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1、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2003.02.19Case1PersonalinformationName:陳XNo.:0577XXX-XAge:85y/oSex:FSentby:Family,at16:02,10/Dec/2002Cons:AlertVitalsign:T37.3,PR79,RR16,BP135/52Triage:IIChiefcomplaintEpigastralgiasince2pm.PresentillnessVomiting,withcoffee-groundsubstance.Abdominalpainradiatedtobilat
2、eralshoulders.Diarrhea(-)SOB(-)Stool:tarryAbdominalfullness,frequentlyinlast6months.PasthistoryHTN,CADandhepatitis,withoralmedicine.Drugallergy:deniedOPHx:UterinemyomaAutoimmunehepatitiswithcombesolone3#bid.HiatalhernianotedatOPD2monthagoaccidentally.PhysicalexaminationCons:alert,acuteill-lookingNec
3、k:suppleConjunctiva:notpaleChestHS:RHB,nomurmurBS:bilateralclearAbdomenDiffusetenderness,tenseReboundtendernessBowelsound:hypoactiveLimbs:NoedemaNE:Nofocalsign.Whatisyourimpression?Dutydoctor’simpressionPeritonitis,r/oPPUDiaphragmherniaPlan(1),Dec/10,pm4:30Triage:IIN/S100ml/hrCXR(PA)KUBCBC/DC,PLTPan
4、elIEKGBedsideechoNPOCXRandKUBAnyfinding?CXRIncreasedlungmarkingonbothsideHugecavityatleftretrocardiacportionMediastinalshifttorightKUBIncreasedlucencyatrighthepaticlevelIncreasedbowelgasshadowwithileuspatternLabdata(1)CBCWBC14500/μl,Seg86.0,Lym9.0,Band1.0,Monocyte4.0Hb12.5gm/dl,Hct36.1%,Plt242k/μlPa
5、nelIGlu155mg/dl,AST206,Bun/Cr40/1.1Na/K:129/4.9Anyidea?Nextplan?Plan(2),Dec/10,pm5:10VomitussentforOBKeto1vialivdrippingOnNGtubef/uCXR(PA)CXRs/pNGAnyfinding?f/uCXRs/pNGRetrocardiaccavityseemincreasedinsizePlan(3)10/Dec,pm7:00ConsultCSArrangeUGIseriesIVchangedtoD5Skeep100ml/hrFleetenema1botstCXRlater
6、al(8pm)Demeral50mgim(10pm)Hb,PT/aPTTf/uincomingmorningNGdecompression(11pm)CXRlateralviewAnyfinding?Labdata(2),Dec/11,6amHb11.6(yesterday12.5)PT13.15/10.4,INR1.68aPTT34.00/31.6Plan(4),Dec/11,am8:30Arrangepanendoscopy(早上pt被送到放射科做UGIseries)NGaspirationandlavageforbariumremoval.(11am)RemoveNGtube(clott
7、ed)ArrangeabdCTwithandwithoutcontrastDCabdCT(duetomuchretainedbarium)AdmittoCSward6233.(12:25noon)UGIseriesreportAnyfinding?TertiaryperistalsisofesophagusfoundAneccentricindentationfoundinL/3esophagus