1、andEchocardiogram（超聲心動圖）1:PTCACaseStudy9（經皮冠狀動脈內成形術），01dwoman,wasadmittedtotheCCUwithchestpain,dyspnea（呼吸困難）A.L.,a68-year-（舌（惡心）.Shehadtakenthreesublingual（發汗）,syncope（昏厥）,andnauseadiaphoresis（跨-minutetimespantablets（片劑）withina10下的）dosesofnitroglycerine（硝化甘油）uptake（攝取）withoutreliefbeforedialing911.A

2、previousstresstestandthallium（鋅）距）scansuggestedcardiacdisease.Herfamilyhistorywassignificantforcardiovasculardisease（心'血管疾病）.Herfatherdiedattheageof62ofanacutemyocardialinfarction（急性心肌梗塞）.Hermotherhadbilateralcarotidendarterectomies（雙側頸動脈內膜切除術）andafemoral-poplitealbypass（股胭動脈旁路術）procedureanddied

3、attheageof72ofcongestiveheartfailure（充血T生心、力衰竭）.A.L.'soldersisterdiedfromarupturedaorticaneurysm（主動脈動脈瘤破裂）attheageof65.HerECG（超聲心動圖）onadmission（入院時）presentedtachycardia（心跳過速）witharateof126bpm（每分鐘心跳次數）withinvertedTwaves.Amurmur（心臟雜音）washeardatS1（第一心音）.Herskincolorwasduskytocyanotic（發紫的）onherlipsa

4、ndfingertips.Heradmittingdiagnosis（入院診斷）waspossiblecoronaryarterydisease（冠心'病）,acutemyocardialinfarction（急性心肌梗塞），andvalvulardisease（心瓣膜病）.Cardiaccatheterization（心導管術）withballoonangioplasty（PTCA）（經皮冠狀動脈腔內成形術）wasperformedthenextday.Significant（顯著的）stenosis（狹窄）oftheleftanteriordescendingcoronaryart

5、ery（冠狀動脈前降支）wasshownandwastreatedwithangioplasty（血管成形術）andstentplacement（支架放置）.Leftventricularfunction（左心室功能）wasnormal.Echocardiogram（超聲心'動圖）,2dayslater,showednormal-sizedleftandenlargedrightventricularcavity.Themitralvalve（二尖瓣）hadnormalamplitudeofmotion（正常運動幅度）Theanteriorandposteriorleaflets（小葉

6、）movedinoppositedirectionsduringdiastole（舒張期）Therewasalatesystolic（收縮期的）prolapse（脫出）ofthemitralleaflet（二尖瓣瓣葉）atrest（靜止）.Theleftatrium（左心房）wasenlarged.Theimpressionofthestudywasmitralprolapse（二尖瓣脫垂）withregurgitation（回流，反流）.Surgerywasrecommended.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CCU。她需要三個舌下服用硝酸甘油片不到1

7、0分鐘的時間跨度無緩解撥打911之前。先前壓力測試和鋅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（PTCQ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，顯示正常大小的左、右心室腔擴大。二尖瓣

8、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。CaseStudy9-2:MitralValveReplacementOperativeReportA.L.wastransferred（轉移到）totheoperatingroom（手術室），placedinasupineposition（仰臥位）,andgivengeneralendotrachealanesthesia（氣管內麻醉）.Herpericardium（心包）wasenteredlongitudinally（縱向）th

9、roughamediansternotomy（正中胸骨切開術）.Thesurgeon（夕卜科醫生）foundthatherheartwasenlargedwithadilated（擴大的）rightventricle（右心室）.Theleftatrium（左心房）wasdilated.Preoperative（手術前的）transesophageal（經食道的）echocardiogram（超聲心動圖）revealedseveremitralregurgitation（二尖瓣回流）withsevereposteriorandanteriorprolapse（脫垂）.Extracorporeal

10、circulation（體夕卜循環）wasestablished.Theaorta（主動脈）wascross-clamped（交叉夾緊）,andcardioplegicsolution（交叉夾緊）（tostoptheheartbeat）wasgivenintotheaorticroot（主動脈根）intermittently（間歇地）formyocardialprotection（心肌保護）.Theleftatriumwasenteredviatheinteratrialgroove（房間溝）ontheright,exposingthemitralvalve.Themiddlescallop（

11、扇貝）oftheposteriorleafletwasresected.Theremainingleafletswereremovedtotheareasofthecommissures（連合）andpreservedforthesliding（滑動的）plasty（成形術）.Theelongated（展長）chordae（腱索）wereshortened（縮短）.Thesurgeonslidtheposteriorleafletacrossthemidlineandsutureditinplace.Ano.30annuloplasty（瓣膜成形術）ring（環）wassuturedinpla

12、cewithinterrupted（間斷的，阻斷的）no.2-0（編號）Dacronsuture（滌綸縫線）.Thevalvewastestedbyinflating（使充氣）theventriclewithNSSandprovedtobecompetent（有活性的）.Theleftatriumwasclosedwithcontinuousno.4-0Prolenesuture（聚丙烯縫線）.Airwasremovedfromtheheart.Thecross-clamp（橫跨鉗閉）wasremoved.Cardiacactionresumedwithnormalsinusrhythm（正常

13、竇，住心、律）.Afteraperiodofcardiacrecoveryandattainment（達至U）ofnormothermia（正常體溫）cardiopulmonarybypass（心肺分流術）wasdiscontinued（不連續的）Protamine（魚精蛋白）wasgiventocounteract（抵抗，解（毒），中和）theheparin（肝素鈉，肝素）Pacer（起搏器）wireswereplacedintherightatriumandventricle.Siliconecatheterswereplacedinthepleuralandsubsternalspace

14、s.Thesternum（胸骨）andsofttissuewoundwasclosed.A.L.recoveredfromhersurgeryandwasdischarged（出院）6dayslater.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

15、。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。CaseStudy11-1:Preoperative（手術前）Testing（測驗）inaPatientWithAsthma（哮喘）A.D.,15yearsold,wasseeninthepread

16、missiontesting（入院前檢查，預進（氣）試驗；）unit（單位，基因，設備）inpreparationforherelectivespinal（脊髓的）surgery（外科手術）.Shehasahistoryofmildasthmasinceage4,withatleastoneattackperweek.Inanacuteattack,shewillhavemild（輕微的）dyspnea（呼吸困難）,diffusewheezing（喘鳴）,yetanadequateairexchangethatrespondstobronchodilators（支氣管擴張齊U）.Shewass

17、enttopulmonaryhealthservicesforaconsult（顧問醫生）withaspecialistandpulmonaryfunctionstudiestoclearherforsurgery.Theanesthesiologist（麻醉科醫師）reviewedthepulmonologist'sreport.Herprebronchodilator（支氣管收縮）spirometry（肺量測定法）showedamildreductioninvitalcapacitybutwithamoderatetoseveredecreaseinFEV1（秒鐘用力呼氣量）and

18、FEV1/FVC（快速肺7S量）ratio（比例）.Afterbronchodilator（支氣管擴張藥）administration（給藥）,therewasamildbutinsignificantimprovementinFEV1.Thepostbronchodilator（支氣管的）FEV1was55%ofpredictedandwasconsideredmoderately（適度的）abnormal.Theflowvolumeloops（流量循環）andspirographiccurves（呼吸描記曲線）wereconsistentwithairflowobstruction.翻譯：

19、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，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。CaseStudy11-2:GiantCellS

20、arcomaoftheLungL.E.,a68-year-oldman,wasadmittedtothepulmonaryunitwithchestpainoninspiration,dyspnea,anddiaphoresis.Hehadsmoked11.2packsofcigarettesperdayfor52yearsandhadquit3monthsago.L.E.wasretiredfromtheadvertisingindustryandadmittedtooccasionalalcoholuse.Hewastreatedforprimarygiantcellsarcomaofth

21、eleftlung3yearsagowithalobectomyoftheleftlungfollowedbyradiationandchemotherapy.Physicalexaminationwasunremarkableexceptforathoracotomyscarinthelefthemithorax,decreasedbreathsounds,anddullnesstopercussionoftheleftbase.Therewasnohemoptysis.Radionucleotidebonescanshowedincreasedactivityintheleftupperp

22、osteriorhemithorax.ChestandupperabdomenCTscanshowed.ndingscompatiblewithrecurrentsarcomaofthelefthemithorax.Abnormalmediastinalnodeswereevident.Thoracentesiswasattemptedbutdidnotyield.uid.L.E.wasscheduledforaleftthoracoscopy,mediastinoscopy,andbiopsy.CaseStudy11-3:TerminalDyspneaN.A.,a76-year-oldwom

23、an,wasintheICUintheterminalstageofmultisystemorganfailure.Shehadbeenadmittedtothehospitalforbacterialpneumonia,whichhadnotresolvedwithantibiotictherapy.Shehada20-yearhistoryofCOPD.Shewasnotconsciousandwasunabletobreatheonherown.HerABGswereabnormal,andshewasdiagnosedwithrefractoryARDS.Thedecisionwasm

24、adetosupportherbreathingwithendotrachealintubationandmechanicalventilation.After1weekandapulmonologistsuggestedtoweanherfromtheventilator,theseveralunsuccessfulattemptspermanenttracheostomyandfamilyconsiderationofcontinuingorwithdrawinglifesupport.Herphysiologicstatusmetthecriteriaofremoteornochance

25、forrecovery.N.A.'sfamilydiscussedsustainingtherapies.N.A.wasassignedherconditionanddecidednottopursueaggressivelife-DNRstatus.Afterthewrittenorderswerereadandsignedbythefamily,theendotrachealtube,wasdripIVelectrodeswereremovedandamorphinefeedingtube,pulseoximeter,andECGstartedwithprnbolusesorder

26、edtopromotecomfortandrelievepainandothersymptomsofwithshallowmanyhourswhileherbreathsbecamedying.ThefamilysatwithN.A.forStokesrespirations.Cheyne-Shediedsurroundedbyherfamily,joinedbythehospitalchaplain.1:CholecystectomyCaseStudy12-andenteredthehospitalwithnauseaaG.L.,42-year-oldobeseCaucasianwoman,

27、vomiting,.atulencepain.upperquadrantandsubscapularandeructation,afeverof100.5°F,andcontinuousrightExaminationonadmissionshowedreboundtendernessintheRUQwithapositiveMurphysign.colored-frequentclayandnails,conjunctivaewereyellowish,andshecomplainedofHerskin,suggestedtheabdomenwascount16,000.AnERC

28、Pandultrasoundofstools.Herleukocytewasdiagnosispossiblythecommonbileduct.Herandmanysmallstonesinhergallbladdercholecystitiswithcholelithiasis.andwithwasattempted,anintraoperativecholangiogramAlaparoscopiccholecystectomycommonwassomevisualizationunexpectedbleeding,ductbileexploration.BecauseofG.L.

29、9;ssizeanddif.cultandtheprocedurewasconvertedtoanopenapproach.SmallstonesandgranularsludgewereirrigatedtheintohadaT-tubeinsertedwasremoved.duct,fromhercommonandthegallbladderSheductforbiledrainage;thistubewasremovedonthesecondpostoperativeday.ShehadanNGtubeinplacebeforeandduringthesurgery,whichwasal

30、soremovedondaytwo.Shewasdischargedonthe.fthpostoperativedaywithaprescriptionforprnpainmedicationandalow-fatdiet.-2:SurgicalPathologyReportCaseStudy12GrossDescription:Thespecimenisreceivedinformalinlabeled“rupturedduodenaldiverticula”and2.8consistsofenterictissuemeasuringapproximately6.30.7cm.Thesero

31、salsurfaceismarkedlydullinappearanceand.brotic.Themucosalsurfaceishemorrhagic.RepresentativesectionsaretakenofsegmentsshowsslideSectionedDescription:Microscopicexamination.microscopicforduodenaltissueswithareasofgangrenouschangeinthebowelwall,andacuteandchronicin.ammatoryin.ltrates.Therearechronican

32、dfocalacutein.ammatorycellin.ltrateswithhemorrhageinthemesentericfattytissue.Thereareareasofacutein.ammatoryexudatesnotedinthefattytissue.Histopathologicchangesareconsistentwithrupturedduodenaldiverticula.CaseStudy12-3:ColonoscopyWithBiopsyS.M.,a24-year-oldman,hadarecenthistoryoflowerabdominalpainwi

33、thfrequentloosemucoidstools.Hedescribedsymptomsofoccasionaldysphagia,dyspepsia,nausea,andaphthousulcersofhistongueandbuccalmucosa.Apreviousbariumenemashowedsomeirregularitiesinthesigmoidandrectalsegmentsofhislargebowel.Stoolsamplesforculture,ova,andparasiteswerenegative.Histentativediagnosiswasirrit

34、ablebowelsyndrome.Hefollowedalactose-free,low-residuedietandtookImodiumtoreduceintestinalmotility.Hisgastroenterologistrecommendedacolonoscopy.Aftera2-dayregimenofsofttoclearliquiddiet,laxatives,andanenemathemorningoftheprocedure,hereportedtotheendoscopyunit.Hewastransportedtotheprocedureroom.ECGele

35、ctrodes,apulseoximetersensor,andabloodpressurecuffwereappliedformonitoring,andanIVwasinsertedinS.M.'srightarm.AnIVbolusofDemerolandabolusofVersedweregiven,andS.M.waspositionedonhisleftside.Thecolonoscopewasgentlyinsertedthroughtheanalsphincterandadvancedproximally.S.M.wasinstructedtotakeadeepbre

36、athwhenthescopeapproachedthesplenic.exureandthehepatic.exuretofacilitatecomfortablepassage.Thephysicianwasabletoadvancepasttheileocecalvalve,examiningtheentirelengthofthecolon.Ulceratedgranulomatouslesionswereseenthroughoutthecolon,withaconcentrationinthesigmoidsegment.Manybiopsyspecimensweretaken.T

37、hemucosaofthedistalileumwasnormal.PathologyexaminationofthebiopsysampleswasexpectedtoestablishadiagnosisofIBD.CaseStudy17-1:PediatricBrainTumorB.C.,a6-year-old.rst-gradestudent,wasreferredtoapediatricneurologistbyhisprimarypediatricianforaneuroconsult.Hehadpresentedwithanacuteonsetofheadaches,vomiti

38、ngonwakinginthemorning,andprogressiveataxia.TheneurologistconductedathoroughneuroexamandorderedaCTscan,MRI,andlumbarpuncture(LP)tolookforpossibletumorcells.WhentheLPrevealedsuspiciouscellsandthescansshowedatissuedensity,hewasreferredtoaneurosurgeonfortreatmentofasuspectedinfratentorialastrocytomaoft

39、heposteriorfossa.B.C.hadacraniotomywithtumorresection5dayslater.Thecerebellartumorwasfoundtobenonin.ltratingandwasenclosedwithinacyst,whichwastotallyremoved.B.C.spent2daysintheneurologicalintensivecareunit(NICU)becausehewasonseizureprecautionsandmonitoringforincreasedintracranialpressure(ICP).Aregim

40、enoffocalradiationfollowedafterrecoveryfromsurgery.HisspinewasalsotreatedbecauseofthepotentialspreadoftumorcellsintheCSF.B.C.didnothavechemotherapybecauseofthedangerthathemightdevelophydrocephalus,whichgenerallyrequiresaventriculoperitoneal(VP)shunt.B.C.wasdischarged6daysafterhissurgerywithamildhemi

41、paresis,whichwasexpectedtoresolvewithinthenextfewweeks.Hewasscheduledfor6weeksofoutpatientrehabilitation,andhisprognosiswasgood.CaseStudy17-2:CerebrovascularAccident(CVA)A.R.,a62-year-oldman,wasadmittedtotheERwithrighthemiplegiaandaphasia.Hehadahistoryofhypertensionandrecenttransientischemicattacks(

42、TIAs),yetwasingoodhealthwhenheexperiencedasuddenonsetofright-sidedweakness.HearrivedintheERviaambulancewithin15minutesofonsetandwasreceivedbyamemberofthehospital'sstroketeam.Hehadarapidgeneralassessmentandneuroexam,includingaGlasgowcomascale(GCS)rating,todeterminehiscandidacyforfibrinolyticthera

43、py.HewassentforanoncontrastCTscantolookforevidenceofhemorrhagicorischemicstroke,postcardiacarrestischemia,hypertensiveencephalopathy,craniocerebralorcervicaltrauma,meningitis,encephalitis,brainabscess,tumor,andsubduralorepiduralhematoma.TheCTscan,readbytheradiologist,didnotshowintracerebralorsubarachnoidhemorrhage.A.R.wasdiagnosedwithprobableacuteischemicstrokewithin1hourofonsetofsymptomsand