病例討論-護理學-0

1/1病例討論-護理學這是5月4號在黃巧冰老師的病生課上討論的病例和問題。

請同學們預習這個病例。

對于整個病例的19個問題，請各位同學按照分組，依次回答問題（第一組回答第一題，第二組回答第二題，如此類推），各組推薦一人在課上回答問題，組長需在5月3號之前以組號+回答問題同學的姓名的形式發(fā)送信息張潔瀅)。

分組情況請各位查看群上病生分組名單的xls文件。

對于要回答的問題，同學們在預習時可以討論和翻閱參考書，尋找答案。

課堂上老師將主要引導同學們根據(jù)病例找出更多可以討論的問題，并共同尋求答案。

病例中的紅色字體是老師查找的翻譯和全稱，以方便同學們的閱讀。

有一些單詞故意沒有解釋，希望同學們可以自己找到答案。

CIRRHOSISPATIENTCASEPatientsChiefComplaintsProvidedbywife:Myhusbandsveryconfusedandhehasbeenactingstrangely.Thismorning,hecouldntanswermyquestionsandseemednottorecognizeme.Ithinkthathisstomachhasbeenswellingupagain,too.Hestoppeddrinkingfouryearsago,buthiscirrhosisseemstobegettingworse.HPI(Historyofpresentillness)S.G.isa46yowhitemalewithahistoryofchronicalcoholismandalcoholiccirrhosis.Hewasadmittedtothehospitalfromtheoutpatientclinicwithabdominalswellingandconfusion.Hehasunintentionallygained15lbsduringthepastfourweeks.Accordingtohiswife,thepatienthasnotbeensleepingwellforseveralweeks,hasbeenfeelingverylethargic（昏睡）forthepastthreedays,cantseemtorememberappointmentslately,and,uncharacteristically,haslosthistemperwithherseveraltimesinthelastmonth.S.G.sbossatworkhadalsotelephonedherlastweekconcernedabouthisunusualandviolentbehavioronthejob.PMH(Pastmedicalhistory)Pneumonia9yearsagothatresolvedwithantimicrobialtherapyCirrhosissecondarytoheavyalcoholusediagnosed4yearsagowithultrasoundandliverbiopsy(micronodularcirrhosis)H/Ouncontrolledascitesandperipheraledema(H/O:historyof)H/OtwoupperGIhemorrhagesfromesophagealvaricesH/OanemiaH/OE.coli-inducedbacterialperitonitis4yearsagoH/OacutepancreatitissecondarytoalcoholabuseNohistorytosuggestcardiacorgallbladderdiseaseNopreviousdiagnosisofviralorautoimmunehepatitisSURGS/Pappendectomyrequiringbloodtransfusions30yearsagoS/Popen-reductioninternalfixationofrightfemursecondarytoMVA5yearsago(SP:statuspost;MVA:motorvehicleaccident)FH(Familyhistory)Fatherdiedatage52fromliverdiseaseofunknownetiologyMotherhadrheumatoidarthritisandulcerativecolitis,diedfrommassivestrokeatage66Maternalaunt,age71,withGravesdiseasePatienthasnosiblingsSH(Socialhistory)EducatedthrougheighthgradeDepartmentstoremensclothingmanagerandsalesman,17-yearcareerMarriedfor19yearswith1daughter,age10H/Oethanolabuse,quit5yearsagofollowingMVA,previouslydrank3casesofbeer/week15yearsH/OIVDA(heroin)andintranasalcocaine,quit5yearsago(IVDA:intravenousdrugabuse)Hassmokedapproximately1/2ppdformanyyears(ppd:packsperday)Meds(medications)Propranolol10mgpoTID(po:bymouth,TID:threetimesdaily)Spironolactone50mgpoQD(QD:everyday)Furosemide20mgpoQDMVI1tabletpoQDOccasionalibuprofenoracetaminophenforheadachePatienthasH/Onon-compliancewithhismedicationsALL(Allergy)NKDA(noknowndrugallergies)ROS(reviewofsystems)Increasingabdominalgirth（周長）(－)complaintsofabdominalpain,fever,chills,nausea,vomiting,hematemesis,tarrystools,lossofappetite,cough,chestpain,SOB(shortnessofbreath),lightheadedness,weakness,bloodintheurine,diarrhea,constipation,anddrymouthPatientCaseQuestion1.Hematemesisandtarrystoolsareclinicalsignsofwhichseriouspotentialcomplicationofcirrhosis?Gen(general)Thepatientisrestless,mildlyjaundiced,anddisorientedtotime,place,andpeople.Heisslowtoanswerquestionsandhisanswersmakelittlesense.Heisill-appearingbutinnoobviousdistress.VS(Vitalsigns)BP120/75,P83andregular(supine)BP118/70,P80andregular(standing)RR14andunlaboredT98.8ForallyWT1711bsHT5ft-7inSaO2=97﹪SkinWarm,dry,andwellperfusedwithnormalturgorMildjaundice(+)spidernevionchest(－)palmarerythemaSeveralecchymoses（瘀斑）onlowerextremitiesLargecobratattooonrightupperarmHEENT(head,eyes,ears,nose,throat)(－)bruises,masses,anddeformitiesonhead(+)ictericscleraPupilsat3mmandreactivetolightEOMI(extra-ocularmovementintact)FunduscopicexamWNL(WNL:withinnormallimits)TMsclearandintact(tympanicmembrane)O/Ppink,clear,andmoistwithouterythemaorlesionsNeck/LN(lymphnodes)Supple(－)JVD(jugularvenousdetension)(－)goiter,thyroidnodules,carotidbruits,andadenopathyChestLungsCTAbilaterallywithoutwheezesorcrackles(CTA:cleartoauscultation聽診)DiaphragmaticexcursionsWNLGoodairexchange(+)gynecomastiaHeartRRR(regularrateandrhythm)NormalS1andS2withnoS3orS4Nom/r/gheard(m/r/g:murmur/rub/gallop)Abd(abdomen)Moderatelydistended,firm,andslightlytender(+)prominentveinsobservedaroundumbilicus(+)HSM(hepatosplenomegaly)ActiveBS(bowelsounds)(－)guarding,reboundtenderness,palpablemasses,andaortic,iliac,andrenalbruitsGenit/Rect(genitalia/rectum)Heme-negativestoolPenisnormal,testiclesmoderatelyatrophicbutwithoutmassesNormalsphinctertone(+)hemorrhoidsProstatemaybeslightlyenlargedbut(－)fornodulesandtendernessMS/Ext(mentalstatus/extremities)NoclubbingoredemaGoodperipheralpulsesat2+throughoutNormalrangeofmotionthroughoutNeuroCNsgrosslyintactBriskDTRsat2+(DTR:deeptendonresponse)SlightasterixisnotedStrengthisequalbilaterallyConfusedanddisorientedNegativeBabinskiSensorygrosslyintactPatientCaseQuestion2.Identifyaminimumof15clinicalsignsandsymptomsthatareconsistentwithadiagnosisofcirrhosis.LaboratoryBloodTestResultsSeePatientCaseTable18.1PatientCaseTable18.1LaboratoryBloodTestResultsNa135meq/LWBC4,700/mm3Mg1.7mg/dLK3.5meq/LPT15.6secAFP90ng/mLCl101meq/LPTT45.1secHBsAg(-)HCO325meq/LNH3250ug/dLHIV(-)BUN12mg/dLAST107IU/LAnti-HCV(+)Cr0.6mg/dLALT86IU/LHCVRNA2.8million/mLGlu,fasting90mg/dLAlkPhos224IU/LANA(-)Hb14.0g/dLBilirubin2.4mg/dLFe75ug/dLHct39.7%Protein6.6g/dLFerritin200ng/mLMCV90fLAlb2.7g/dLTransferrinsaturation38%Plt34,500/mm3Ca8.5mg/dLCeruloplasmin37mg/dLAFP:-fetoprotein(normal0-15ng/mL),ANA:antinuclearantibody,MCV:meancorpuscularvolume,NH3(normal18-60g/mL)PatientCaseQuestion3.Isthepatientanemicatthistimeand,ifso,istheanemianormocytic,microcytic,ormacrocytic?PatientCaseQuestion4.WhatisthemostsignificantabnormalitythatthispatientsCBC(completedbloodcount)hasrevealed?PatientCaseQuestion5.Basedonthelaboratorydata,whyhasthispatientscirrhosisshownasuddenandunexpectedprogression?PatientCaseQuestion6.Identifyfourriskfactorsthatmayhavecontributedtothispatientscurrentcondition.PatientCaseQuestion7.Whycanbacterialperitonitisberuledoutasacurrentpotentialdiagnosis?PatientCaseQuestion8.WhatjustificationmightthepatientsprimaryhealthcareproviderhaveforconductinganANAtest?PatientCaseQuestion9.Whycanhemochromatosisberuledoutasacontributingfactortothispatientscondition?PatientCaseQuestion10.WhycanWilsondiseaseberuledoutasacontributingfactortothispatientscondition?PatientCaseQuestion11.Whycanautoimmunehepatitisandprimarybiliarycirrhosisberuledoutascontributingfactorstothispatientscondition?PatientCaseQue