Transcript 三軍總醫院宗旨、願景、核心價值

嗜鹹魚的周奶奶
M111 縱貫組 陳建賓
Subjective data
• Chief Complain：
SOB and limbs edema progression
for half a month.
WHAT may cause these symptoms?
Objective data
• Present illness:
According to the description from the patient and her
family, this 78-year-old woman who has history of VHD
with CHF; arrhythmia post PPM implantation;
hypertensive cardiovascular disease and gout with
medication
treatment
at our
CV OPD.
time she
WHAT
is the
definition
of This
CHF?
suffered from SOB and limbs edema progression for
half a month. She denied dizziness, chest pain, chest
tightness, cold sweating, nausea or vomiting. Due to
above symptoms persisted, she went to our CV OPD for
help. Under the umpression of CHF Fc II-III and limbs
edema. She was admitted to our ward for further
evaluation and management.
O
• Past history:
1. History of other systemic diseases:
VHD with CHF
Arrhythmia post PPM implantation
HCVD
Gout
2. History of major operation or trauma:
Arrhythmia post PPM implantation
3. Allergy to food or drugs: denied
O
• Personal history:
1. Habit of cigarette smoking: denied
2. Habit of alcoholic drinking: denied
3. Occupation: nil
4. Denied recent traveling history
• Family history:
As pedigrees
O
• Review of systems:
1.Positive findings: shortness of breath, limbs edema.
2.Negative findings: fever, chills, dizziness, headache,
dysphasia, night sweating, cough, sputum, orthopnea,
hemoptysis, epistaxis, chest pain, abdominal pain,
anorexia,
dysphagia,
nausea,
vomiting,
constipation,
WHY
we need
Negative
findings?
diarrhea, hematemesis, hematochezia, melena, dysuria,
oligouria, body weight loss.
O
•
Physical examinations:
Vital signs: BP: 122/48 mmHg, BT: 36.1C, PR: 67/min, RR: 18/min
General appearance: ill-looking
Conscious: alert Mentality: intact to JOMAC, GCS:E4M6V5
Skin: no petechiae, ecchymosis, normal skin turgor
HEENT: grossly normal, no pale conjunctiva, no icteric sclera
Neck: supple, no jugular vein engorgement, no carotid bruits, no Goiter
Chest: symmetrical and free expansion, coarse and rales of bil breathing
Vital sign、外觀、意識、皮膚、頭部、頸部、胸、心、腹、背、下肢(運動能力)、神經學
sound, no wheezing
Heart: PMI over midline of left clavian, 5th intercostal space, regular heart
beats, systolic murmur, no S3, no S4
Abdomen: soft and flat, normoactive bowel sound, Liver/Spleen: impalpable,
no Murphy's sign, no shifting dullness, no tenderness or no rebounding pain
Back: no spine deformity, no CV angle knocking pain
Extremities: freely movable, limbs pitting edema grade 2-3
Neurological examinations: essentially negative
O
• General lab. data
• Special lab. data
• X-ray data
Analysis
• Impression:
1.Valvular heart disease with congestive
heart failure, New York Heart Association
Functional class II-III
2.Cardiac arrhythmia post permanent
pacemaker implantation
3.Hypertensive cardiovascular disease
4.Gout
Plan
• Diagnostic plans:
1.Check B/R,SMA,PT/APTT and BNP
2.Arrange cardiac echo
• Therapeutic plans:
1.Rasital iv form
2.NTG iv pump drip
3.Keep OPD oral medications
4.On EKG monitor
5.Record I/O and BW Qd
• Educational plans:
1.Explain the present condition & following treatment direction to
patient and family in detail.
2.Water and salt restriction.
EKG
X-ray
2015/11/02 V.S 2015/11/09
初始用藥策略
•
•
•
•
•
•
DIOVAN：ACEI，血管擴張，降低前負荷，降低心作功
RASITOL：furosemide腎小管利尿劑
LANOXIN：digoxin
ORFARIN：warfarin
NTG：nitrate
Albumin：提高血管內膠體壓，拉回組織間液
利尿劑使用注意
修改用藥策略
•
•
•
•
•
•
•
GENDOBU：Dobutamine：升壓
CCB：降低左心室作功
Spironolactone：保鉀型利尿劑
LANOXIN：digoxin
ORFARIN：warfarin
NTG：nitrate
Albumin：提高血管內膠體壓，拉回組織間液
Thank u for ur attention