新光医院外科急诊科联合病例讨论会课件

新光醫院外科急診科 聯合病例討論會 報告：侯勝文醫師 指導：連楚明醫師 2003.02.19 Case 1 Personal information Name: 陳X No.: 0577XXX-X Age: 85 y/o Sex: F Sent by: Family, at 16:02, 10/Dec/2002 Cons: Alert Vital sign: T37.3, PR79, RR16, BP 135/52 Triage: II Chief complaint Epigastralgia since 2 pm. Present illness Vomiting, with coffee-ground substance. Abdominal pain radiated to bilateral shoulders. Diarrhea (-) SOB(-) Stool: tarry Abdominal fullness, frequently in last 6 months. Past history HTN, CAD and hepatitis, with oral medicine. Drug allergy: denied OP Hx: Uterine myoma Autoimmune hepatitis with combesolone 3# bid. Hiatal hernia noted at OPD 2 month ago accidentally. Physical examination Cons: alert, acute ill-looking w Neck: supple w Conjunctiva: not pale Chest w HS: RHB, no murmur w BS: bilateral clear Abdomen w Diffuse tenderness, tense w Rebound tenderness w Bowel sound: hypoactive Limbs: w No edema NE: No focal sign. What is your impression? Duty doctors impression Peritonitis, r/o PPU Diaphragm hernia Plan (1), Dec/10, pm 4:30 Triage: II N/S 100 ml/hr CXR (PA) KUB CBC/DC, PLT Panel I EKG Bed side echo NPO CXR and KUB Any finding? CXR w Increased lung marking on both side w Huge cavity at left retrocardiac portion w Mediastinal shift to right KUB w Increased lucency at right hepatic level w Increased bowel gas shadow with ileus pattern Lab data (1) CBC w WBC 14500/l, Seg 86.0, Lym 9.0, Band 1.0, Monocyte 4.0 w Hb 12.5 gm/dl, Hct 36.1%, Plt 242k/l Panel I w Glu 155 mg/dl, AST 206, Bun/Cr 40/1.1 w Na/K: 129/4.9 Any idea? Next plan? Plan (2), Dec/10, pm 5:10 Vomitus sent for OB Keto 1 vial iv dripping On NG tube f/u CXR (PA) CXR s/p NG Any finding? f/u CXR s/p NG w Retrocardiac cavity seem increased in size Plan (3) 10/Dec, pm 7:00 Consult CS Arrange UGI series IV changed to D5S keep 100 ml/hr Fleet enema 1 bot st CXR lateral (8 pm) Demeral 50 mg im (10 pm) Hb, PT/aPTT f/u in coming morning NG decompression (11pm) CXR lateral view Any finding? Lab data (2), Dec/11, 6 am Hb 11.6 (yesterday 12.5) PT 13.15/10.4, INR 1.68 aPTT 34.00/31.6 Plan (4), Dec/11, am 8:30 Arrange panendoscopy (早上pt被送到放射科做UGI series) NG aspiration and lavage for barium removal. (11am) Remove NG tube (clotted) Arrange abd CT with and without contrast DC abd CT (due to much retained barium) Admit to CS ward 6233.(12:25 noon) UGI series report Any finding? Tertiary peristalsis of esophagus found An eccentric indentation found in L/3 esophagus, it may due to enlarged heart Paraesophageal hernia with organoaxial rotation of stomach found. Deformed duodenal bulb with pseudodiverticulum formation. Barium leakage from base of duodenal into LUQ. In CS ward Abd CT was done Consult GS The answer was Duodenal ulcer with perforation Barium peritonitis OP note, Dec/11, 19:00 Pre-OP Dx: r/o PPU Post OP Dx: w Duodenal ulcer with perforation w Diaphragmatic hernia (paraesophageal) w Liver cirrhosis Procedure w Simple closure of perorated DU with omental patch w Gastrostomy (post reduction of hernia) w Feeding jejunostomy OP-picture Follow up SICU: 91-12-11 till 91-12-30 Surgical ward:91-12-30 till 92-01-15 Discharged on 92-01-15 Discussion Positive contrast media w Iodinated ionic e.g. gastrografin s Methylglucamine diatrizoate = gastrografin s 37% iodine (undiluted) s Osmotically active and hypertonic s 10 years of age and over, 60 mL s Children up to 10 years of age, 15-30 mL s Children: diluted x 2, Baby diluted x 3 Non-ionic w Barium Barium sulphate particles high radiographic density inert and isosmolar low cost aspiration of small amounts is tolerated well cause severe constipation Gastrografin aspiration Gastrografin aspiration w Rapidly progress to respiratory failure w Immediate cyanosis, respiratory distress, and pulmonary edema, cardiopulmonary arrest w Diffuse bilateral opacities on x-ray. w Only 50 mL aspirated: acute pulmonary edema and arrest. 新光醫院外科急診科 聯合病例討論會 報告：侯勝文醫師 指導：連楚明醫師 2003.02.19 Case 2 Personal information Name: 呂X No.: 05417XX-X Age: 81 y/o Sex: M Sent by: Family, at 17:50, 08/Feb/2003 Cons: Alert Vital sign: T36.9, PR98, RR20, BP 230/120 Triage: II Chief complaint No stool passage for 2 days. Present illness Tenesmus Abdominal discomfort Sciatica for many years Past history Allergic Hx: (-) Hemorrhoid (+) Physical examination Cons: alert w Neck: supple Chest w BS: symmetric Abdomen w Low abdominal pain w Bowel sound: hyperactive Limbs: w No edema Back: low back pain What is your impression? Duty doctors impression Stool impaction Sciatica r/o ileus Plan (1), day 1, 6 pm Triage: II Fleet enema 1 bot st Demerol 40 mg im st. Recheck BP after enema (140/80) S-S enema KUB WBC/DC+Hgb+Plt Panel I N/S keep 60 ml/hr Demerol 50 mg im st. On Foley Failed Abd CT without contrast Image and lab data KUB and CT CBC w WBC 14800/l, Seg 84.0, Lym 7.0, Band 1.0, Monocyte 6.0, Metamyelocyte 1.0 w Hb 9.2 gm/dl, Plt 157000/l Panel I w Glu 206 mg/dl, AST 28, BUN/Cr 62/2.5 w Na/K: 137/4.3 2 days ago: w WBC 12200/l, S:L 79/10, Hb 10.3 w BUN/Cr 48/3.0 Plan (2), day 1, 10 pm On NG for decompression Demerol 50 mg im st Blood culture x 2 Prepare PRBC 4u Consult GI 借舊片 排GI admission Plan (3), day 1, 11:25 pm 11:25 pm, postural syncope BP 118/60, PR 90 (supine) On monitor Os mask 8L/min NPO 轉OBN 輸PRBC 2u st Arrange MRI (Pelvis and abdomen) 12 leads EKG PT/aPTT (PT 12.95/10.4, INF 1.62, aPTT 41.6/31.3) 禁下床 U/A + U/C, on Foley Hold Foley due to failure Consult GS for admission Plan (4), day 2, midnight Demerol 40 mg im st Cefamezin 1g iv q6h + st. Record I/O q4h IV 改 Taita No.5 run 80 ml/hr Consult Urologist 6AM, on Foley Demerol 40mg iv dripping Vit K (10) 1 amp. ivd qd. Demerol 40 mg im st. Plan (5), day 2, 6 pm IVF改D5S(500)+D5W(500), each + 10 meq K+, 100 ml/hr alternatively. f/u WBC, BUN/Cr, Na/K cm L/R 500 ml iv st. Demerol 40 ivd st Morphine 5 mg ivd st 補Hb Burinex Amp iv st Plan (6), day 3, midnight Morphine 5 mg iv st Con