临床病理讨论会课件.ppt
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1、臨床病理討論會小兒科:盧俊維醫師放射科:吳金珠醫師病理科:蕭正祥醫師临床病理讨论会课件1A 10 y/o girlChief complaint:Chest discomfort,vomiting and dry cough for one day临床病理讨论会课件2Brief HistoryGrowth&development:Weight:22 kg(3rd-10th percentile)Height:130 cm(25-50th percentile)Development milestone:within normal limitPast historyHand-foot-mouth
2、 disease in 1998Frequent URI and fever during childhoodNo drug or food allergy临床病理讨论会课件3Brief HistoryFamily history:Her sister had fever and URI recently.临床病理讨论会课件4Present IllnessFever and bilateral hand arthralgia attack once 1 month agoChest discomfort and cough since 9/11 afternoon,2001Visit LMD
3、and URI was toldVomiting and chest tightness on 9/12 0 AM and 5 AM临床病理讨论会课件5Present Illness9/12 morning,visit LMD again,ECG showed arrhythmiaRefer to 亞東 hospital临床病理讨论会课件6Present IllnessFindings at 亞東 hospital Clear consciousness,ill-looking,pallor appearance,no cyanosis Irregular heart beat EKG:VPC
4、 bigeminy临床病理讨论会课件7Present IllnessLab.findings at 亞東 hospital WBC 9000/mm3,Hb 13.5 g/dl BUN 11 mg/dl,Cre 0.6 mg/dl GOT 25 U/L,CK 665 U/L,CK-MB 175 U/L临床病理讨论会课件8Present IllnessEchocardiogram at 亞東 hospital Multiple small VSDs,muscular trabecular type,at apex LV dyskinesia,LVEF 60-70%Mild TR,mild MR临床
5、病理讨论会课件9Present IllnessManagement at 亞東 hospital Lidocaine iv drip Dopamine 10 mg/kg/min Refer to NTUH(2pm)临床病理讨论会课件10Physical ExaminationPhysical 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 lip临床病理
6、讨论会课件11Physical Examination Neck:jugular venous engorgement Chest:bilateral basal rles Heart:irregularly irregular beats,distant heart sound no murmur临床病理讨论会课件12Physical Examination Abdomen:no hepatomegaly hypoactive bowel sound Extremities:freely movable cold and cyanotic poor capillary refilling临床
7、病理讨论会课件13Initial 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 临床病理讨论会课件14Initial Lab DataVBG: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 临床病理讨论
8、会课件15Initial Lab DataEKG(9/12):临床病理讨论会课件16Initial Lab DataEKG(9/12):临床病理讨论会课件17Initial Lab DataEKG(9/12):临床病理讨论会课件18Initial Lab DataEchocardiogram(9/12):LV enlargementLVEF 45%Muscular VSDMild MR,TR,PR 临床病理讨论会课件19Echocardiogram(9/12)临床病理讨论会课件20Course and TreatmentManagementFor cardiogenic shock:Dopam
9、ine,Dobutamin,Primacor,LasixFor ventricular arrhythmia:Amiodarone,Lidocaine,MgSO4For myocarditis:IVIG,Consider extracorporeal membranous oxygenator(ECMO)support临床病理讨论会课件21Course and Treatment9/12 5pm(3 hr after admission)Progressive hypotensionSudden onset of coma,BP drop(pulseless)EKG:ventricular t
10、achycardiaStart CPR(40 min)Start ECMO,transfer to SICU临床病理讨论会课件22EKG(9/12,5 PM)临床病理讨论会课件23Course 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/hr临床病理讨论会课件24Echocardiogram(9/13)临床病理讨论会课件25Course in SICUVT per
11、sistent 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 form临床病理讨论会课件26Course in SICUEndomyocardial biopsy(9/14)Mild to moderate perivascular and interstitial lymphocyte
12、infiltrationFoci of myocyte degeneration Interstitial edemaNo giant cell Compatible with acute myocarditis临床病理讨论会课件27Course in SICULA drain(9/17):To decompress LV,avoid thrombosisLA dome cannulation connecting to FV cannula ECMO FALAP:22 mmHg 10 mmHg临床病理讨论会课件28Echocardiogram(9/17)临床病理讨论会课件29Course i
13、n SICU9/18,4am Acute thrombosis at LA cannula and ECMO circuit poor flowCPR for 30 min.and emergent re-set ECMO tubing Cons.After CPR:E1M1VTLight reflex(+)临床病理讨论会课件30Course in SICU9/19,8am:gross hematuria and ECMO tube thrombosis reset ECMOProgressive dilated pupils,no light reflex,suspected hypoxic
14、 encephalopathyRemove ECMO on 9/23(10th day)临床病理讨论会课件31Lab data9/129/139/149/159/169/17TnI31.962.41007437.3CK104091242342126759138647026CK-MB196368687403207101Cre0.630.590.560.50.470.51Bil1.240.510.651.361.51.35临床病理讨论会课件32Lab DataDATE9/229/209/189/169/149/12Troponin I(ng/ml)120100806040200DATE9/229/
15、209/189/169/149/12U/L8006004002000GOTCK-MB临床病理讨论会课件33Lab DataSerology study;Mycoplasma pneumonia IgM:(9/12)positive,(9/21)negativeOther virology study:all negative Coxsackie A,Coxsackie B1-B6,CMV IgG&IgM,Enterovirus 70,Influenza A&B临床病理讨论会课件34Lab DataCulture:Throat swab(9/12):Staphylococcus aureusNa
16、sal swab(9/12):Staphylococcus aureus,Viridans streptococciBlood(9/19):Staphylococcus epidermidis临床病理讨论会课件35DiscussionDiagnostic approach:Cause of chest pain in childrenIdiopathic:12-45%Costochondritis:9-22%Musculoskeletal trauma:21%Cough,asthma,pneumonia:15-21%Psychogenic factors:5-9%GI disorders:4-
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