A*******s
发帖数: 9638 | 1 下面这个case是一个医生俱乐部贴出来的，我给了他们一个建议，结果今天看到LZ回帖
证实了我的诊断，并且根据诊断治疗有效，病人出院了！
网上咨询看来确实有它的实际效果。
大家讨论一下，第一个答对的请版主发奖。
??? ANY IDEAS REGARDING HYPOTHERMIA????
68 year old family with no past medical history except basal cell carcinoma
of face who has no primary care physician and is on no chronic medications
presents with altered mentation. She has difficulty speaking, hearing,
ambulating and seems "catatonic" per family who admits she has been severely
withdrawn and depressed since the death of her 98 year old mother 4 months
ago. She lived with her parents all her life and was their primary
caregiver. No job, no "friends". Very isolated lifestyle.
In the ED, patient had extensive work-up including CT head, lumbar puncture,
CMP, LFT's, CBC; all normal. On physical exam she was moderately
hypothermic with rectal temp of 82.6F. She attempts to answer questions
appropriately but has diffculty forming words and speaks in a whisper.
Otherwise, no focal neuro deficits. Gait not tested though. Since
admission, she has had MRI brain with contrast, thyroid function studies,
adrenal work-up and results all normal. CT chest, abdomen, pelvis to
evaluate for source of infection due to presumed hypothermia of sepsis.
Only finding is "mild diverticulitis." With warming, patient's temp
improves and Bair hugger discontinued. She is on Flagyl and Cefepime per ID
specialist for diverticulitis. Now, 6 days later, she continues to have
intermittent temps below 90F (rectally) and requires intermittent warming.
Awake, alert, appropriate at this point but mentally slowed with
intermittent hypothermia. Resides in CA with ambient temps in the 70's.
Any thoughts regarding intermittent moderate hypothermia???? |
w******z
发帖数: 1872 | 2 what's patient's stress coping style, drugs, alcohol, smoking? anything? |
A*******s
发帖数: 9638 | 3 According to the author, there is no history of ETOH/Smoking. No other
details as well.
【在 w******z 的大作中提到】
: what's patient's stress coping style, drugs, alcohol, smoking? anything?
|
g*****d
发帖数: 991 | 4 stop all the meds, tell the patient her mother left a recorded video at home
for her to review, only her knows where it was located. |
A*******s
发帖数: 9638 | 5 They did hold all meds but she remained hypothermic.
home
【在 g*****d 的大作中提到】
: stop all the meds, tell the patient her mother left a recorded video at home
: for her to review, only her knows where it was located.
|
J*********l
发帖数: 1185 | 6 PKD?
Malnutrition ? Lz didn't mention nutrition status |
n******1
发帖数: 7 | |
A*******s
发帖数: 9638 | 8 Maybe but no details.
★ 发自iPhone App: ChineseWeb 8.6
【在 J*********l 的大作中提到】
: PKD?
: Malnutrition ? Lz didn't mention nutrition status
|
A*******s
发帖数: 9638 | 9 Normal
★ 发自iPhone App: ChineseWeb 8.6
【在 n******1 的大作中提到】
: D-dimer? CBC with diff?
|
M***D
发帖数: 249 | 10 1. Death of mother---> depression ---> decreased appetite ---> decreased
calorie intake ---> decreased temperature to reserve energy. I want to check
her Vit B12/folic acid level as well.
2. Death of mother and no friends---> self induced low temperature --->
factitious disorder to assume the sick role ---> stays in the hospital
instead of being alone at home. I want to check her RPR and HIV labs. |
|
|
z**********4
发帖数: 467 | 11 Could not figure out why. Something could be wrong with thermoregulation in
hypothalamus . If MR is normal, I have no idea of why. |
A*******s
发帖数: 9638 | 12 看来做什么专业想什么问题，大家都有自己的道理。
这两天下雪在家没事，看狄仁杰断案传奇。 在案件到了关键时刻，有人提供了线索，
狄仁杰往往会问：你到底想到了什么？
楼上有人提到了营养的问题，我也想套用狄仁杰的话，你一定想到了什么，文芳你说呢
？lol
in
★ 发自iPhone App: ChineseWeb 8.6
【在 z**********4 的大作中提到】
: Could not figure out why. Something could be wrong with thermoregulation in
: hypothalamus . If MR is normal, I have no idea of why.
|
s*********e
发帖数: 120 | 13 lol,brain? neuromuscular？peripheral neuropathy？ |
d******g
发帖数: 258 | |
z**********4
发帖数: 467 | 15 看样子像长期某种微量元素缺乏导致下丘脑功能紊乱 ？其实美国很多老人生活的很惨 |
n*******c
发帖数: 501 | 16 wernicke's encephalopathy?
【在 A*******s 的大作中提到】
: 看来做什么专业想什么问题，大家都有自己的道理。
: 这两天下雪在家没事，看狄仁杰断案传奇。 在案件到了关键时刻，有人提供了线索，
: 狄仁杰往往会问：你到底想到了什么？
: 楼上有人提到了营养的问题，我也想套用狄仁杰的话，你一定想到了什么，文芳你说呢
: ？lol
:
: in
: ★ 发自iPhone App: ChineseWeb 8.6
|
z**********4
发帖数: 467 | 17 Bingo. Hypothermia is one of the presentations of wenickie based on wiki
【在 n*******c 的大作中提到】
: wernicke's encephalopathy?
|
A*******s
发帖数: 9638 | 18 你想到了什么？
【在 d******g 的大作中提到】
: Having too much ice?
|
A*******s
发帖数: 9638 | 19 嗯，你在想什么。。。
【在 z**********4 的大作中提到】
: 看样子像长期某种微量元素缺乏导致下丘脑功能紊乱 ？其实美国很多老人生活的很惨
|
A*******s
发帖数: 9638 | 20 Newprozac应该得到包子。
Hypothermia说白了就是人体不能产生足够的热量来维持体温，如果下丘脑体温中心没
有明显的病理变化或诱因， 代谢性疾病应该是主要的鉴别诊断。 人体热量主要依赖
Glucose产生ATP， 这个病人的glucose供给应该没有问题，在ICU5-6天还是低温自然而
然要考虑Glucose转化为ATP出了问题。 Vitamin B1缺乏，特别是在给予IV Glucose后
这种缺乏会变得更加严重， 导致长期的低温， 神志改变，甚至其他神经系统的症状。
我当时打了个thiamine，这个医生一下子心领神会了，她查了Vitamin B1， 并同时给
了thiamine。 这个病人第二天体温就上升了， Vitamine B1和folate结果回来都是缺
乏，证实了诊断。
诊断就像断案，文芳你说呢？
【在 n*******c 的大作中提到】
: wernicke's encephalopathy?
|
|
|
J*********l
发帖数: 1185 | 21 A加，我是不是也可以得个包子呀？vit b1缺乏也是malnutrition的一种哈，最为护士
想到这个不容易呢！
【在 A*******s 的大作中提到】
: Newprozac应该得到包子。
: Hypothermia说白了就是人体不能产生足够的热量来维持体温，如果下丘脑体温中心没
: 有明显的病理变化或诱因， 代谢性疾病应该是主要的鉴别诊断。 人体热量主要依赖
: Glucose产生ATP， 这个病人的glucose供给应该没有问题，在ICU5-6天还是低温自然而
: 然要考虑Glucose转化为ATP出了问题。 Vitamin B1缺乏，特别是在给予IV Glucose后
: 这种缺乏会变得更加严重， 导致长期的低温， 神志改变，甚至其他神经系统的症状。
: 我当时打了个thiamine，这个医生一下子心领神会了，她查了Vitamin B1， 并同时给
: 了thiamine。 这个病人第二天体温就上升了， Vitamine B1和folate结果回来都是缺
: 乏，证实了诊断。
: 诊断就像断案，文芳你说呢？
|
A*******s
发帖数: 9638 | 22 呵呵，你已经在敲门了， 就是没敢进去。请版主发包子
如果大家觉得这样的病例交流有意思，我们可以将它长期搞下去，我捐包子
★ 发自iPhone App: ChineseWeb 8.6
【在 J*********l 的大作中提到】
: A加，我是不是也可以得个包子呀？vit b1缺乏也是malnutrition的一种哈，最为护士
: 想到这个不容易呢！
|
A*******s
发帖数: 9638 | 23 Here is the comments from the club:
Author:
Thank to very much for your valuable input!!
I have to be honest, XXXX, I find it shocking that a well nourished, person
living in the USA who never drinks alcohol and supposedly eats a well-
balanced diet includining processed foods can be thiamine and folate
deficient in 2014. Homeless, alcoholic, malnourished, poor...I get that.
Anyway, I learned a lot from this patient and also from my colleagues on
XXXX. This is what keeps medicine interesting and challenging.
A GI guy's comment:
I learned quite a lot from this whole thing also. XXXX that would have been
my thought as well re thiamine. I have often been fussy about the gratuitous
giving of thiamine supplements in hospitals. May not be such a bad idea. I
do hope you will write this up, please. It needs to be. Just do it as a
letter to AJM or AIM. I wonder if there is something more to this, some
tendency to malabsorb or not bind up thiamine as she should. Celiac wouldn't
be my first thought, but....
Make a draft and email it to me and i will buff it for you. Please publish
it. |
N****a
发帖数: 100 | 24 对wernicke's encephalopathy请问給Thiamine的剂量多大比较合适？需要IVPB吗？
有时psych consult也遇到alcoholic delirious，delusion， confabulation 都有，
但在給Thiamine时总有些保守。 |
A*******s
发帖数: 9638 | 25 100 mg IV daily
★ 发自iPhone App: ChineseWeb 8.6
【在 N****a 的大作中提到】
: 对wernicke's encephalopathy请问給Thiamine的剂量多大比较合适？需要IVPB吗？
: 有时psych consult也遇到alcoholic delirious，delusion， confabulation 都有，
: 但在給Thiamine时总有些保守。
|
n*******c
发帖数: 501 | 26 呵呵，多谢！
我们这里icu常规高剂量thiamine up to 300mg tds iv for everyone 确诊的病例在普
通病房的也是这样给。
七十年代有一篇文章检查尸检病例发现大多数都有wernicke encephalopathy 病变但临
床没症状，也就没查vitamin b1所以其实有很多隐性病例，而这些人出现应激情况下或
大量用糖就会发病。
不过我倒没有想到hypothermia. 还有我会好奇MRI是不是完全正常，would be
interesting look hard in mamillary body and periventricular area...
【在 A*******s 的大作中提到】
: Newprozac应该得到包子。
: Hypothermia说白了就是人体不能产生足够的热量来维持体温，如果下丘脑体温中心没
: 有明显的病理变化或诱因， 代谢性疾病应该是主要的鉴别诊断。 人体热量主要依赖
: Glucose产生ATP， 这个病人的glucose供给应该没有问题，在ICU5-6天还是低温自然而
: 然要考虑Glucose转化为ATP出了问题。 Vitamin B1缺乏，特别是在给予IV Glucose后
: 这种缺乏会变得更加严重， 导致长期的低温， 神志改变，甚至其他神经系统的症状。
: 我当时打了个thiamine，这个医生一下子心领神会了，她查了Vitamin B1， 并同时给
: 了thiamine。 这个病人第二天体温就上升了， Vitamine B1和folate结果回来都是缺
: 乏，证实了诊断。
: 诊断就像断案，文芳你说呢？
|
