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ㄧ般內科病例討論PGY侯欣妤VS陳志雄1业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 PatientProfileChartNo.:27356231,王清祥Age:61y/oGender:maleDateofadmission:2009/04/232业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 ChiefcomplaintGeneralizedpolymorphouseruptionofmaculeswithmilditchingoverwholebodyfor20days&mouthulcerssince7daysago3业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 PresentillnessAcaseofHTN,type2DMfor10yearswithpoorcontrolat台南署立醫院andgoutyarthritisGeneralizedpolymorphouseruptionskinlesionoverface,trunkandlimbsfor20daysInitial:leftshoulderitchingspreadtoantchestwallwholebody,SharplydemarcatedredmaculesNotenderness,nobullae,nonecrosisMouth&lipsulcersince7daysagoWeeksago:Lowgradefever,mildcoldrecoverynowNodysuria,abdominalpainNotravelhistory4业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 PresentillnessRecentdruguse:Anti-goutagent5业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 PastMedicalHistory1.Medicalhistory:Hypertension--------(+)Diabetesmellitus---(+)ChronichepatitisB--deniedChronichepatitisC--deniedGout--(+)2.Surgicalhistory:nil3.Drugallergy:unknown6业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 7业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 PersonalHistorySmoking:(-)Drinking:(-)Betelnutsuse:deniedHistoryofoverseatravel:deniedHistoryofcontactwithanimalsorsickpeople:denied8业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 PhysicalexamVitalsign:T:36.9P:76R:18BP:131/71mmHgConsciouslevel:clearPeripheralperfusion:distalextremities:warm,pinkSkin:pruritis(+),rash(+),normalturgor,normalskincolor,nobullae,nodesqumateHEENT:Eyes:conjunctivanotpale,Mouth:ulcer(+)esp.lowerlipsNeck:Supple,nolymphadenopathyNothyroidenlargement9业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 PhysicalexamChest&Lungs:Symmetricalexpansion,clearbreathingsoundHeart:HS:Regularheatbeat,nomurmurAbdomen:soft,flattenderness(-),reboundingpain(-)Normalactivebowelsounds,Noabdominalbruit10业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 ThereisnopreviousCXRonthePACS.>Bilateralapicalpleuralthickeningnoted.ThereisanodularshadowatLLLoflung,couldbenippleshadowortruepulmonarylesion.>Normalheartsizeisnoted.>Degenerativechangewithmarginalspurformationofspinenoted.11业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 LAB12业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 ImpressionErythemamultiform(Steven-johnsonsyndrome),r/odrugrelated(Allopurinol)Diabetesmellituspoorcontrol13业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 AtwardMaintenanceoffluidandelectrolytebalanceWithdrawnpotentiallyoffendingdrugsSolucortef100mlq6hIncidal1#tid14业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 DISCUSSION15业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 Stevens-Johnsonsyndromesevereexpressionoferythemamultiformeinvolvestheskinandthemucousmembranesoral,nasal,eye,vaginal,urethral,GI,andlowerrespiratorytractmucousmembranespotentialforseveremorbidityandevendeath16业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 17业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 Stevens-JohnsonsyndromeEtiologiccategoriesInfectionDrug-inducedMalignancy-relatedCollagenvasculardiseaseIdiopathic18业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 Stevens-JohnsonsyndromeAdultsandtheelderlyDrugsandmalignanciesinducedaremostoftenChildsRelatedmoreoftenduetoinfections19业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 Stevens-JohnsonsyndromeMale-to-femaleratiois2:1Mortalityrate:3-15%(TEN30%)secondtofourthdecadehavebeenreportedasyoungas3months20业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 Stevens-JohnsonsyndromeIndividualsappeartobemoresusceptibletodevelopingSJSHLA-Bw44ApartofHLA-B12HLA-DQB1*060121业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 HistoryTypicallybeginswithanonspecificupperrespiratorytractinfection1to14daysfever,sorethroat,chills,headache,vomiting,diarrheaandmalaisemaybepresent22业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 HistoryMucocutaneouslesionsdevelopabruptlylast2-4weeks.typicallyarenonpruriticmayleadtomucosalscarringandlossoffunctionoftheinvolvedorgansystem23业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 HistoryEsophagusinvolvementEsophagealstricturesTracheobronchialmucosasheddingRespiratoryfailureOcularsequelaeCornealulcerationAnterioruveitisKeratitisorpanophthalmitis(3-10%blindness)VaginalstenosisandpenilescarringRenalcomplications(rare)24业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 OcularsymptomsRedeyeTearingDryeyePainItchingForeignbodysensationDecreasedvisionBurnsensationPhotophobiaDiplopia25业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 HistoryTherashcanbeginasmaculesthatdevelopintopapules,vesicles,bullae,urticarialplaques,orconfluenterythema.Thecenteroftheselesionsmaybevesicular,purpuric,ornecrotic.Thetypicallesionhastheappearanceofatarget.Thetargetlesionexhibitscentralnecrosissurroundedbyarimofperivenularinflammation26业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 Mucosalinvolvementmayincludeerythema,edema,sloughing,blistering,ulceration,andnecrosis.27业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 HistoryAlthoughlesionsmayoccuranywhere,buttherashmaybeconfinedtoanyoneareaofthebodymostoftenthetrunk.Lesionsmaybecomebullousandlaterrupture,leavingdenudedskin.TheskinbecomessusceptibletosecondaryinfectionFeverorlocalizedworseningFeveroccurinupto85%ofcases28业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 HistoryRecurrencesmayoccuriftheresponsibleagentisnoteliminatedorreexposed29业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 DrugetiologiesincludePenicillinsSulfasPhenytoin(andrelatedanticonvulsants)CarbamazepineBarbituratesvaldecoxib(COX-2inhibitor)30业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 DrugsassociatedwithSJSinTaiwanPotentialcausesNo.ofpatients%oftotalpatientsAnticonvulsants9139.57Carbamazepine6026.1Phenytoin198.26Phenobarbital83.48Other41.74Antibiotics2310NSAIDs177.39Allopurinol146.09Other8536.96Datafrom230ptsadmittedtoChang-GungMemorialHospitalduring1996-2003Estimatedincidence:8casespermillion-personyearinTaiwan31业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 Infectiousdiseaseshavebeenreportedherpessimplexvirus(HSV)InfluenzaMumpscat-scratchfever(Bartonellahenselae)mycoplasmalymphogranulomavenereumHistoplasmosischoleraInchildren,Epstein-Barrvirusandenteroviruseshavebeenidentified32业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 Elevatedinserumlevel:TNF-aIL-2receptorIL-6CRPHowever,noneoftheseserologictestsisusedroutinelyindiagnosingSJS33业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 CBCmayrevealNormalWBCcountoranonspecificleukocytosisAseverelyelevatedWBCcountindicatesasuperimposedbacterialinfection34业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 SkinlesionsaretreatedasthermalburnsAttentiontoairwayandhemodynamicstabilityfluidstatus,wound/burncareElectrolytecorrectionpaincontrolTreatmentofSJSisprimarilysupportiveandsymptomatic35业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 OffendingdrugsmustbestoppedUnderlyingdiseasesandsecondaryinfectionsmustbeidentifiedandtreatedOrallesionsmouthwashesTopicalanestheticsUsefulinreducingpainAllowingthepatienttotakeinfluidsAreasofdenudedskinCoveredwithcompressesofsaline36业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 ThesystemicsteroidsuseiscontroversialUsefulinhighdosesearlyinthereactionButmorbidityandmortalityactuallymayincreaseinassociationwithsteroiduseBecauseofincreasingsecondaryinfectionrateSomeauthorsbelievethattheyarecontraindicated37业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 THANKYOU38业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友 39业精于勤荒于嬉行成于思毁于随→【医学生物PPT，欢迎收藏分享】豆丁网友
