Download 诊断学PBL CASE （循环系统呼吸困难急性发作）

PBL Case 4
Renji Hospital affiliated to Shanghai Jiaotong
University
TUTORIAL 1
PAGE 1
Mr. Wang，76 years old, asks for help because of abrupt dyspnea, cough, cough the pink foam
sputum in the injection process.
1. Which important symptoms does the above-mentioned medical history have?
2. Please analyse the causes and mechanisms of abrupt dyspnea.
3. Which diseases may cause the abrupt dyspnea of Mr. Wang?
TUTORIAL 1
PAGE 2
According to Mr. Wang's description, he comes to hospital because of throat pain, fever and
slightly cough for three days. After the diagnosis of the upper respiratory infection, he was given
anti-infection injection by the physician. The total liquid is about 2000 ml. The nurses of
emergent department are very busy, they can’t often go around and inspect. After injected 1000
ml liquid in three hours, the patient has abrupt dyspnea, can’t lie down, cough strongly and
cough the pink foam sputum. Mr. Wang has the history of hypertension for more than 20 years, the
history of the diabetes for 6 years, the history of coronary heart disease for 5 years. He feels
dyspnea after activity sometimes, and use high pillows.
1. Please analyze the characteristics of these main symptoms and concomitant symptoms, do you
think what the most possible disease of Mr. Wang?
2. Which examinations will you perform ? (Physical examination, laboratory examination and
special examination)
TUTORIAL 1
PAGE 3
On examination, Mr. Wang is a fat man with a weight of 80 kilograms and a height of 1.68
meters. His body temperature is 37.2 degrees. His pulse is 120 times per minute; His breath rate is
28 times per minute. The blood pressure is 160/75 mmHg. The facial expression slightly delivers
white, fidgety uneasy, the skin is damp and cold and the big sweat pours. He sit upright, the heart
rate is 120 times per minute with regular rhythm, without any murmur. Hoarse breath sound is
founded in two lungs accompanying with moist rales and little wheezing rales in the bottom of
two lungs. There is obvious edema in the legs.
1. How does the information help you in your hypothesis?
2. You order the following investigations(choose and explain its meaning and purpose)
⑴ blood routine examination
⑵ arterial blood gas measurements
⑶ urine routine examination and kidney function
⑷ Liver function
⑸ B type natriuretic peptide(BNP)
⑹ electrocardiogram
⑺ chest X ray
⑻ echocardiogram
TUTORIL 2.
PAGE 1
Mr. Wang is examined after emergent treatment. The physician has got the results after an hour.
1. blood routine examination: WBC 13.2*109, N 85%, Hb 119 g/l, BPC 10*109
2. arterial blood gas measurements: PH7.32, PaCO252 mmHg, PaO256 mmHg
3.: urine routine examination and kidney function Normal
4. Liver function: Normal
5. BNP: 630pg/ml
6. Electrocardiogram: Sinus tachycardia, left ventricular hyperpressure, T wave change
7. chest X ray: pulmonary markings grow in number, thick and fuzzy , the line of Kerley B is seen.
8. echocardiogram: LA enlargement, LV enlargement, IVST thickening, LVPW thickening, the
E/A ratio upside down, LVEF 40%
1. What’s your ultimate diagnosis according to above check result?
2. How to treat the disease?
TUTORIAL 1
PAGE 2.
The processing that you give is: Sit up, droop the lower limbs, high flow rate oxygen, the
morphine 5 mg intravenous injection, furosemide 20 mg intravenous injection, lanatoside 0.4 mg
intravenous injection, nitroglycerin intravenous injection, reduce liquid afterwards, warn the nurse
control injection rate, continue anti- infection treatment.
1. Why you make such treatment?
2. What’s your treatment principle?
TUTORIAL 1
PAGE 3
20 minutes after treatment, Mr. Wang passes water more than 500 ml, dyspnea becomes mild. One
hour after treatment, he feels great headache and pass water 450 ml one again. He wants to know
the reason of urine amount increase and headache.
1. How to explain the increase of urine amount?
2. How to explain his headache? Do you have any treatment to ease it?