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General question, 水腫:star:, palpitation, Approach tp palpitation, 水腫…
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水腫:star:
Definition and Classification
1.微血管的靜水壓增加
- renal sodium retention
-HF
-各種腎臟病(AKI,CKD,nephrotic syndrome,glomerulopehritis)
-Early hepatic cirrhosis
- 靜脈阻塞
-pulmonary hypertension
-Cirrhosis or hepatic venous obstruction
-門脈高壓
-Acute pulmonary edema
-Local venous obstruction(DVT, Venous stenosis,cancer)
- 血液中的oncotic pressure降低(白蛋白低下)
-各種慢性肝臟疾病(製造↓)
-腎病症候群(排出↑)
-營養不良
-protein-losing enteropathy
- 微血管的通透性增加
-燒傷
-trauma
-發炎
-cellulitis
-infection
-sepsis
-systemic capillary leak syndrome
- 淋巴循環阻塞
-常見是術後清淋巴結，導致淋巴循環阻塞，造成lymphedema
-有些血絲蟲會入侵淋巴系統，導致象皮病
- 黏液性水腫Myxedema
-Glycosaminoglycan在皮膚沉積，為甲狀腺功能低下的重要表現
-主要是non-pitting edema
- 藥物造成的edema
-CCB：precapillary sphicter擴張，導致水分滲漏出微血管，產生水腫
-NSAIDs、Steroid、Estrogen等都可以造成水腫
-Vasodilator
7.baker cyst
-膕窩水囊腫，滑夜製造太多。破裂滑夜流向小腿，壓迫小腿組織，產生壓痛，症狀和靜脈血栓塞類似。
- 其他
-懷孕
:star:
臨床思考
- acute or chronic
- 位置
1.單側?局部?
-靜脈or淋巴管阻塞
->DVT:單側下肢紅腫熱; 有risk factor(ex臥床, 癌症, 過去病史, 最近手術)
-局部受傷(燒燙傷,trauma,infection,免疫)
->感染:局部紅腫熱痛,界線清楚
Acute leg swelling may appear asymmetric in patients who have baseline unilateral or asymmetric chronic venous disease. In such patients, causes of acute bilateral edema (eg, drug-induced edema, heart failure) may present with asymmetric leg swelling.
no?
->
2.systemic disease心
-S/S: 喘, PND, orthopnea
-PE: JVP, S3 gallop, ±displaced or dyskinetic apical pulse; peripheral cyanosis; cool extremities, small pulse pressure when severe
-Lab: ↑ urea nitrogen / creatinine ratio is common, serum Na often diminished, ↑BNP肝
-S/S: dyspnea uncommon(除非assoicted with significant degree of ascites), hx of長期喝酒
-PE: ascites is common; JVP is normal or low; one or more additional sign of chronic liver disease(jaundice, palmar erythema, dupuytren's contracture, spider angiomata, male gynecomastia, asterixis and other signs of encephalopathy)
-Lab: if severe, reductions in serum albumin, cholesterol, other hepatic proteins(transferrin, fibrinogen); ↑肝功能指數, depending on the cause and severity of liver injury; tendency toward hypokalemia, respiratory alkalosis; macrocytosis from folate deficiency 腎(CKD)
-S/S: usually chronic; may be associated with uremic S/S(decreased appetite, altered(金屬or 魚腥) taste, difficulty concentrating, restless leg, or myoclonus; dyspnea can be present, but less prominent than HF)
-PE: ↑BP; hypertensive retinopathy; nitrogenous fetor; pericardial friction rub in advanced cases with uremia
-Lab: ↑ serum creatinine and cystatin C; albuminuria; hyperkalemia, metabolic acidosis, hyperphosphatemia, hypocalcemia, anemia(usually normocytic)腎(NS)
-S/S: Childhood DM, plasma cell dyscrasia,泡泡尿
-PE: periorbital edema; HTN
-Lab: proteinuria; hypoalbuminemia; hypercholesterolemia; microscopic hematuriaNO?
->
angioedema
藥物
甲狀腺功能低下
-S/S:無活力, 怕冷, 低體溫, 便祕等
-PE: nonpitting edema. 甲狀腺檢查
腫瘤
DVT
等等
- 後續安排檢查
1.基本抽血:CBC, 肝腎功能, NT-proBNP, albumin
懷疑甲狀腺功能低下->排thyroid panel並查autoantibody
2.尿液檢查: 是否有蛋白尿; 可做Pro/Creat. or 24hrs 尿蛋白
3.CXR, 心電圖
4.懷疑是DVT->排doppler sono, 凝血功能等
5.無明顯risk factor: 查癌症, protein C, protein S, anti-phospholipid syndrome
-
palpitation
心因性補充資料
- 開始發作年紀: 幫助鑑別診斷Arrhythmia(may help narrow the differential diagnosis of likely causative arrhythmias)
-since childhood: SVT(AVRT or AVNRT)
-begun at an older age: (1)PSVT，(2)atrial tachycardia，(3)atrial fibrillation，(4) atrial flutter，(5)ventricular arrhythmia(也有例外)
-20歲之前: congenital long QT syndrome(->torse de points)
-idiopathic: VT
- Duration
-instant: PVC or PAC
-last for minutes (or longer): supraventricular or ventricular arrhythmia
- HR and rhythm: 快or慢, 規則or不規則
-Rapid and regular rhythms: PSVT or VT
-Rapid and irregular rhythms: AF, atrial flutter, or atrial tachycardia with variable block
- 病人的描述
-rapid fluttering: ->arrhythmia
-flip-flopping(一下重擊,一下沒有跳): PAC, PVC
-irregular, pounding feeling in the neck:->arrhythmia
-occur randomly and episodically and last for an instant: PAC or PVC
-gradual onset and resolution of palpitations: sinus tachycardia
-abrupt in onset and termination: SVT or VT
-A sense of rapid and regular neck pulsations:->arrhythmia(especially AVNRT)
-Associated presyncope or syncope:->arrhythmia(especially VT)
-姿勢影響:->arrhythmia
-常見誘發因子:Paget disease of bone, fever, anemia, pregnancy, hyperthyroidism, and vascular shunt
catecholamine(運動, 情緒,壓力)
high output state:
-做哪些事可讓心悸改善:valsalva maneuver(用力憋氣or用力咳嗽or排便)->arrhythmia
-心臟病史or家族有心臟病史
Approach tp palpitation
Definition and Classification
- 病人主觀的描述
- etiology:1,2,3,4,5
(1)心因性(43%)
- 各種心律不整
-PVC, PAC等..
- 瓣膜性心臟病
- 病人的特色: 男性&description of an irregular heartbeat&有心臟病史&duration greater than five minutes
- psychiatric(31%)
(3)其他(10%)
- Metabolic and endocrine: (1)低血糖，(2)甲亢，(3)pheochromocytoma，(4)停經症候群
- 咖啡因&酒精&藥物戒斷&毒品: (1)咖啡因，(2)alcohol，(3)amphetamine, cocaine等等
- 藥物: (1)Sympathomimetic agents，(2)Vasodilators，(3)Anticholinergics，(4)Beta blocker withdrawal
- high output states: (1)normal pregnancy，(2)anemia，(3)fever，(4)Paget disease of bone
- Catecholamine excess: (1)壓力，(2)運動
- 類癌症候群
- 不明(16%)
Approach to palpitation
LQQO
- 過去有類似經驗?(->心因性，發作年紀?)
- 發作頻率:acute or episodic(->心因性or Others cause),gradual or sustained(->心因性)
- duration, HR, rhythm(->心因性的DD)
PE
- (1)壓力，(2)運動(->心因性)
- (1)normal pregnancy，(2)anemia，(3)fever，(4)Paget disease of bone(->心因性)
- 喝咖啡/酒?(->咖啡因&酒精&吸毒)
- 焦慮(->psychiatric)
- 特定藥物?(->medicine)
- 低血糖(->hypoglycemia related)
- fever(->心因性or fever)
R做哪些事會讓心悸改善?
- valsalva maneuver(用力憋氣or用力咳嗽or排便)(->心因性)
- 姿勢(->心因性)
A & differential diagnosis
心因性
- 先確認心血管危險因子:男，年齡(>55)，三高，糖尿病，肥胖，家族史，抽菸喝酒，低社經地位，種族(亞洲or非洲)
- 相關症狀: 胸痛，胸悶，呼吸困難，水腫，presyncope or syncope
精神科
甲亢
- 相關症狀: 甲狀腺腫，食慾增加但體重減輕，手抖，腹瀉，失眠，怕熱，經期不規則
- PE:
Pheochromosytoma
- 相關症狀:為5P:(1)Pressure高血壓，(2)Pain胸痛或頭痛，(3)Palpitation心悸，(4)Perspiration大量盜汗，(5)Pallor蒼白
成癮低血糖
- related to diabetes treatment, insulinoma, or another cause
-相關症狀:低血糖會有兩階段的反應: 第一部分會先刺激交感神經，導致冒冷汗/diaphoresis，心悸，手抖的表現。第二部分: 若低血糖持續未校正，會導致CNS的表現: 虛弱，意識狀態改變，甚至昏迷
COPD
-相關症狀: 長期cough, 有痰, dyspnea停經症候群
類癌症候群
- 是一種neuroendocrine tumor，好發於腸道。分泌的賀爾蒙可能造成症狀像: 腹痛，腹瀉，皮膚潮紅，心悸，wheezing
- 相關症狀: :QUESTION:
不明原因
Past history
(1)過去有無什麼內科疾病?(三高，糖尿病，心血管，甲狀腺，tumor, etc....)
(2)如果有糖尿病，是否有使用胰島素?用那些藥?
(3)有無什麼重大醫療事件?最近手術?
(4)婦女要注意是否有停經症候群的症狀?(要問月經狀況)
Family hx
(1)心血管，甲狀腺...Personal hx
(1)抽菸喝酒檳榔?
(2)平常使用藥物?
(3)過敏史
PE
- vital signs
-Elevated temperature: raises the possibility of infection, malignancy, and even intracardiac myxoma
-Elevated blood pressure and pulse: pheochromocytoma, substance use, beta-blocker withdrawal, or another condition associated with catecholamine excess
- 心血管檢查
- COPD: prolonged expiratory phase of respiration, wheezing, lung hyperinflation, decreased breath sounds
- 甲狀腺檢查
- 甲亢相關findings:眼球突出/exophthalmos，眼瞼退縮eyelid retraction，觸診甲狀腺較大，聽診有bruit，有hand tremor，下肢可能有黏液水腫
後續檢查
- 抽血(CBC/DC)，電解質，血糖值，腎功能，甲狀腺功能(TSH最sensitive)
- 12-lead ECG
-Holter(如果懷疑但ECG沒有findings, 但又懷疑有arrhythmia時)
- Cardiac Echo:if懷疑心因性
水腫
Definition and Classification
:STAR:
- excessive fluid in body tissues extravascularly(1)inside the cell or in the interstitium or body cavities
- TBW=60% of BW，2/3 ICF, 1/3 ECF(1/4組織間液)。
- 機轉
各種原因
-->Effective arterial volume↓
-->活化代償機轉
-->活化RAAS&交感神經
-->鈉水滯留,有時就會造成水腫
:STAR:
一些幫助理解
- 系統
1.Cardiac:
- HF
->心臟收縮or舒張功能受損
->↓EAV&血液積在v.(v.淨水壓↑)
->edema
2.Renal
各種腎臟病造成的腎臟功能受損
->GFR↓ (normal CO)
->排鈉能力↓
->edema3.hypoalbuminemia
腎病症候群，營養不良，慢性肝臟疾病
->hypoalbuminemia
->血液中的oncotic pressure降低
->↓EAV
->edema4.liver cirrhosis
(1)肝臟靜脈回流受損(venous outflow obstruction->v.的淨水壓↑)->周邊血管擴張
(2)hypoalbuminemia
->↓EAV
->edema5.others
edema
Acute unilateral, asymmetric leg edema
對於患有急性單側或不對稱水腫的患者，我們首先評估深靜脈血栓形成（DVT）。如果排除了DVT，我們會評估其他原因引起的急性單側或不對稱水腫。
- DVT(最優先考慮)
(1).WELL score ->2 to 9 points:DVT likely
-癌症(6個月內)
-下肢paralysis, 輕癱, 或最近石膏固定
-臥床(3天)or手術(4個月內)
-沿著deep venous system的局部壓痛
-整隻腿在腫
-單側Calf swelling by more than 3 cm when compared with the asymptomatic leg (measured below tibial tuberosity)
-pitting edema (greater in the symptomatic leg)
-Collateral superficial veins (nonvaricose)
-過去病史
-Alternative diagnosis as likely as or more likely than that of DVT (-2 points)
(2)D-dimer testing
- 外傷(40%)
- Leg swelling in a paralyzed limb – 9 percent
- Lymphangitis or lymph obstruction – 7 percent
- Venous insufficiency(Superficial thrombophlebitis) – 7 percent
- Popliteal (Baker's) cyst – 5 percent
- Cellulitis – 3 percent
- Knee abnormality – 2 percent
- Unknown – 26 percent
Chronic unilateral or asymmetric edema
- chronic venous disease(most common)
-hx of thrombophlebitis in the affected leg
-pigmentary changes and skin ulceration(If the edema is longstanding, it often leads to characteristic )
- Lymphedema
-hx of ipsilateral inguinal or pelvic lymph node 切除, or of radiation therapy.
-The edema is initially pitting, but becomes non-pitting as cutaneous fibrosis occurs
3.Complex regional pain syndrome
-hx of trauma( usually occurs four to six weeks after limb trauma)
-characterized by pain, edema, and alteration in skin color and temperaturenext step
->做超音波
1.Confirmation of lower extremity chronic venous disease
if not
->
2.Suggestion of pelvic outflow obstruction
->懷疑cancer
-history of cancer
-慢性消耗性症狀
->next step:
CT
(A pelvic neoplasm can cause unilateral or asymmetric leg edema by compressing the veins or lymphatic system)
Acute bilateral leg edema
1.Bilateral DVT, which is often associated with malignancy
2.Acute heart failure
3.Acute nephrotic syndrome
4.Side effect of medications->
the possibility of DVT must be considered.
-risk factor
-Echoif not
->
-查看最近用藥
-心衰竭症狀?
-尿檢
-D-dimer test
-Echo
Chronic bilateral leg edema
- chronic venous disease(most)
- 心肝腎腎
- 營養不良,肺高壓,甲低, pelvic neoplasm
Acute isolated upper extremity edema
1.trauma
2.infection
3.superficial thrombophlebitis
4.inflammatory arthritis
-the underlying etiology is typically apparent from the history and examination.if not?
->
5.Upper extremity venous thrombosis
->Echo
Isolated pulmonary edema
-S/S: shortness of breath and orthopnea.
-PE: usually reveals a tachypneic patient with rales and possibly a diastolic gallop (S3).
-CXR confirm1.心因性(most)(eg, acute myocardial infarction, heart failure, mitral or aortic valvular pathologies)
2.Renal disease
3.ARDS
4.其他; high-altitude; neurogenic; opioid overdose
-不會造成pulmonary edema的
1.uncomplicated cirrhosis(leads to selective increases in venous and capillary pressures proximal to the hepatic vein)
2.isolated hypoalbuminemia
Ascites
1.cirrhosis
2.hepatic veno-occlusive disease (eg, Budd-Chiari syndrome)
3.malignancy
4.infection
5.Right-sided heart failure or constrictive pericarditis (typically also cause peripheral edema)
->
-If ascites is suspected, the diagnosis can be confirmed by ultrasonography
- Abdominal paracentesis is used to determine the cause of ascites.
Lymphedema
major causes of lymphedema in adults in developed countries
- axillary lymph node dissection in patients with breast cancer
- axillary or inguinal lymph node dissection in patients with melanoma.
- filariasis(worldwide, the most common cause )
-S/S:局部; cutaneous and subcutaneous thickening(clinical hallmark)(as manifested by cutaneous fibrosis, peau d'orange, and a positive Stemmer sign(遠端肢體也產生水腫時會出現Stemmer sign，即腳趾或手指的皮膚無法被捏起))
Nonpitting edema
1.Moderate to severe lymphedema(初期pitting)
2.myxedema
腹痛
Step1: Rule out emergency
- check vital sign and hemodynamic status: if unstable
AKI
定義
KDIGO AKI guideline
診斷條件(符合任一項即可)
- 48hrs內ΔSCr上升≥0.3mg/dl
- SCr≥1.5倍baseline(七天內的數值或推測)
- 尿量<0.5ml/kg/hr, 持續6小時以上
- 嚴重度分類
stage / Serum Creatinine / 尿量
1 / ΔSCr≥0.3mg/dl or SCr 1.5-1.9倍 / <0.5ml/kg/hr(持續≥6小時)
2 / SCr 2.0-2.9倍 / <0.5ml/kg/hr(持續≥12小時)
3 / SCr ≥3倍以上 or SCr≥4.0mg/dl，開始腎臟替代療法 / <0.3ml/kg/hr(持續≥24小時) or 無尿≥12hrs
- estimated GFR(However, we cannot estimate GFR using Cr in setting of AKI or ∆’ing Cr)
=(140-age)BW / 72Cr
- 有些書會以氮血症(azotemia)描述腎衰竭，其實更為貼切，指的就是腎臟不能排除含氮廢物，導致血中含氮廢物增加，造成氮血症(azotemia)
腎前性
- 原理:讓腎臟可以處理的水分減少(濾出的水分減少), 導致毒素累積。腎組織本身沒有器質性損傷
- 原因
- ↓ Effective arterial volume
-心衰竭(↓ CO), Cardiorenal syndrome
-慢性肝病 ; 肝硬化 ; 腎病症候群(↓ oncotic pressure)
-敗血症(低血壓)
-出血
-體液減少(經口進食量少, 腹瀉, 嘔吐, 發燒, 感染)
-利尿劑
- 腎動脈狹窄 ; 阻塞
- 血行動力學異常:
-藥物: NSAID, ACEI/ARB, CCB, contrast, calcineurin inhibitor
-高血鈣
- 特徵
- hx: hypovolemia or 心衰竭 or 慢性肝病(右述)
- BUN/Cr >20
- FENa <1%
- FEUN ≤35%
- 尿液沉澱物中無顆粒狀圓柱體(cast) (or hyaline cast)
- ps.所謂FENa指的是腎絲球過濾出的Na之中由尿液排出的比例。如果是prerenal，交感和RAAS系統亢進，鈉的再吸收增加，FENa會降低。相反地，intrinsic AKI無法再吸收鈉->尿液鈉排出增加再吸收減少->FENa會升高
- 但是, FENa在尿液濃縮有困難的高齡or CKD or 服用利尿劑的pts上難以評估。->FEUN不會受到利尿劑影響
- 治療
- 治療重點為使體夜量與血壓最佳化，以達到適當腎血流
- 腎血流減少的原因如果是脫水或出血，就進行輸夜和輸血
- 相反地，如果原因是心衰竭(Cardiorenal syndrome)，需使用利尿劑治療，如果原因是肝衰竭，也須治本(控制腹水等)
- prerenal AKI如果未適當矯正體夜量，會從prerenal轉為intrinsic AKI。常導因於腎血流減少導致腎小管壞死(ATN)，可藉由有無顆粒狀圓柱體(granular cast來鑑別診斷)。ps. 缺血性ATN治療方針一樣是使體夜量與血壓最佳化
腎性
- 原理: 腎實質遭到破壞，可以工作的腎元減少，導致毒素累積。尿中會出現圓柱體
- 原因: 依據不同腎組織損傷部位(腎絲球, 腎小管, 腎間質, 小血管)臨床表現&尿中圓柱體也會不同
- 腎絲球:腎炎症候群(RPGN)Link Title
- 臨床表現
1.hematuria w/ :star:dysmorphic RBCs or RBC casts, ± 未達腎病症候群的蛋白尿(<3g/d)
2.通常合併:star: 腎衰竭(AKI), HTN, edema
- Management
如果懷疑是急性GN, 在等待腎臟切片結果時, 立即給予1g methylprednisolone, 1天1次,共3天, 接下來則依據診斷出來的結果治療(上述)
- 腎小管: 急性腎小管壞死ATN
- 缺血性: 腎前性AKI惡化
- 藥物: NSAID, Cisplatin, Aminoglycoside, 顯影劑, amphotericin
- 色素(pigment)/蛋白(protein): Rhabdomyolysis(Mgb), 溶血(Hb), Multiple Myeloma(Ig light chain), 高尿酸血症
- 臨床表現: 各異
- 特徵
1.:star:Granular muddy brown cast
2.FENa >2%,
3.BUN/Cr <20 (except pigment, CIN)
- Management:
-ischemic:輸夜
-藥物:停藥&支持性療法
-其他:治療根本原因
- 腎間質:急性間質性腎炎(AIN)
- :star:藥物(Allergic):β-lactams, sulfa drugs, NSAIDs, PPIs
- 感染:急性腎盂腎炎
- 浸潤性疾病: lymphoma, sarcoidosis, leukemia
- 自體免疫疾病:Sjögren’s, TINU syndrome, IgG4, SLE
- 特徵
- :star:WBCs, WBC casts ± RBCs, w/ neg UCx
- 臨床表現(藥物性AIN)
- 皮膚紅疹
- 血中嗜伊紅性白血球增加(eosinophilia)
- 尿中出現嗜伊紅性白血球(eosinophiluria)
- Management
- 立即停藥, 並使用類固醇(藥物性AIN)
- 治療感染(感染性AIN)
- 血管性(疾病/特徵/治療)
- 血管炎 / ANCA陽性, 多以RPGN表現 / 類固醇, ENDOXAN(cyclophosphamide)
- 惡性高血壓 / 血壓非常高 / 降壓
- 硬皮症危象 / SSc, 高血壓 / ACEI
- TMA / 貧血, 血小板低下, 紫斑 / 血漿置換
- 腎血管栓塞 / 腹痛, LDH↑, 心房顫動 / 抗凝血劑
腎後性
- 原理:集尿系統阻塞, 導致尿液回堵, 影響腎臟正常運作, 導致毒素累積
- 原因
- 輸尿管(需雙側): 結石, 腫瘤, 血塊
ps.通常單側輸尿管阻塞不會導致AKI
- 膀胱頸: 結石, 腫瘤, 血塊, 攝護腺肥大, 神經性膀胱, 抗膽鹼藥物
- 尿道: 結石, 腫瘤, 血塊
- 臨床表現&特徵
- 尿滯留
- 超音波檢查發現水腎
- 若有結石，驗U/R的鏡檢可見non-dysmorphic RBC(跟GN的dysmorphic RBC不同)
- Management
- 治療原則:解除阻塞，
- 如放置尿管, 尿路支架, 腎臟造廔等
- 阻塞解除後，會因突然利尿導致大量稀釋尿液產生，反而出現脫水引起的prerenal AKI，要特別注意並視情況補充輸夜aA
藥物引起的AKI
分類
- prerenal
NSAID, ACEI/ARB, CCB, 顯影劑, calcineurin inhibitor
- intrinsic
- ATN:NSAID, Cisplatin, 顯影劑, aminoglycoside, amphotericin
- AIN:β-lactams, sulfa drugs, NSAIDs, PPIs
- 一堆抗生素
- 一堆抗癌藥
等等....
緊急透析適應症
AEIOU
-合併以下任一情況時要急洗腎
- Acidosis酸血症
- Electrocyte合併電解質異常
- 高血鈣 or
- 高血鉀 or
- 高血鎂
- tumor lysis syndrome
- Intoxication藥物中毒
- Overload水分過多
- Uremia尿毒症
- 血清BUN≥100 mg/dl or
- 腦病變(意識障礙, 癲癇) or
- 心內膜炎, 心包膜炎, 出血
Approach to AKI
重點整理
- :red_flag::遇到腎功能障礙者，首先鑑別AKI or CKD，為此須檢查過去腎功能&超音波
- 沒有過去資料的話，安排腹超，觀察腎臟亮度與萎縮程度。一般而言，CKD常常亮度會上升, 腎皮質變薄, 腎臟萎縮(例外:糖尿病腎病變, 多囊性腎病變, amyloidosis, HIV腎病變)
- :red_flag:診斷為AKI後，要依序鑑別postrenal-> intrinsic or prerenal
- 首先排除post renal AKI ->腹超
- 鑑別診斷prerenal or intrinsic: 病史, vital sign, 身體檢查, 其他檢查(血液,尿液)，需綜合評估，不可用單一指標下診斷
評估體夜量
體夜量減少 / 體夜量增加(in AKI)
- 病史
經口進食量減少, 嘔吐腹瀉, 發燒, 感染, 藥物史(利尿劑等) / 心衰竭/肝衰竭史
- vital sign
低血壓, 心率增加 / 血壓上升
-體重變化
體重減輕 / 體重增加
- I/O
負 / 正
- 身體檢查
口腔內乾燥, 腋窩乾燥, 皮膚乾燥, 頸靜脈塌陷 / 頸靜脈怒張, 肺音crackle, 第三心音, 下肢水腫, hepato-jugular reflex
- CXR
nil / 心臟肥大, 肋膜積液
- CVP
<5 / >10
prerenal vs. ATN(intrinsic AKI)(尿檢)
- 尿量
- 比重
- 滲透壓
- FENa
- FEUN
- BUN/Cr
- 尿液沉澱
無cast or hyaline cast / muddy brown granular casr
- 尿蛋白
噁心嘔吐
定義 *手冊/小黃
- 噁心為催促去吐的感覺
- 嘔吐是將胃內容物強烈排出的動作
病因
- 鑑別診斷多如繁星
- 急症:
- IICP
- bowel obstruction
- DKA/HHS
- 系統
- 腸胃道: 胃, 腸道(腸胃炎, 腸阻塞..), 肝膽(肝炎), 胰, 腹膜
- 藥物
- 感染:Gastroenteritis, Otitis media(中耳炎)
- Meta/Endocrine: 懷孕, 腎衰竭(uremia), 甲亢/甲低, 腎上腺功能低下, 電解質不平衡,DKA
- 神經性
- 精神性
- 其他:AMI, FEVER, 懷孕,APN等
診斷
- 病史詢問
- Q:.嘔吐物的味道及內容物
- Q: 頻率
- O: 飲食及嘔吐之時間關係(進食中, 餐後數小時, 早上)
- P
- E
- R
- A: 除了這個症狀外你還有什麼症狀呢
-系統;general, gi, neuro, meta, drug
- hx: 過去腸胃道,甲狀腺, 腎上腺疾病及手術情形, 過去病史, 目前是否有吃藥, 體重狀況, 社會及精神狀況
- PELink Title :star:
- general: vital sign, fever
- HEENT: ne, 眼(黃疸), 甲狀腺, 眩暈,
- Chest:
- Heart: heartburn(ami, gerd)
- integument: hyperpigmentation(adrenal insufficiency), skin turgor(dehydration)
- Abdomen: pain(先排除obstruction->其他實質器官), knocking pain(APN, stone)
- extremities
- 實驗室檢查->小手冊
- 影像檢查
- 藥物治療->p.
-