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Dhr D Case Report June 2009
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Transcript of Dhr D Case Report June 2009
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12/01/09 1
Casus dhr. D.
Samay Nadery
Medisch Centrum Haaglanden
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12/01/09 2
Programma
Korte inleiding Casuspresentatie Interactief Diagnostiek Diagnose Behandeling
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12/01/09 3
Inleiding
http://www.youtube.com/watch?v=S1ZZreXEqSY
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12/01/09 4
Casuspresentatie
03:11 uur Dhr. D., 73 jr. oud Met ambulance Gezien door neuroloog Hoofdpijn/ verwardheid/ mgl insult Midazolam 5 mg ivm onrust Op CT kamer van SEH Plots tensie daling RR 70/35 mmHg, pols 150/ minuut Zuurstof saturatie 90 %
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12/01/09 5
Vervolg
VG: Atriumfibrilleren CVA Longembolie Hoofdpijn klachten Fors roker (52 PY) Recent diagnose NCSLC
• Nog in diagnostiek proces• Stadiering volgt
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12/01/09 6
Wat zou je willen doen?
A: vrij B: geen cyanose, tachypnoe 20/ minuut,
o2 sat 90 % (meteen O2) ABG: lichte hypoxemie
C: geen cyanose, capil refill 4 seconden, pols 150 / min irreg., RR 70/ 35 mmHg, diurese ntb
D: E4M5V3 E: temp 36.5 C, na CAD urine retentie
300 cc. Abd: gb; Ext. geen oedeem.
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12/01/09 7
Probleem Analyse
HD instabiliteit bij d.d.: Midazolam gebruik Forword failure Sepsis? (reageert op vulling) Bloedverlies (waar?) Intoxicatie Massale longembolie? Iets neurologisch?
Mogelijk insult bij: Meta’s
Acuut verwardheid bij: Meta’s Intoxicatie?
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12/01/09 8
Actie?
Stabiliseren op CT kamer indien niet lukt icc IC
Na CT snel naar de kamer Gezien de snel respons op vulling geen
IC icc Opnieuw evalueren met ABCDE En nu blijkt ABDE status quo C: RR 115/ 60 mmHg rechts, pols 140/
min. Meer informatie?
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12/01/09 9
Aanvullend Informatie
Gistermiddag al hoofdpijn w.v. paracetamol, zonder effect
Omstreeks 2000 uur naar bed Rond 2400 uur is hij door vriendin
verward aangetroffen (riep: “Juffie! Juffie!”)
Trekkingen armen en benen Incontinent voor urine Geen tongbeet (geen gebit) Bij ambu: glucose 18.2 mmol/l
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12/01/09 10
Medicatie
Marcoumar Simvastatine Zantac Selokeen zoc Codeïne Ventoline
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12/01/09 11
Lichamelijk onderzoek
Verwarde man, onrustig Rustig ademhaling; CVD ntb O2 99% met 3 lit zuurstof Pols 140/ min irr. RR 115/ 60 mmHg rechts RR 75/35 mmHg links, pols nauwelijks S1 S2 irr souf ntb Pulmones: VAG geen bg Abd: nl p, soepel Ext: geen oedeem. Pulsatie liezen intact bdz.
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12/01/09 12
Aanvullend onderzoek
BSE 39 mm/uur; Hb 9.7 mmol/l Trombocyten 246 x10^9/l Leuc 10.3 x10^9/l, Neutr 6.90 x10^9/l, PT sec 42.7 sec(H), PT INR 4.36 ABG: 7.39/ 191/ 34.7/ 21.9/ 99.5 % CK 323 U/l, CKMB 5.1 ug/l, Trop <0.01 Glucose 16 mmol/l
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12/01/09 13
ECG
QuickTimeª and a decompressor
are needed to see this picture.
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12/01/09 14
En nu?
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12/01/09 15
Probleem analyse
Status na HD instabiliteit Verwardheid Rechts en links tensie verschil Onduidelijk over POB
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12/01/09 16
Differentiaal diagnose
Aorta Dissectie Longtumor gerelateerd:
Groeien van tumor richting Aorta Lymfklier vergr.
Anders?
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12/01/09 17
X thorax
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12/01/09 18
Plan?
CT thorax Echo cor? Herhalen CT hoofd? Overleg IC?
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CT thorax
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CT thorax
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12/01/09 21
CT thorax
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12/01/09 22
CT thorax
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12/01/09 23
Werkdiagnose
Occulsie van art subclavia links
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12/01/09 24
Take home message!
Valkuilen in acute situatie Schade door de actie Kritisch in alle situaties Belang van het basaal lichamelijk
onderzoek
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12/01/09 25
Vragen?