临床病理讨论会.ppt
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1、臨床病理討論會A 10 y/o girlChief complaint:Chest discomfort,vomiting and dry cough for one dayBrief HistoryGrowth&development:Weight:22 kg(3rd-10th percentile)Height:130 cm(25-50th percentile)Development milestone:within normal limitPast historyHand-foot-mouth disease in 1998Frequent URI and fever during c
2、hildhoodNo drug or food allergyBrief HistoryFamily history:Her sister had fever and URI recently.Present IllnessFever and bilateral hand arthralgia attack once 1 month agoChest discomfort and cough since 9/11 afternoon,2001Visit LMD and URI was toldVomiting and chest tightness on 9/12 0 AM and 5 AMP
3、resent Illness9/12 morning,visit LMD again,ECG showed arrhythmiaRefer to 亞東 hospitalPresent IllnessFindings at 亞東 hospital Clear consciousness,ill-looking,pallor appearance,no cyanosis Irregular heart beat EKG:VPC bigeminyPresent IllnessLab.findings at 亞東 hospital WBC 9000/mm3,Hb 13.5 g/dl BUN 11 mg
4、/dl,Cre 0.6 mg/dl GOT 25 U/L,CK 665 U/L,CK-MB 175 U/LPresent IllnessEchocardiogram at 亞東 hospital Multiple small VSDs,muscular trabecular type,at apex LV dyskinesia,LVEF 60-70%Mild TR,mild MRPresent IllnessManagement at 亞東 hospital Lidocaine iv drip Dopamine 10 mg/kg/min Refer to NTUH(2pm)Physical E
5、xaminationPhysical findings at NTUH Consciousness:lethargic,acute ill-looking T/P/R:37/140/25 BP 80/46 SaO2 97%HEENT:pale conjunctiva anicteric sclera mild cyanotic lipPhysical Examination Neck:jugular venous engorgement Chest:bilateral basal rles Heart:irregularly irregular beats,distant heart soun
6、d no murmurPhysical Examination Abdomen:no hepatomegaly hypoactive bowel sound Extremities:freely movable cold and cyanotic poor capillary refillingInitial Lab DataCBC:WBC Hb Hct Plt 8840 12.7 37.2%160 K Seg 82.4%,Lym 13.8%,Eos 0.1%BCS:BUN Cre Na K Cl Ca 12.8 0.63 141 4.5 104 2.41 Initial Lab DataVB
7、G:pH pCO2 pO2 HCO3 BE 7.36 47.4 27.3 26.9 +1.4Cardiac enzyme:CPK(U/L)CK-MB Troponin I(ng/ml)1040 196.5 31.9CRP:0.53 mg/dl Initial Lab DataEKG(9/12):Initial Lab DataEKG(9/12):Initial Lab DataEKG(9/12):Initial Lab DataEchocardiogram(9/12):LV enlargementLVEF 45%Muscular VSDMild MR,TR,PR Echocardiogram(
8、9/12)Course and TreatmentManagementFor cardiogenic shock:Dopamine,Dobutamin,Primacor,LasixFor ventricular arrhythmia:Amiodarone,Lidocaine,MgSO4For myocarditis:IVIG,Consider extracorporeal membranous oxygenator(ECMO)supportCourse and Treatment9/12 5pm(3 hr after admission)Progressive hypotensionSudde
9、n onset of coma,BP drop(pulseless)EKG:ventricular tachycardiaStart CPR(40 min)Start ECMO,transfer to SICUEKG(9/12,5 PM)Course in SICUECMO settingV-A ECMO:15 Fr Rt femoral artery,19 Fr Rt femoral vein by cutdownFlow:2000 ml/minMean BP:70 mmHgUrine output:1.72 ml/kg/hrEchocardiogram(9/13)Course in SIC
10、UVT persistent despite of cardioversion,Lidocaine,Amiodarone,MgSO4 9/12 9/17:ECMO 5 daysPoor LV functionPersistent lung edema(CXR,clinically)TnI slowly decreaseA-line flatten,no pulsatile wave formCourse in SICUEndomyocardial biopsy(9/14)Mild to moderate perivascular and interstitial lymphocyte infi
11、ltrationFoci of myocyte degeneration Interstitial edemaNo giant cell Compatible with acute myocarditisCourse in SICULA drain(9/17):To decompress LV,avoid thrombosisLA dome cannulation connecting to FV cannula ECMO FALAP:22 mmHg 10 mmHgEchocardiogram(9/17)Course in SICU9/18,4am Acute thrombosis at LA
12、 cannula and ECMO circuit poor flowCPR for 30 min.and emergent re-set ECMO tubing Cons.After CPR:E1M1VTLight reflex(+)Course in SICU9/19,8am:gross hematuria and ECMO tube thrombosis reset ECMOProgressive dilated pupils,no light reflex,suspected hypoxic encephalopathyRemove ECMO on 9/23(10th day)Lab
13、data9/129/139/149/159/169/17TnI31.962.41007437.3CK104091242342126759138647026CK-MB196368687403207101Cre0.630.590.560.50.470.51Bil1.240.510.651.361.51.35Lab DataLab DataSerology study;Mycoplasma pneumonia IgM:(9/12)positive,(9/21)negativeOther virology study:all negative Coxsackie A,Coxsackie B1-B6,C
14、MV IgG&IgM,Enterovirus 70,Influenza A&BLab DataCulture:Throat swab(9/12):Staphylococcus aureusNasal swab(9/12):Staphylococcus aureus,Viridans streptococciBlood(9/19):Staphylococcus epidermidisDiscussionDiagnostic approach:Cause of chest pain in childrenIdiopathic:12-45%Costochondritis:9-22%Musculosk
15、eletal trauma:21%Cough,asthma,pneumonia:15-21%Psychogenic factors:5-9%GI disorders:4-7%Cardiac disorders:0-4%Diagnostic approachHx:cough,vomitingPE:hypotension jugular venous distention tachycardia irregular heart beat basal rles poor peripheral perfusion Cardiovascular compromise Diagnostic approac
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