cv-cvs-nephro conference presented by f1 潘恆之 commented by dr. 謝宏昌 2012/04/18
TRANSCRIPT
CV-CVS-Nephro CV-CVS-Nephro ConferenceConference
Presented by F1 潘恆之Commented by Dr.謝宏昌2012/04/18
CASE 1: 8480511CASE 1: 8480511CASE 2: 21508337CASE 2: 21508337CASE 3: 8853407 CASE 3: 8853407
CASE 1: 8480511CASE 1: 8480511
General DataGeneral DataAge: 40-year-oldGender: FemaleEthnic: TaiwaneseMarital status: Married
Past historyPast historyHypertensionSystemic lupus erythematous
with lupus nephritisChronic kidney disease, lupus
nephritis relatedVasculitis related enteritisHypothyroidism
2012/04/10 Nephro OPD◦ Hydroxychloroquine sulfate(200mg)--1# QD◦ Ultracet tab -------------------------------1# BID◦ Prednisolone(5mg) ---------------------- 4# QD ◦ Amlodipine (5mg) ------------------------1# QD ◦ Isosorbide-5-mononitrate(60mg) ---- 0.5# HS
2012/04/10 Rheuma OPD◦ Etoricoxib (60mg) ------------------------1# QD ◦ Esomeprazole mups (40mg) ------------1# QD ◦ Sennoside A+B calcium (12mg) --------1# HS◦ Cobamamide (250mcg) ------------------1# BID ◦ Prednisolone (5mg) -----------------------2# QD
Medication historyMedication history
Personal HistoryPersonal HistoryAllergy to SulindacShe denied smoking, alcohol, or
betel nut chewing.
Family historyFamily history
Younger sister: SLEFather: lung cancerGrandmother: Arrythmia
Course Course 2011/02/08 ~ 2011/03/15 Admission
2011/03/22 Nephro OPD
UrosepsisAcute on chronic kidney disease
◦ On FDL for H/D◦ Arrange Hickman insertion and AVF creation
Discharge on 03/15
2011/03/31 Nephro OPD
Ga
S/S: local heat and swelling around left AVF◦Cefuroxime 1# BID x 7 days
S/S: local heat and swelling around left AVF◦Vancomycin 1g st, Dicofenac, Neo-
cortisone cream◦Return to CVS OPD on 05/30
Course Course 2011/05/30 CVS OPD
2011/07/11 CVS OPD
S/S: left forearm swelling ◦Arrange Duplex of AVF
2011/06/13 CVS OPDS/S: left forearm swelling
◦Consider repair the stenotic basilic vein◦Arrange revision of A-V shunt with intering
Graft
S/S: no local swelling, heat nor tenderness around AVF◦Arrange Duplex of AVF for follow up
Course Course 2011/10/22 ~ 2011/11/12 Admission
2012/03/06 Nephro OPD S/S: Left forearm swelling, severe pain over
the left hands for 2 months◦Arrange Duplex of AVF
Sepsis due to catheter related infection◦Remove Hickman catheter on 10/24◦Try AVG => AVG malfunction was noted on
10/26◦Arrange Duplex of AVF*◦Arrange AVG transposition and l’t Hickman
insertion *
◦Discharge on 11/12
Course Course 2012/03/14~2012/03/30 Admission
Left index finger cellulitis ◦ Give empiric antibiotics: Oxacillin◦ Arrange antegrade venography*◦ Arrange reposition of the left basilic ven and interposition with intering graft*
Discharge on 03/30
2012/04/10 Nephro OPD S/S: no local swelling, heat nor tenderness
around AVF
Discussion
DiagnosisDiagnosisLeft forearm swelling due to arteriovenous
graft-antero cubital vein junction stenosis, status post repransposition of the left basilic vein and interposition with intering graft on 2012/03/22
End-stage renal disease, favor lupus nephritis related, under regular hemodialysis QW135
HypertensionLeft ovarian cyst and multiple uterine
myoma
DiscussionDiscussion
CASE II: 21508337CASE II: 21508337
General DataGeneral DataAge: 56-year-oldGender: FemaleEthnic: HakkaneseMarital status: MarriedAdmission date: 2011/10/31
Chief ComplaintChief ComplaintPoor appetite for one month
Present IllnessPresent Illness This 55-year-old female has history of
hypertension, chronic kidney disease and asthma.
She had experienced progressive anorexia for almost a month. General malaise, nausea, vomited with food content, dyspnea on exertion, orthopnea, abdominal pain, dysuria and insomnia were also mentioned. She denied fever, chills, tarry stool, bloody stool, diarrhea, headache or dizziness.
Besides, she also suffered from left arm weakness for 2+ months.
She had tried Chinese herbal medicine for renal function deterioration since 2 weeks before admission. However, the symptoms persisted and progressed, so she went to our ER for help. Under the impression of chronic kidney disease related uremic symptoms, she was admitted to our ward for further management.
Past historyPast historyHypertensionChronic kidney diseaseAsthma
Personal HistoryPersonal HistoryNo known allergy history to drug
or foodShe denied smoking, alcohol, or
betel nut chewing.
Family historyFamily history
No family history of diabetes mellitus, hypertension, malignancy, chronic kidney disease or other systemic diseases.
Physical ExaminationPhysical ExaminationBH: 148cm BW: 44.96kg Vital signs: BT:36.6 ℃ HR:97/min RR:20/min BP: right arm -- 229/104 mmHg left arm – 52/41 mmHgGeneral appearance: fair lookingConsciousness: alert but disoriented,
E4V4M6HEENT: conjunctiva: not pale, sclera:
anictericChest: symmetrical expansion, bilateral
clear breathing sounds.Heart: regular heart beats, no audible
murmurs.
Abdomen: soft and flat normal bowel sounds, no local tendernessBack: No knocking pain over bilateral flank area Extremity: freely movable, no deformity bilateral lower legs grade I pitting edema left radial artery pulse decrease left hand light tough sensation decrease MP of upper arms-- L/R: 4+/5 MP of hands – L/R: 5/5Skin: no rash, no petechiae nor ecchymosis fair skin turgor
Hemogram
unit 10/30
WBC /uL 10400
RBC million/uL
3.72
Hemoglobin
g/dL 9.9
Hematocrit
% 30.8
MCV fL 82.8
MCH pg/cell 26.6
RDW % 17.2
Platelets 1000/uL 238
Segment % 88.3
Lymphocyte
% 8.0
Monocyte % 2.9
Eosinophil % 0.5
Laboratory FindingsLaboratory FindingsBiochemistry
10/30
BUN 69.5
Creatinine 8.56
ALT 27
Alk-P 141
Na/K/Cl 136/5.9/113
Ca/P 8.7/5.3
Albumin 3.91
Total protein 6.6
Sugar 140
PH 7.191
PCO2 29.3
PO2 69.4
HCO3 11.0
Sa% 90.1
11/02
T-protein(U)
250.6 mg/dL
Creatinine(U)
242.86 mg/dL
24hr U/O 200 ml
24hr TP(U) 501.2 mg
24hr Ccr 3.94 ml/min
Urinalysis 11/01
Color Yellow
Turbidity Cloudy
Sp. Gravity 1.015
pH 5.5
Leukocyte Negative
Nitrite Negative
Protein 3+(1000)
Glucose Negative
Ketone Negative
Urobilinogen
0.1
Bilirubin Negative
Blood Negative
RBC 1
WBC 7
Epi. 11
2011/10/30 CXR2011/10/30 CXR
2011/11/02 Cardiac 2D 2011/11/02 Cardiac 2D echoechoIVS: 19 mm; LVEDD: 34 mm; LVESD: 14 mm;
PW:15 mm; EF by M-mode: 87 %Pericardial effusion: nil, tamponade: nilLV systolic function: adequateVavular lesions: TR -- Vmax: 4.0m/s, max gradient: 64 mmHgAsynergy: no regional wall motion abnormality
Conclusion: Thick IVS & LVPW, mild MR, TR&PR, pulmonary hypertension maybe due to CRF (group 5)
2011/11/03 Kidneys echo2011/11/03 Kidneys echo
Left / Right : 7.1 cm / 7.1 cm Both kidneys are small in size with irregular contour. The cortical echogenicity is increased with inadequate thickness. The pelvocalyceal systems are not dilated. There is an echo-free lesion (1.2 X 0.6 cm) with posterior wall enhancement over the lower pole of right kidney. No obvious evidence of renal stone or mass is noted.
Imp: Parenchymal renal disease
2011/11/03 Peripheral 2011/11/03 Peripheral Doppler of Upper ExtremitiesDoppler of Upper Extremities
Brachial Forearm Ankle Right Systolic BP, sensor PTA 203 針頭 220 Left Systolic BP, sensor PTA 111 87 206
Conclusion: Proximal left subclavian dumped flow, favored proximal
left subclavian atery significant stenosis. Left vertebral
dumped flow, suspect left vertebral ostium stenosis lesion. Asymmetric brachial systolic BP.
2011/11/05 Hickman 2011/11/05 Hickman insertion and left distal insertion and left distal forarm AV fistula creationforarm AV fistula creationLeft distal forearm radial-cephalic AV
fistula anastomosis Post-OP thrill(+/+++), bruit(++/+++),
cephalic vein is engorged well to upper arm. wrist radial artery pulsation: YES, strong, hand numbness:NO, finger tips cyanosis: NO
Comment: Need further intervention for proximal subclavain artery lesion to assist this AV fistula maturation.
2011/11/10 TCD/CCD2011/11/10 TCD/CCDB-Mode Finding: Moderate, hypoechoic, heterogeneous,
circumscribed atherosclerotic change at both CCAs. R't CCA 19- 51%, L't CCA 29% diameter stenosis. Doppler Findings: Decreased flow at left extracranial VA. TCD Diagnosis: Focal stenosis at both MCAs. Proximal stenosis at L't VA or L't subclavian steal syndrome should be considered. R't intracranial VA increased flow due
to compensation.
2011/11/16 CTA of Brain2011/11/16 CTA of Brain1. Multiple small hypodensities in left corona radiata, suggesting lacunar infarct.2. High grade stenosis of left subclavian artery with abrupt occulsion just proximal to the orifice of the vertebral artery. The left vertebral artery is perfused by the retrograde filling of the right vertebral artery via vertebrobasilar junction. 3. Mild hypoplasia of left vertebral artery.
2011/11/16 CTA of Brain2011/11/16 CTA of Brain4. Atherosclerotic calcification with focal stenosis of right CCA (<50%)5. Atherosclerotic calcification in bilateral ICAs and right VA.6. Irregular contour of bil. MCA, ACA, and left VA suggestive of atherosclerosis.
2011/11/16 CTA of Brain2011/11/16 CTA of Brain Arterial stenosis measurement: CCA: Rt:<50% Lt:0% Extra-ICA: Rt:0% Lt:0%; Intra-ICA: Rt:0% Lt:0% ACA: Rt:<50% Lt:<50%, MCA: Rt:<50%
Lt:100% PCA: Rt:0% Lt:0% Extra-VA: Rt:0% Lt:0%, Int-VA: Rt:0% Lt:<50% BA: 0%
IMP: Left subclavian artery occulsion with steal phenomenon. Hypoplasia of left VA. Focal stenosis of right CCA ( 〈 50%). Atherosclerosis of intracranial arteries.
2012/01/19 Peripheral 2012/01/19 Peripheral Doppler of Lower ExtremitiesDoppler of Lower Extremities
Segmental blood pressures: ABI: Right 1.11 normal
Left 1.08 normal A mild to mod narrowing at Rt distal ATA
2012/02/09 P.T.A2012/02/09 P.T.AOsital to proximal segment of left
subclavian artery with atherosclerotic change and near total occlusion.
Total occlusion after vertebral a. branch.Collaterals via left vertebral a. to distal left
subclavian artery Pressure gradient between AO-subclavian
was 60-100 mmHg
Conclusion: Left subclavian artery stenosis and occlusion(see text), s/p PTCA failed.
2012/03/15 CTA of Left 2012/03/15 CTA of Left Upper ExtremitiesUpper ExtremitiesGreat arteries: - Segmental stenosis (66%, 2.3cm) of proximal left subclavian artery. - Segmental CTO of mid/distal left subclavian artery with collaterals to contribute the small left axillary artery (2.7mm, id). - R/O thrombus in the pulmonary trunk (se4im34). - Dilated pulmonary trunk (4.3cm, od) - SMA ostium occlusion with colalteral from IMA via Riolan artery.
MedicationMedicationAmlodipine 5mg/tab -------------- 1 PC
QDClonazepam 0.5mg/tab ----------- 1 PC
HSColchicine 0.5mg/tab ------------ 1 PC
QDImipramine 25mg/tab ------------- 1 PC
HSAspirin 100mg/cap -----------------1 PC
QDCilostazol 50mg/tab ---------------1 PC BID
DiagnosisDiagnosisLeft subclavian artery stenosis
and left vertebral artery hypoplasia.
End-stage renal diseaseHypertensionAsthma
DiscussionDiscussion
CASE III: 8853407 CASE III: 8853407
General DataGeneral DataAge: 49-year-oldGender: FemaleEthnic: TaiwaneseOccupation: Counselor
Past HistoryPast HistoryHypertensionEnd stage renal disease, s/p
CAPD during 1995~2002, complicated with CAPD peritonitis, shift to H/D since 2002
Peptic ulcer disease
MedicationMedicationFamotidine (20mg) ------------------------ 1#
QODBisoprolol hemifumarate(1.25mg) ----
0.5# QDIrbesartan (300mg) -----------------------
0.5# QODAlprazolam (25mg) ------------------------ 1#
HSMetoclopramide (5mg) ------------------ 1#
QD
Personal HistoryPersonal HistoryNo known allergy to drug or foodSmoking: deniedAlcohol: deniedBetel nut chewing: deniedNo recent travel historyNo contact history
Family historyFamily history
Father: hypertension, strokeMother: hypertension, ESRD
Course Course 2010/10/11 ~ 2010/10/25 Admission (SKH)
2010/10/28 ~ 2010/11/16 Admission
Left AVF infection ◦ On FDL for H/D◦ Remove left AVF
Transffered to LinKou CGMH on 10/25
2010/11/29 CVS OPD
Ga
Arrange right AVF creation*Discharge on 11/16
S/S: local heat, swelling with painful sensation around
right AVF◦Arrange duplex of AVF*◦Arrange revision of AV shunt with intering
jump graft*
Course Course 2011/03/28 CVS OPD
2012/03/15 CVS OPD
S/S: Persistent swelling with intermittent ischemic pain over right hand, bruit (++, mild steal)◦Give Cilostazol 1# BID x 14 days◦Arrange Duplex of AVF *◦Arrange Antegrade Venography*◦Arrange Percutaneous Transluminal
Angiography*S/S: Progressive right upper limb swelling
with limited ROM and intermittent ischemic pain over right hand, favor venous hypertension related◦Arrange Antegrade Venography*
Course Course
2012/03/29~ CVS & Nephro OPDS/S: Still mild swelling over right upper limb and intermittent ischemic pain with cyanosis change over right handFavor mixed problem of venous hypertension, steal and big fistula flow are noted
Discussion
DiscussionDiscussion