閉處後, 昏沈感消失 ; 睡眠不足敖夜後, 隔天感覺飄浮的現象, 但經休息後, 上述不舒服的感覺消失臨床上最常見於慢性多重器官衰竭長期臥床的病人, 服用安眠藥鎮定劑精神安定劑, 也可能是腦循環障礙貧血缺氧中毒所致 2) 因憂鬱工作壓力焦慮幻想等在精神科求診的病人, 常用窒悶不清爽 (stuffy head) 頭重脚輕 (heavy-headed) 頭内空空(empty- headed) 腦中空白 (blank-minded) 或頭頸部周圍緊縮感 (bandlike tightness) 來表示

11 3) 由視覺障礙引起的頭昏, 有別於内耳中樞神經引起的眩暈, 通常初戴眼鏡不適應的人, 白内障, 青光眼, 複視的病人, 點散瞳劑者或由暗處出來突然遇到強光而引起眼前發亮 (glare) 或變白 (whiteout) 伴隨頭昏稱為目眩或眩昏 (dazzle) 偏頭痛病人在突然發作前, 會有光光圏的頭昏感覺 ; 特殊癲癇病也會以目眩為前兆 4) 突然頭昏前, 眼前一片黒 (black) 暗(dark) 灰(gray), 後有失神感, 好像昏過去 (going to faint away) 飄浮感(Swimming), 嚴重時會失神 (syncope) 而倒下, 即所謂黒暗暈 (blackout), 意識恢復後, 會有盗汗手脚冰冷心跳快的感覺健康人常見於天氣太熱肚子餓或路蹲太久, 突然站立引起立性低血壓 (orthostatic postural hypotension), 恢復後不會有神經學障礙嚴重者, 若很快失神失神時間較長或引起尿失禁, 則考慮有潛伏性病態, 如 : 心臓衰竭服用血管擴張劑高血壓治療劑利尿劑等, 以及貧血自律神經障礙新陳代謝内分泌障礙等遇到恐怖緊張心理壓力受驚嚇生氣等心理性表現時, 也會失神昏厥是由副交感神經過度興奮所致的現象 (vasovagal syncope)

12 5) 突然間, 病人感覺眼前物體在旋轉 (spinning around), 整個房間以身體為中心打轉 (rotating), 站立不穏 (unsteady) 或傾斜一側, 常伴随噁心嘔吐, 不敢站立, 想閉上眼睛而躺下來, 以減輕不適感, 此種發作稱之為眩暈 (vertigo) 與上述頭暈的現象不同, 則考慮内耳前庭器官疾病或平衡失調健康的人也會有此經驗, 例如 : 暈車暈船, 坐在車内往窗外看流動的物體, 到兒童樂園玩旋轉木馬, 或一直注視旋轉, 或由高處往下看海浪河流, 經閉上眼睛後, 雖然看不到旋轉, 由於平衡不良, 身體仍在感覺在轉, 躺下或休息後即可恢復良性陣發性姿勢性眩暈 (benign paroxysmal positional vertigo) 前庭神經炎(vestibular neuronitis) 以及其他内耳水腫 Meniere 氏病, 治療 2-3 週後症狀會減輕若眩暈拖太久尤其是年長者, 則要考慮腦幹或小腦病變所致慢性暈眩病人, 也要則考慮罹患腦瘤藥物中毒或小腦退化症

13 Syncope 定義 : Transient loss of consciousness with loss of posture 症狀 ( 問題 ) 之分析 QQOPERA 解決方法 : Pathophysiologic approach transient hypotension (mechanism): electrical, coronary perfusion, mechanical 鑑別診斷 : seizure, hypoglycemia, psychiatric disorder panic disorder (hyperventilation)

14 Syncope - Analyses QQ: near syncope, syncope O: sudden (blackout, graying out, white out) P: situational: vasovagal, tussive, glutition, micturition, orthostatic, exertional; positional: orthostatic, supine upward gaze (carotid hypersentivity) Drugs: NTG, alpha-blocker etc. R: spontaneous, rapid recovery A: 1) Pre: palpitation, chest distress/pain (myocardial ischemia, aortic dissection) 2) During: incontinence (infrequent) 3) Symptoms from inflicted trauma

15 Blood Pressure ( 血壓 ) Non-invasive, indirect assessment of aortic pressure Assumptions: 1) Reliable sphygmomanometer 2) Correct technique 3) No obstruction between aorta and arm 4) Adequate minimal blood flow no extreme arterial vasoconstriction Parameters: Direct: 1) Systolic pressure 2) Diastolic pressure Indirect: 3) Pulse pressure (PP) = (systolic diastolic pressure) *Normal range = mmhg

16 BP = f (SVR, HR, preload, afterload, contractility) SV Preload Contractility Hung s Slingshot Cardiac Physiology CO Afterload BP SVR HR Arterial compliance Peak ventricular presuure Afterload, mainly determined by SVR Thus, In practicality, BP = f (SVR, HR, preload, afterload, contractility) unless presence of significant LV outflow resistance

17 Mechanism of Hypotension in Shock HR Preload Contractility PVR 1) Hypovolemic 2) Obstructive 3) Cardiogenic 4) Distributive a) Anaphylactic b) Neurogenic c) Septic N

18 4) 心血管病胸不適感或痛 (Distress/Pain) 1. 心包囊炎 (pericarditis): 痛在前胸 Pleuritic and positional Pleuritic ( 吸氣更痛 ) 與 thorax and pleuritis pain 同 ; Positional ( 躺下更痛 ) - 與 pleuritis 不同 Non-tender - 與 thorax pain 不同 2. 心肌缺血症候群 (myocardial ischemic syndrome) 狹心症 (angina), 急性冠狀動脈症候群 (ACS) 3. 主動脈剝離症 (aortic dissection): 其特徵為 1) tearing; 2) persistent; 3) abrupt or dramatic onset; 4) migratory; 註不一定出現在胸部

19 Myocardial Oxygen Economics 心肌氧氣經濟學 Perfusion pressure Coronary arterial resistance O 2 Supply (F x C) Coronary Flow (F) = (ADP LVDP)/Rc O2 content (C) = f (Hemoglobin, SaO2%) Heart rate Myocardial tension Contractility O 2 demand determinants Clinical Index Double Product SBP x HR Laplace s Law T = P x R/ 2 x W R P T T T = tension P = pressure R = radius W = wall thickness W

20 心肌氧氣經濟學冠狀動脈正常血氧供需平衡冠狀動脈硬化血氧供需失衡 - 心肌缺血缺氧供應增加需求增加供應不足需求增加供應驟減需求不變動用儲備流量儲備流量不足 1) Microvasculature disorder 2) 1) Spasm 2) Dissection 3) No-, slow-flow 4) 需求不變血流儲備量供需平衡狹心症 ACS 心衰竭不整脈猝死

ACS Pathophsiology Unstable Plague Angina (+) Rupture Thrombosis Vasoconstriction Thrombolysis Collaterals Varying Occlusion/Ischemia Incomplete

21 ACS Pathophsiology Unstable Plague Angina (+) Rupture Thrombosis Vasoconstriction Thrombolysis Collaterals Varying Occlusion/Ischemia Incomplete Complete; Collateral (+) Complete; Collateral (-) ECG Non-ST Elevation ST Elevation Markers (-) NSTEMI Markers (+) STEMI Unstable Angina Non-Q MI Q-MI

22 心肌缺血症候群 (myocardial ischemic syndrome) 狹心症 (angina), 急性冠狀動脈症候群 (ACS) 1) Directly resulting from ischemia Chest pain/distress Typical Atypical in Location and/or Quality Non-chest pain/distress* Limited to radiating sites; epigastrium,head etc. 2) Indirectly resultant Symptoms Related to acute ventricular dysfunction Related to arrhythmias ( 不整脈 ) Sudden death 3) Silent ischemia * High index of suspicion

23 Classic Angina Increase in myocardial oxygen demand L: Retrosternal/precordial, diffuse with/without radiation Q: Discomfort/pain (oppressive, strangling) P: Effort/mental stress induced Precipitated by a heavy meal or exposure to cold O: Sudden but not abrupt R: Rest and/or NTG relief Q 2 : Duration: Several minutes; if > 20 min, consider ACS (unstable angina/ami) or, unrelated to ischemia

24 Atypical Presentations (ACS) Abdominal pain (epigastric etc.) Ingestion Shortness of breath Nausea, vomiting or diarrhea Generalized feeling of unwellness or weakness, sweating Back or jaw tightness/pain Atypical presentations High-risk groups 1. The elderly; 2. Diabetic patients 3. Heart transplantation recipients * High index of suspicion HEART & LUNG 2001

25 Angina Pectoris - Heberden 1768 A disorder of the breast, marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it, and not extremely rare, of which I do not recollect any mention among medical authors. The seat of it, and sense of strangling and anxiety with which it is attended, may make it not improperly be called angina pectoris. Those who are afflicted with it are seized, while they are walking, and more particularly when they walk soon after eating, with a painful and most disagreeable sensation in the breast, which seems as if it would take their life away, if it were to increase or to continue: the moment they stand still, all this uneasiness vanishes. In all other respects, the patients are, at the beginning of this disorder, perfectly well.

26 徵候症候群 Arrhythmia Clinical significance? Hemodynamic significance? Potentially life threatening? Where to seek assistance?

27 Symptoms Relevant to Arrhythmias Direct - 心悸 (Palpitation) Mechanical 定義 : 自覺心臟在跳動症狀 ( 問題 ) 之分析 QQOPERA Perfusion 機轉 : 很多種 ; 有心悸不一定代表有心律不整或心臟病 ; Electrical No palpitation normal? Indirect 1) Hemodynamic consequences 肺充血 (pulmonary venous congestion) 之症狀 2) 全身性充血 (systemic venous congestion) 之症狀 3) 低心輸出量 (low cardiac output) 之症狀 Syncope, Shock, death 2) Consequence on impaired coronary perfusion

28 6) 其他 (Miscellaneous) 任何症狀皆有可能為心臟病有關之症狀, 因此在 systems review 中需分析辨別是否與已有之心臟病有關特舉比較有特徵者 : Fever ( 感染性心內膜炎粘液瘤 ) Dysphagia ( 左心房主動脈擴大, 壓到食道 ) Hoarseness (Ortner syndrome) 左心房主動脈或肺動脈擴大, 壓迫到左 recurrent laryngeal nerve 導致左聲帶麻痺 )

29 6) 其他 (miscellaneous) - I Any symptom in Systems Review may be related to CV disorders* Because symptoms are non-specific and may be related to multiple systems, each symptom is assigned to the system in which it is more or most commonly associated as follows. 1. General:weakness, fatigue, anorexia, fever, insomnia 2. Integument (skin, hair and nails):changes in color (pigmentation, jaundice, cyanosis), pruritus, rash, hair loss 3. HEENT: Head - headache, dizziness, vertigo Eyes - visual acuity, color vision, corrective lenses, photophobia, diplopia, pain Ears - pain, discharge, hearing loss, tinnitus Nose - epistaxis, discharge, stuffiness, sense of smell Throat - status of teeth, gums, dentures, taste, soreness, hoarseness, lump 4. Respiratory:cough, sputum, hemoptysis, wheezing 5. CV:dyspnea, edema, chest distress/pain, palpitation, intermittent claudication, cold limbs, cyanosis etc; e.g. * Headache rare, angina symptom; vasodilator.

30 6) 其他 (miscellaneous) - II Any symptom in Systems Review may be related to CV disorders 6. GI:dysphagia, nausea, vomiting, abdominal distress pain, change in bowel habit (diarrhea, constipation, character of stool), hematemesis, melena, bloody stool 7. GU:urinary frequency, hesitancy, urgency, dribbling, incontinence, dysuria, hematuria, nocturia, polyuria, impotence Female - menarche, menstrual history (including the date of last period), vaginal bleeding or discharge; pregnancy 8. Metabolic and endocrine:growth and development, weight change heat/cold intolerance, nervousness, sweating, polydipsia 9. Hematotologic: anemia, easy brusity or bleeding, lymphadenopathy, transfusions 10. Neuropsychiatry:dizziness, syncope, seizures, speech disturbance, loss of sensation, paresthesia, ataxia, weakness or paralysis, tremor, anxiety, depression, irritablility 11. Musculoskeletal:joint pain, stiffness, limitation of motion, muscular weakenss, wasting

31 Acute Limb Arterial Occlusion 6 Ps Pain Paresthesia Palsy Pale Pulseless Poikiothermia (cold blooded)

32 Elevation Dependency Test Detection of subclinical ischemia 60 seconds Delayed filling Capillaries and veins Elevation pallor (normal VFT < 15 ) Dependent rubor (Ischemic hyperemia) JSH

33 Chronic Limb Arterial Occlusion Intermittent claudication, cold limbs, atrophic skin changes, cyanosis, gangrene etc; Acute 6 Ps Pain Paresthesia Palsy Pale Pulseless Poikiothermia (cold blooded)

34 心臟病之症狀 - 篩檢性問診在無有關心臟血管系統主訴或沒有心血管疾病病史者, 初步可只問 : 1) dyspnea 2) legs edema Mechanical 3) dizziness/syncope 4) palpitation 5) chest distress/pain Perfusion Electrical 若有上述症狀或理學檢查有異常者, 則再進一步詳細問如, 有 legs edema 進一步問, 運動時上腹部會不會脹痛

35 問題提示分類剖析解決 1. 提示類型 2. 剖析 * 3. 解決策略 A. 症狀 1. Dyspnea 2. Legs edema 3. Syncope 4. Chest distress/pain 5. Palpitation 定量非定量 LQQOPERA 法 LQQOPERA 法依質量不減定律或經濟 ( 會計 ) 學法則剖析解決 Approaches: 1) Systems 2) Anatomic C. 定量性檢驗 Hypoalbuminemia 3) Pathophysiologic 4) Pathologic D. 症候群 / 疾病 1. HTN; 2. HF 依指引綱領 (Guidelines) 剖析解決 * 知己知彼百戰不殆孫子兵法 - 謀攻篇

36 策略 (Strategy) Similarity between Warfare and Clinical Problem Solving 戰爭 (Warfare) 知彼 (Intelligence Gathering) 戰術策略 (Strategy) 地面戰 (ground) 海戰 (sea) 空戰 (air) 飛彈戰 (bomb, missile) 生物戰 (biological) 化學戰 (chemical) 心理戰 (psychological) 資訊戰 (e-information) 臨床問題解決 (Clinical Problem Solving) 問題剖析 (Problem Analyses) LQQOPERA 非定量問題解決策略 (Strategy) 1) Systems 2) Anatomic 3) Pathophysiologic 4) Pathologic * 知己知彼百戰不殆孫子兵法 - 謀攻篇

37 2. 問題之剖析 (Problem Analyses) 洪氏 LQQOPERA 法 - History Taking 此剖析法原則上應包括 LQQOPERA 8 要項, 較特殊者可依情略去其中一些項目, 如在呼吸困難省略位置 (L) Location ( 位置 ) Quality ( 型態 ) Quantity/time course ( 歷時長短 / 時相 ) Onset mode ( 起病狀態或發作形式 ) Precipitation factors ( 情境或誘發因素 ) Exaggerating factors ( 加重因素 ) Relieving factors ( 緩解因素 ) Accompanying symptoms ( 伴隨症狀 ) LQQOPERA: 老勼勼唱歌仔戲 (very old person singing Taiwan opera)

38 疼痛 / 不適感 (Pain/Distress) 此症狀的分析應包括下列 LQQOPERA 8 項內涵 1. 位置 (Location) 局部性 (localized - somatic) 瀰漫性 (diffuse visceral or diffuse somatic) 移位性 (migratory), 放射性 (radiation) etc. 2. 形態 (Quality) 刺痛 (needling), 銳利 (sharp pain), 頓痛 (dull ache) 壓迫性 (oppressive), 難忍的 (excruciating) etc. 3. 歷時 / 時相 (Quantity/Process) 持續性 (persistent) 間歇性 (intermittent): 其頻率 (frequency), 單次持續時間 (duration of each episode), 發作間隔 (intervals between episodes)

39 疼痛 / 不適感 (Pain/distress) 4. 起病狀態 (Onset mode) 超急性 (abrupt) 突然 (sudden) 緩慢性 (insidious) 5. 情境誘發因素 (Precipitating factors) 6. 加重因素 (Exaggerating factors) 7. 緩解因素 (Relieving factors) 8. 伴隨因素 (Accompanying symptoms)

40 超急性 ( 晴天霹靂 ) 發作 (Abrupt/Dramatic Onset) 超急性發作代表 1) 神經性疼痛 ; 或 2) 組織器官連續性突然喪失如為後者, 以系統類歸法舉例如下 : 系統類歸法 (systems approach) 1. Integument: laceration 2. HEENT: subarachnoid hemorrhage 3. Respiratory: pneumothorax 4. CV: aortic dissection, rupture of aneurysm, AMI 5. GI: 1) Halo/solid organ rupture/perforation: esophagus, stomach, intestines, spleen, liver 2) gall stone 6. GU: ureter stone, ectopic pregnancy, ovarian torsion 7. Musculoskeletal: tissue laceration, fracture, tendon rupture

41 疼痛 / 不適感 (Pain/distress) - 加重因素 (Exaggerating factors) 1) Food intake, swallowing, defecation, urination ( 進食吞嚥排便排尿 ) 2) Inspiration, coughing, sneezing ( 吸氣咳嗽打噴涕 ) 3) Body position/motion Supine, sitting up, leaning, turning, twisting ( 仰臥起坐前傾側躺扭動 ) 4) Exercise 5) Tenderness 壓痛 6) Emotion 焦慮 7) Temperature change - Coldness

42 人體構造 10 系統建議排序位置包覆全身 1. Integument* * 皮膚系統包含毛髮指甲 2. HEENT 胸部 3. Respiratory 4. Cardiovascular 由上到下 3 4 可對調 5 6 可對調腹部 5. Gatrointestinal 6. Genitourinary 7. Hematology ** 肌肉與神經關係全身 8. Metabolic/endocrine 9. Muscloskeletal** 10. Neurophychiatry* 密切, 故排第 9 * 精神系統為抽象, 故放在最後第 10

43 B. 非定量問題 (Non-quantitative Problem) 4) Pathologic Approach ( 病理類別法 ) 1) Infectious (inflammatory) ( 感染性發炎 ) 2) Non-infectious (inflammatory) ( 非感染性發炎 ) 3) Neoplasm ( 新生物 ) Benign ( 良性 ) Malignant ( 惡性 ) 4) Circulatory ( 循環 ) 5) Metabolic/endocrine ( 新陳代謝 / 內分泌 ) 6) Hematologic ( 血液 ) 7) Degeneration( 退化性 ) 8) Physical/chemical injury ( 物理 / 化學性傷害 )

44 Trepopnea is dyspnea (shortness of breath) that is sensed while lying on one side but not on the other. It results from 1) disease of one lung, one major bronchus, or 2) chronic conngestive heart failure. 1) Patients with trepopnea from lung disease prefer to lie on the opposite side of the diseased lung (good side down), as the gravitation increases perfusion of the lower lung. Increased perfusion in diseased lung would increase shunting and hypoxemia, resulting in worsening shortness of breath. To maximize function of the healthier lung, the patient is best to lie on the side of the healthier lung, so that it receives adequate perfusion. 2) Patients with chronic heart failure prefer to lie mostly on the left side, to enable a better blood return, whereby cardiac output is augmented Other types of positional dyspnea include orthopnea and paroxysmal nocturnal dyspnea. Rates of breathing are described with the terms eupnea, bradypnea (slow), and tachypnea (fast).

45 Myocardial Oxygen Economics Ohm s Law P 1 R P 2 F = (P 1 - P 2 ) x R Perfusion pressure Arterial resistance O 2 Supply determinants F Heart rate Myocardial tension Contractility O 2 demand determinants Clinical Index Double Product SBP x HR Laplace s Law T = P x R/ 2 x W T = R P T T T = tension P = pressure R = radius W W = wall thickness

46 Mechanisms of Impaired Coronary Artery Perfusion Ostial fibrotic disease, aortic dissection Epicardial artery 1) Extramural compression Anomalous origin of coronary artery Myocaradial bridging, enlarged PA, tumor 2) Mural functional spasm organic atherosclerosis, dissection 3) Intramural thrombus, air Microvascular disorders LV hypertrophy; Syndrome X No/slow flow

47 問題提示分類剖析解決 1. 提示類型 2. 剖析 * 3. 解決策略 A. 症狀 1. Dyspnea 2. Legs edema 3. Syncope 4. Chest distress/pain 5. Palpitation 定量非定量 LQQOPERA 法 LQQOPERA 法依質量不減定律或經濟 ( 會計 ) 學法則剖析解決 Approaches: 1) Systems 2) Anatomic C. 定量性檢驗 Hypoalbuminemia 3) Pathophysiologic 4) Pathologic D. 症候群 / 疾病依指引綱領 (Guidelines) 剖析解決 * 知己知彼百戰不殆孫子兵法 - 謀攻篇

48 策略 (Strategy) Similarity between Warfare and Clinical Problem Solving 戰爭 (Warfare) 知彼 (Intelligence Gathering) 戰術策略 (Strategy) 地面戰 (ground) 海戰 (sea) 空戰 (air) 飛彈戰 (bomb, missile) 生物戰 (biological) 化學戰 (chemical) 心理戰 (psychological) 資訊戰 (e-information) 臨床問題解決 (Clinical Problem Solving) 問題剖析 (Problem Analyses) LQQOPERA 非定量問題解決策略 (Strategy) 1) Systems 2) Anatomic 3) Pathophysiologic 4) Pathologic * 知己知彼百戰不殆孫子兵法 - 謀攻篇

49 Problem Solving - Combined Approaches Obstruction of Tubular Structure Pathophysiologic Approach Pathologic approach Functional ( 機能性 ) Organic ( 器質性 ) Anatomic Approach Intraluminal ( 管內 ) Mural ( 管壁 ) Extraluminal ( 管外壓迫 ) ( 病灶 ) Lesion Systems approach Pathologic approach Anatomic approach

50 Versatility of Symptomattoloy in Vascular Diseases - Mechanisms of Organ/Tissue Ischemia Functional resistance to flow - Spasm Organic resistance to flow 1) Intraluminal 2) Mural Thrombosis; Embolism thrombus (Af), tumor (e.g. cardiac myxoma), clacicim, air,fat, cholesterol, Atherosclerotic plaque, vasculitis, dissection 3) Extramural compression Neoplasm, hematoma, compartment syndrome etc.

51 Neighborhood Anatomic Relations Left recurrent laryngeal nerve Esophagus 食道 Aortic Isthmus LA Aortic valve annulus Nerve Palsy Ortner syndrome Enlarged PA, LA Aorta, relatively fixed at isthmus in front of vertebra 1) TEE and aortic annulus 2) Dysphagia 1) Isthmus portion, vulnerable to trauma - transection 2) Arterosclerotic,aorta, elongated to right and anteriorly; heart, lying more horizontally Enlarged LA

52 Atrial Kick Atrial Sound (S 4 ) in Stiff LV Shinjuku Station in morning rush hours What is the consequence of lost atrial kick in train station? What is the consequence of lost atrial kick in stiff LV, onset of Af, or AV dissociation?

53 Systems Review ( 系統環顧評估 - 症狀 ) Because symptoms are non-specific and may be related to multiple systems, each symptom is assigned to the system in which it is more or most commonly associated as follows. 1. General:weakness, fatigue, anorexia, fever, insomnia 2. Integument (skin, hair and nails):changes in color (pigmentation, jaundice, cyanosis), pruritus, rash, hair loss 3. HEENT: a. Head - headache, dizziness, vertigo b. Eyes - visual acuity, color vision, corrective lenses, photophobia, diplopia, c. Ears - pain, discharge, hearing loss, tinnitus d. Nose - epistaxis, discharge, stuffiness, sense of smell e. Throat - status of teeth, gums, dentures, taste, soreness, hoarseness, 4. Respiratory: dyspnea, wheezing, cough, sputum, hemoptysis, chest pain 5. CV:dyspnea, edema, dizziness/ syncope, palpitation. chest distress/pain: intermittent claudication, cold limbs, cyanosis, (gangrene)

54 Systems Review ( 系統環顧評估 - 症狀 ) - continued) 6. GI:dysphagia, nausea, vomiting, abdominal distress pain, change in bowel habit (diarrhea, constipation, character of stool), GI bleeding (hematemesis, melena, bloody stool) 7. GU:urinary frequency, hesitancy, urgency, dribbling, incontinence, dysuria, hematuria, nocturia, polyuria, impotence Female - menarche, menstrual history (including the date of last period), vaginal bleeding or discharge; pregnancy 8. Metabolic and endocrine:growth and development, weight change*, heat/cold intolerance, nervousness, sweating, polydipsia 9. Hematotologic: anemia*, easy brusity or bleeding, lymphadenopathy, transfusions 10. Musculoskeletal:joint pain, stiffness, limitation of motion, muscular weakenss, wasting 11. Neuropsychiatry:dizziness, syncope, seizure, speech disturbance, loss of sensation, * weight paresthesia, change, anemia ataxia, 為定量問題 weakness : or 其他為非定量問題 paralysis, tremor, anxiety, depression, irritablility

Microsoft PowerPoint - PGY Training Program.ppt

Microsoft PowerPoint - PGY Training Program.ppt PGY Training Program: Cardiovascular Department 羅東博愛醫院心臟內科許育誠醫師臨床醫學問題導向以病患為中心全方位醫療 Problem-based, Patient centered, Integrated care 一般醫學內科核心課程症狀或徵候貧血, 胸痛, 腹痛, 水腫, 心悸, 呼吸困難, 發燒, 寡尿病態或疾病休克, 意識障礙,