1、and Echocardiogram （超聲心動圖） 1: PTCA Case Study 9-（經皮冠狀動脈內成形術）, old woman,was admitted to the CCU with chest pain, dyspnea（呼吸困難） A.L., a 68-year-（舌（惡心）.She hadtaken three sublingual （發汗）,syncope （昏厥）,and nauseadiaphoresis （跨-minute time spantablets （片劑） within a 10 下的） doses of nitroglycerine （硝化甘油）up

2、take （攝取） without relief before dialing 911. A previous stress test and thallium （鉈） 距） scan suggested cardiac disease.Her family history was significant for cardiovascular disease （心血管疾病） . Her father died at the age of 62 of an acute myocardial infarction （急性心肌梗塞） . Her mother had bilateral caroti

3、d endarterectomies （雙側頸動脈內膜切除術） and a femoral -popliteal bypass （股腘動脈旁路術） procedure and died at the age of 72 of congestive heart failure （充血性心力衰竭） . A.L.'s older sister died from a ruptured aortic aneurysm （主動脈動脈瘤破裂） at the age of 65. Her ECG （ 超聲 心動圖 ） on admission （入院時） presented tachycardia

4、（心跳過速） with a rate of 126 bpm （ 每 分鐘心跳次數） with inverted T waves. A murmur （心臟雜音） was heard at S1 （第一心音） . Herskin color was dusky to cyanotic （發紫的） on her lips and fingertips. Her admitting diagnosis （入院診斷）was possible coronary artery disease （冠心病） , acute myocardialinfarction （ 急性心肌梗塞） , and valvul

5、ar disease （ 心瓣膜病） .Cardiac catheterization （ 心導管術 ） with balloon angioplasty （PTCA） （ 經皮冠狀動脈腔內成形術）was performed the next day. Significant （顯著的）stenosis （狹窄）of the left anteriordescending coronary artery （ 冠狀動脈前降支） was shown and was treated with angioplasty （ 血管成形術 ） and stent placement （ 支架放置 ） . L

6、eft ventricular function （ 左心室功能） wasnormal.Echocardiogram （ 超聲心動圖 ） , 2 days later, showed normal -sized left and enlarged right ventricular cavity. The mitral valve （二尖瓣） had normal amplitude of motion （正常運動幅度） . The anterior and posterior leaflets （小葉） moved in opposite directions during diastole

7、 （舒張期） . There was a late systolic （收縮期的） prolapse （脫出） of the mitral leaflet （二尖瓣瓣葉） at rest （靜止） . The left atrium （左心房） was enlarged. The impression of the study was mitral prolapse （二尖瓣脫垂） with regurgitation （回流，反流） . Surgery was recommended.翻譯：AL, 一個68歲的女子，被送往胸痛，呼吸困難，出汗，暈厥，惡心的CCUIo她需要三個舌下服用硝酸甘油

8、片不到 10 分鐘的時間跨度無緩解撥打911 之前。先前壓力測試和鉈的吸收掃描表明心臟疾病。 她的家族史對心血管疾病有重要意義。她的父親死于急性心肌梗死的 62 歲。她母親雙側頸動脈 內膜切除術和動脈旁路手術的股骨、享年72 歲的充血性心力衰竭。這是姐姐死于主動脈瘤破裂65歲。她入院時的心電圖出現心動過速126次/分的頻率倒置 T波。聽到雜音在 S1o她的皮膚的顏色在她的嘴唇和指尖青紫暗。她承認診斷為冠心病、急性心肌梗死、心臟瓣膜病是可能的。球囊血管成形術（PTCA）心導管檢查是下一天進行。左前降支冠狀動脈的顯著狹窄的顯示， 并與血管成形術和支架置入術。左室功能正常。超聲心動圖， 2 天后，顯

9、示正常大小的左、右心室腔擴大。二尖瓣有正常的運動幅度。前部和后部的傳單在相反的方向移動，在舒張期。在休息時，有一個晚期收縮期脫垂的二尖瓣單張。 左心 房擴大。這項研究的印象是二尖瓣脫垂伴反流。手術推薦。Case Study 9-2: Mitral Valve Replacement Operative ReportA.L. was transferred （轉移到） to the operating room （手術室） , placed in a supine position （仰臥 位） , and given general endotracheal anesthesia （ 氣管內麻

10、醉） . Her pericardium （心包）was entered longitudinally （縱向）through a median sternotomy （ 正中胸骨切開術） . Thesurgeon （夕卜科醫生） found that her heart was enlarged with a dilated （擴大的）right ventricle （右心室）. The left atrium （左心房） was dilated. Preoperative （手術前的） transesophageal（經食道的） echocardiogram （ 超聲心動圖 ） revea

11、led severe mitral regurgitation （二尖瓣回流） with severe posterior and anterior prolapse （脫垂） . Extracorporeal circulation （體外循環） was established. The aorta （主動脈） was cross-clamped （交叉夾緊） , and cardioplegic solution （ 交叉夾緊） （to stop the heartbeat） was given into the aortic root （ 主動脈根） intermittently （間歇

12、地） for myocardial protection （心肌保護） .The left atrium was entered via the interatrial groove （房間溝） on the right, exposing the mitral valve. The middle scallop （扇貝） of the posterior leaflet was resected. The remaining leaflets were removed to the areas of the commissures （連合） and preserved for the sli

13、ding （滑動 的） plasty （成形術） . The elongated （展長） chordae （腱索） were shortened （縮短） . The surgeon slid the posterior leaflet across the midline and sutured it in place. A no.30 annuloplasty （瓣膜成形術） ring （環） was sutured in place with interrupted （間斷的，阻斷的） no.2-0 （編號）Dacron suture （滌綸縫線）.The valve was test

14、ed by inflating （使充氣）the ventricle with NSS and proved to be competent （有活性的） . The left atrium was closed with continuous no.4 -0 Prolene suture （聚丙烯縫線） . Air was removed from the heart. The cross-clamp （橫跨鉗閉） was removed. Cardiac action resumed with normal sinus rhythm （正常竇 性心律） . After a period o

15、f cardiac recovery and attainment （達到） of normothermia （正常體溫） cardiopulmonary bypass （心肺分流術） was discontinued （不連續的） . Protamine （魚精蛋白） was given to counteract （抵抗,解 （毒 ）,中和） the heparin （肝素鈉,肝素）Pacer （起搏器） wires were placed in the right atrium and ventricle. Silicone catheters were placed in the pl

16、eural and substernal spaces. The sternum （胸骨）and soft tissue wound wasclosed. A.L. recovered from her surgery and was discharged （出院） 6 days later.翻譯：這是轉移到營業廳，放置于仰臥位， 并給予氣管插管全麻。 她的包進入縱向通過胸骨正中 切口。 外科醫生發現她的心臟擴大了擴張的右心室。 左心房擴張。 術前經食管超聲心動圖顯示嚴 重的前、后脫垂二尖瓣重度關閉不全。建立體外循環。主動脈交叉夾緊，和心臟停搏液（停止心 跳）進行主動脈根部間斷心肌保護。 左心

17、房是通過右邊的房間溝進入， 顯露二尖瓣。 經手術切除后小葉中孔扇貝。 剩下的傳單被拆除 的連合的區域和保存滑動成形術。細長的腱索縮短。外科醫生地滑過中線后葉縫合到位。 30 瓣 環縫合的地方，打斷了 no.2-0滌綸縫線。該閥是由NSS充氣室測試并證明是主管。左心房是連續 no.4 -0 聚丙烯縫線關閉。空氣被從心臟取出。取十字鉗。正常竇性心律恢復正常。一段時間 的心臟復蘇和實現常溫體外循環停止后。 魚精蛋白中和肝素的了。 起搏器導線放置在右心房和右心室。 硅膠導管放置在胸腔和胸骨后間隙。 胸骨和軟組織創面封閉。這從她的手術6 天后出院。Case Study 11-1: Preoperativ

18、e （手術前） Testing （測驗） in a Patient With Asthma （哮喘） A.D., 15 years old, was seen in the preadmission testing （入院前檢查，預進（氣）試驗;） unit（單位，基因，設備） in preparation for her elective spinal （脊髓的） surgery （外科手術）. Shehas a history of mild asthma since age 4, with at least one attack per week. In an acute attack,

19、she will have mild（輕微的）dyspnea （呼吸困難） ,diffuse wheezing （喘鳴）,yet an adequateair exchange that responds to bronchodilators（支氣管擴張齊 U）. She was sent to pulmonaryhealth services for a consult （顧問醫生）with a specialist and pulmonary function studies toclear her for surgery. The anesthesiologist（麻醉科醫師）revie

20、wed the pulmonologist's report.Her prebronchodilator （支氣管收縮）spirometry（肺量測定法）showed a mild reductionin vital capacity but with a moderate to severe decrease in FEV1（秒鐘用力呼氣量）andFEV1/FVC（快速肺7S量）ratio （比例）.After bronchodilator （支氣管擴張藥）administration （給藥）,there was a mild but insignificant improveme

21、nt in FEV1. The postbronchodilator（支氣管的）FEV1 was 55% of predicted and was considered moderately（適度的）abnormal. The flowvolume loops （流量循環） and spirographic curves （呼吸描記曲線） were consistent with airflow obstruction.翻譯：年，15歲，在她的脊柱手術術準備住院前的測試單元。從 4歲開始，她有輕度哮喘史， 每周至少有一次發作。在急性發作時，她會有輕度的呼吸困難、彌漫性喘息，但適當的空氣交換，

22、對支氣管擴張劑。她被派到肺部健康服務，向一位專家咨詢，并進行肺功能檢查，以清除手術中的她。麻醉師回顧專家的報告。肺功能檢查顯示她的prebronchodilator肺活量輕微下降，但與中度至重度減少FEV1和FEV1/FVC比值。支氣管擴張藥后，有一個輕微但顯著改善FEV1。55%的postbronchodilatorFEV1預測被認為是中度異常。流量循環和呼吸描記曲線與氣流阻塞一致。Case Study 11-2: Giant Cell Sarcoma of the LungL.E., a 68-year-old man, was admitted to the pulmonary unit

23、 with chest pain on inspiration, dyspnea, and diaphoresis. He had smoked 11.2 packs of cigarettes per day for 52 years and had quit 3 months ago.L.E. was retired from the advertising industry and admitted to occasional alcohol use. He was treatedfor primary giant cell sarcoma of the left lung 3 year

24、s ago with a lobectomy of the left lung followed by radiation and chemotherapy. Physical examination was unremarkable except for a thoracotomy scar in the left hemithorax, decreased breath sounds, and dullness to percussion of the left base. There was no hemoptysis. Radionucleotide bone scan showed

25、increased activity in the left upper posterior hemithorax. Chest and upper abdomen CT scan showed .ndings compatible with recurrent sarcoma of the left hemithorax. Abnormal mediastinal nodes were evident.Thoracentesis was attempted but did not yield .uid. L.E. was scheduled for a left thoracoscopy,

26、mediastinoscopy, and biopsy.Case Study 11-3: Terminal DyspneaN.A., a 76-year-old woman, was in the ICU in the terminal stage of multisystem organ failure. She had been admitted to the hospital for bacterial pneumonia, which had not resolved with antibiotic therapy.She had a 20-year history of COPD.

27、She was not conscious and was unable to breathe on her own.HerABGs were abnormal, and she was diagnosed with refractory ARDS. The decision was made to support her breathing with endotracheal intubation and mechanical ventilation. After 1 week and a pulmonologist suggested to wean her from the ventil

28、ator, the several unsuccessful attempts permanent tracheostomy and family consideration of continuing or withdrawing life support. Her physiologic status met the criteria of remote or no chance for recovery. N.A.'s family discussed sustaining therapies. N.A. was assigned her condition and decide

29、d not to pursue aggressive life -DNR status. After the written orders were read and signed by the family, the endotracheal tube, was drip IV electrodes were removed and a morphine feeding tube, pulse oximeter, and ECG started with prn boluses ordered to promote comfort and relieve pain and other sym

30、ptoms of with shallow many hours while her breaths became dying. The family sat with N.A. forStokes respirations.Cheyne - She died surrounded by her family, joined by the hospital chaplain.1: CholecystectomyCase Study 12 -and entered the hospital with nausea a G.L., 42 -year-old obese Caucasian woma

31、n,vomiting, .atulencepain. upper quadrant and subscapular and eructation, a fever of 100.5° F, andcontinuous rightExamination on admission showed rebound tenderness in the RUQ with a positive Murphy sign. colored -frequent clayand nails, conjunctivae were yellowish, and she complained of Her sk

32、in, suggested the abdomen was count 16,000. An ERCP and ultrasound of stools. Her leukocyte was diagnosis possibly the common bile duct. Her and many small stones in her gallbladder cholecystitis with cholelithiasis.and with was attempted, an intraoperative cholangiogram A laparoscopic cholecystecto

33、mycommonwas some visualization unexpected bleeding, duct bile exploration. Because of G.L.'s size anddif.cultand the procedure was converted to an open approach. Small stones and granular sludge wereirrigatedthe into had a T -tube inserted was removed. duct, from her common and the gallbladder S

34、heduct forbile drainage; this tube was removed on the second postoperative day. She had an NG tube inplace before and during the surgery, which was also removed on day two. She was discharged on the .fth postoperative day with a prescription for prn pain medication and a low -fat diet.-2: Surgical P

35、athology ReportCase Study 12Gross Description: The specimen is received in formalin labeled “ruptured duodenal diverticula ”and2.8 consists of enteric tissue measuring approximately 6.3 0.7 cm. The serosal surface is markedlydull in appearance and .brotic. The mucosal surface is hemorrhagic. Represe

36、ntative sections are takenof segments shows slide Sectioned Description: Microscopic examination. microscopic for duodenal tissues with areas of gangrenous change in the bowel wall, and acute and chronic in.ammatory in.ltrates. There are chronic and focal acute in.ammatory cell in.ltrates with hemor

37、rhage in the mesenteric fatty tissue. There are areas of acute in.ammatory exudates noted in the fatty tissue. Histopathologic changes are consistent with ruptured duodenal diverticula.Case Study 12-3: Colonoscopy With BiopsyS.M., a 24-year-old man, had a recent history of lower abdominal pain with

38、frequent loose mucoidstools. He described symptoms of occasional dysphagia, dyspepsia, nausea, and aphthous ulcers of histongue and buccal mucosa. A previous barium enema showed some irregularities in the sigmoid andrectal segments of his large bowel. Stool samples for culture, ova, and parasites we

39、re negative.His tentative diagnosis was irritable bowel syndrome. He followed a lactose -free, low -residue diet and took Imodium to reduce intestinal motility. His gastroenterologist recommended a colonoscopy. After a 2 -day regimen of soft to clear liquid diet, laxatives, and an enema the morning

40、of the procedure, he reported to the endoscopy unit. He was transported to the procedure room. ECG electrodes, a pulse oximeter sensor, and a blood pressure cuff were applied for monitoring, and an IV was inserted in S.M.'s right arm. An IV bolus of Demerol and a bolus of Versed were given, and

41、S.M. was positioned on his left side. The colonoscope was gently inserted through the anal sphincter and advanced proximally. S.M. was instructed to take a deep breath when the scope approached the splenic .exure and the hepatic .exure to facilitate comfortable passage. The physician was able to adv

42、ance past the ileocecal valve, examining the entire length of the colon. Ulcerated granulomatous lesions were seen throughout the colon, with a concentration in the sigmoid segment. Many biopsy specimens were taken. The mucosa of the distal ileum was normal. Pathology examination of the biopsy sampl

43、es was expected to establish a diagnosis of IBD.Case Study 17-1: Pediatric Brain TumorB.C., a 6-year-old .rst -grade student, was referred to a pediatric neurologist by his primary pediatricianfor a neuro consult. He had presented with an acute onset of headaches, vomiting on waking in themorning, a

44、nd progressive ataxia. The neurologist conducted a thorough neuro exam and ordered a CTscan, MRI, and lumbar puncture (LP) to look for possible tumor cells. When the LP revealed suspiciouscells and the scans showed a tissue density, he was referred to a neurosurgeon for treatment of a suspected infr

45、atentorial astrocytoma of the posterior fossa. B.C. had a craniotomy with tumor resection 5 days later. The cerebellar tumor was found to be nonin .ltrating and was enclosed within a cyst, which was totally removed. B.C. spent 2 days in the neurological intensive care unit(NICU) because he was on se

46、izure precautions and monitoring for increased intracranial pressure (ICP). A regimen of focal radiation followed after recovery from surgery. His spine was also treated because of the potential spread of tumor cells in the CSF. B.C. did not have chemotherapy because of the danger that he might deve

47、lop hydrocephalus, which generally requires a ventriculoperitoneal (VP) shunt. B.C. was discharged 6 days after his surgery with a mild hemiparesis, which was expected to resolve within the next few weeks. He was scheduled for 6 weeks of outpatient rehabilitation, and his prognosis was good.Case Stu

48、dy 17-2: Cerebrovascular Accident (CVA)A.R., a 62-year-old man, was admitted to the ER with right hemiplegia and aphasia. He had a historyof hypertension and recent transient ischemic attacks (TIAs), yet was in good health when he experienced a sudden onset of right -sided weakness. He arrived in th

49、e ER via ambulance within 15 minutes of onset and was received by a member of the hospital's stroke team. He had a rapid generalassessment and neuro exam, including a Glasgow coma scale (GCS) rating, to determine his candidacyfor fibrinolytic therapy. He was sent for a noncontrast CT scan to loo

50、k for evidence of hemorrhagic or ischemic stroke, post cardiac arrest ischemia, hypertensive encephalopathy, craniocerebral or cervical trauma, meningitis, encephalitis, brain abscess, tumor, and subdural or epidural hematoma. The CT scan, read by the radiologist, did not show intracerebral or subarachnoid hemorrhage. A.R. was diagnosed with probable acute ischemic stroke within 1 hour of onset of symptoms and cleared a