Prolong pt ptt case report
Download
1 / 49

Prolong PT/PTT Case Report - PowerPoint PPT Presentation


  • 174 Views
  • Uploaded on

Prolong PT/PTT Case Report. Ri 鄭千威. Patient Infomation. Name: 謝 XX Gender: female Age: 19 Chart Number: 5075664. Past history. 1.DM(-), HTN (-), Hyperlipidemia (-) 2.Other major systemic disease: gouty arthritis 3.Alcohol consumption: denied 4.Smoking: denied 5.Allergy: denied

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Prolong PT/PTT Case Report' - bishop


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

Patient infomation
Patient Infomation

  • Name:謝XX

  • Gender: female

  • Age: 19

  • Chart Number: 5075664


Past history
Past history

  • 1.DM(-), HTN (-), Hyperlipidemia (-)

  • 2.Other major systemic disease: gouty arthritis

  • 3.Alcohol consumption: denied

  • 4.Smoking: denied

  • 5.Allergy: denied

  • 6.Surgical history: denied

  • 7.Family hx not contributory


Brief history
Brief History

  • Jan – Feb 2006, felt short of breath, weakness while climbing to her classroom on 4th floor

  • URI symptoms and exertional dyspnea developed in March then went to 耕莘 hospital on April 18.

  • Cardiac ECHO showed dialated LA and LV with LEVF = 20%, severe MR and moderate TR and PR without vegetation


  • Hospitalized from July 27 – Aug 5 due to SOB and cough with sputum for 1 wk

  • Heart ECHO on July 28:

    pericardial effusion without tamponade sign, LVEF~16%, mod-severe MR, mod TR, PR with pul. HTN, without evidence of IE

  • Abd ECHO on July 29:

    All normal except a 2.61 cm left renal cyst

  • Refer to NTU OPD on Aug 10




Lab findings at er 10 05

PH 7.47 vomiting, flapping tremor, chronic renal insufficiency (CRI) with acute exacerbation

PCO2 36.0

PO2 114.4

HCO3 25.6

WBC 4.92

RBC 2.94

HB 9.2

PLT 206.0

UN 38.5

CRE 1.8

Lab findings at ER (10/05)


Physical finding
Physical finding vomiting, flapping tremor, chronic renal insufficiency (CRI) with acute exacerbation

  • Conscious clear until E1VTM4 (10/14)

  • Conj: anemic (-) Sclera: icteric (-)

  • Pupils: isocoric (+) Light reflex : R/L ( + / + )

  • Throat: injected (-) Gum bleeding (-)

  • Neck: supple (+) , LAP (-), JVE (-), goiter (-)

  • Chest: symmetric expansion

  • BS: clear (+), rales (-), wheezing (-), crackle (-)

  • Heart:

  • PMI : at 6 ICS 3 fb, to LMCL

  • heart sound: regular heart beat

  • murmur: systolic murmur at mitral area, diastolic murmur over pulmonary valve area

  • Abdomen: inspection: soft (+), flat (+),

  • tenderness (-), rebounding tender(-), shifting

  • dullness (-) , central obesity (-), striae (-)

  • Liver: impalpable

  • Spleen :impalpable

  • Bowel sound : normoactive

  • Back: CV angle knocking pain (-)

  • Ext.: non-pitting edema,

  • tremor of extremities (+), purpura over forearms & cannulation wounds ;(+),Cyanosis of finger tips & toes(+)


Treatment course
Treatment course vomiting, flapping tremor, chronic renal insufficiency (CRI) with acute exacerbation

  • Oct 6: Unasyn: new onset fever (38.5) , resp s/s (cough + sputum)

    • Blood: no pathogen

    • Sputum: Gram (-) rods1+, Gram (+) cocci in chains3+

      WBC 4920

      CRP 0.13

      U/A: negative findings

      BNP 3621.47

  • Oct 9: cough with occasional blood tinged sputum

  • Oct 10: BT↑:39℃ Tazocin: nosocomial infection, new fever onset, persistent cough with sputum

    WBC 7250

    CRP 1.46

    U/A: negative findings

    • Blood: no pathogen

    • Sputum: few Enterobacter cloacae


  • Oct 11: fever flare up 39.4 ℃, tremor vomiting, flapping tremor, chronic renal insufficiency (CRI) with acute exacerbation

    On CVP, O2 mask

    Hb↓, blood tinged sputum, susp. pulmonary hemorrhage

    E4V5M6

  • Oct 11 (1700): transfer to 3B1 for ionotropic support

    Dx: CHF NYFc IV, Cardiac ECHO: LVEF=20%, 4 chamber dilatation


  • Oct 11 (2000): sudden attack of partial seizure with 2nd generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    E2VTM5

  • Oct 11 (2100): profound shock after seizure despite full dose ionotropic

    On ECMO (L’t femoral a & v), on R’t femoral CVP


Lab findings

Immunology generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

Oct 11:

Anti-Nuclear Antibody : -

C3 Quantitation: within normal limit

C4 Quantitation : within normal limit

RA Factor : -

Anti-ds DNA : -

Oct 12

Adenovirus ab: -

Coxsackievirus ab B1-B6: -

CMV IgM ab: -

Anti-CCP: -

P-ANCA: -

C-ANCA: -

Anticardiolipin: -

SLE

Rheumatoid arthritis

SLE

Rheumatoid arthritis

Wegener's granulomatosis

Wegener’s granulomatosis

Anti-phospolipid dz

Lab findings


Lab findings1

Immunology generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

Oct 13

HBsAg: Non reactive

Anti-HBs: reactive

HBeAg: Non reactive

Anti-HBe:Non reactive

Anti-HBc: reactive

Anti-HCV: Non reactive

Anti-HAV: reactive

STS: non reactive

Anti-HIV: negative

Lab findings


  • Oct 12: CAVH due to anuria, hyperkalemia generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

  • Oct 13: IABP, R’t femoral a.

    • Transfer to 4FI

      • Dopamine 20 ml/hr taper to 10 before transplant

      • Levophed 8 ml/hr DC 10/19

      • Isuprol 2 ml/hr DC 10/18

  • Oct 14: E1VTM4: fever switch to fortum + vancomycin

    • Blood: no pathogen

    • Sputum: Enterobacter cloacae3+

    • Prophylaxis MRSA infection

      CRP: 8.18

      WBC: 11020

  • Oct 16: bronchoscope

    • diffuse bloddy secretion, pulmonary parechyma hemorrhage is likely

    • no obvious airway injury

  • Oct 17: LA drain with artificial ASD: toes and finger tip darken

    • Anterior tibial a, dosalis pedis a. L +/+ R +/+

  • Oct 18: aortic ligation and aortic valve suturing

    • PGE1 and nitroderm for improving distal circulation

  • Oct 21: heart transplant


  • Fortum generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    Vancomycin

    Tazocin

    Unasyn


    AST generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    ALT


    ECMO generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    DIC

    10/11 PT 20.3 -> 23.7

    PTT 30.3 ->35.7

    10/14 PT 45.3

    PTT >200


    Oct 10 generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway


    Oct 12 generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway


    Oct 20, after LA drain generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway


    Discussion generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway


    B type natriuretic peptide

    a protein produced bythe ventricles of the heart generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    test has a negative predictive value of at least 96%, so heart failure can confidently be ruled out for patients in the normal range

    B-type natriureticpeptide

    CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70 • NUMBER 4 APRIL 2003


    Dilated cardiomyopathy
    Dilated cardiomyopathy generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    Def: dilation & impaired contraction of one or both ventricle

    Def: LVEF <40%

    • Imparied systolic function -> HF

      common s/s: progressive dyspnea with exertion, impaired exercise capacity, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema


    Etiology

    Primary generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    Idiopathic

    familial

    Secondary

    Infective (coxsaki, CMV, HIV, adeno)

    Metabolic

    Familial storage disease (glycogen storage dz)

    Deficiency (e-, nutrient)

    Connective tissue disorder (SLE, RA)

    Infiltration & granulomas (maglinancy, amyloidosis)

    Neuromuscular (Muscular dystrophy)

    Toxic reaction (alcohol, drugs-doxorubicin, cyclophosphamide)

    Peripartum heart disease

    Etiology

    Harrison's Principles ofInternal Medicine, 15th Edition


    Treatment
    Treatment generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • Most downhill course

    • Death due to CHF, arrythmia, sudden death

    • Systemic embolization

    • Rx for heart failure

      • Salt restriction

      • Beta blocker carvedilol 3.125 mg qd -> 20-50 mg q12h

      • ACEI captpril 6.25 mg po tid

      • Digitalis 0.5 mg po/iv ->0.25 mg q6h

      • Diuretics spirolactone 25 mg po qd

      • Avoid alcohol, NSAID

      • transplant


    Hemoptysis
    Hemoptysis generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    Def: expectoration of blood from the respiratory tract

    • From sputum blood streak to large amount of pure blood

    • Dx: respiratory track vs GI source

    • GI tract -> a dark red appearance and an acidic pH,

    • Respiratory track-> bright red appearance and alkaline pH


    Etiology1

    Systemic coagulopathy, anticoagulant, thrombolytic agents generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    Primary vascular source

    AVM

    Embolism

    ↑pul venous pressure (MS)

    Tracheobronchial source

    Neoplasm

    Bronchitis

    Bronchiectasis

    Broncholithiasis

    Airway trauma

    Froeign body

    Pulmonary parenchyma source

    Lung abscess

    Pneumonia

    TB

    Fungus ball

    Lung contusion

    Idiopathic pulmonary hemosiderosis

    Goodpasture syndrome

    Wegener’s granulomatosis

    Lupus pneumonitis

    Etiology

    Harrison's Principles ofInternal Medicine, 15th Edition


    Treatment1
    Treatment generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • blood-streaking of sputum or small amounts of pure blood -> priority -> diagnosis, (gas exhange usually unaffected)

    • massive hemoptysis

      • maintaining adequate gas exchange

      • preventing blood from spilling into unaffected areas of lung,

      • avoid asphyxiation.

    • rest and partially suppressing cough may help the bleeding to subside

    • If too severe may need endotracheal intubation and mechanical ventilation

    • laser phototherapy, electrocautery, embolotherapy, and surgical resection of the involved area of lung.


    C reactive protein
    C reactive protein generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • Why high fever, but low CRP?

    • CRP produced by hepatocytes stored in ER

    • During acute phase response, CRP catabolic rate independent of plasma level CRP therefore ambient level depend on syn rate


    • elevated generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway CRP value is not specific for any condition,

    • a very sensitive index of ongoing inflammation,

    • In differentiating between bacterial and viral infections -> very high CRP likely to occur in bacterial than viral infection, and a normal CRP is unlikely in bacterial infection.


    Crp elevation

    Infections generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    Hypersensitivity complications of infections

    Rheumatic feverErythema nodosum leprosum

    Inflammatory disease

    Rheumatoid arthritischronic arthritisAS

    Psoriatic arthritis Systemic vasculitis

    Allograft rejection

    Renal tranplantation

    Malignancy

    Lymphoma

    sarcoma

    Necrosis

    MI

    acute pancratitis

    Trauma

    Burns

    fracture

    CRP elevation


    Production
    Production generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • CRP production in hepatocytes stimulated by IL6

    • Cytokines network can be stimulated by various stimuli (IL-1, TNF…) to stimulate and provide feedback to acute phase protein response

    • Liver failure can affect acute phase protein production

    • Defects in cytokine network also ↓ acute phase protein production

    Seminar in dialysis: 17(6): 438 Nov, 2004


    ECMO generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • Extra corporeal membrane oxygenator

    • GOAL: to increase tissue oxygenation

    • va was used to bypass pulmonary circulation and pump flow determine the systemic flow perfusion due to poor LVEF

    • vv better: maintain pul blood flow, ↑myocardial oxygenation, keep thrombin or emboli to pul (vs systemic)


    Ecmo setup
    ECMO setup generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    Current Opinion in Critical Care 2005, 11:87–93


    Indication ecmo
    Indication ECMO generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • ECMO high-end therapy for respiratory

      failure

    • all other treatment options failed to ↑

      tissue oxygenation

    • defined as a PaO2/FiO2 ratio below 50mmHg.

    Current Opinion in Critical Care 2005, 11:87–93


    Contra indication of ecmo
    Contra-indication of ECMO generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • Prolonged mechanical ventilation (>5days)

    • Sepsis

    • Absolute contra-indication to systemic anticoagulant


    Complication of ecmo
    Complication of ECMO generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • Bleeding (surgical & chest tube site)


    IABP generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • Intra-aortic balloon pump

    • GOAL: provide hemodynamic support to

    • critically ill patients with cardiac disease.

    • Improvement depend on: volume of balloon, position in aorta, heart rate, rhythm, compliance of aorta, systemic resistance

    Am J Cardiol 2006;97:

    1391–1398


    Indication for iabp
    Indication for IABP generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • Hemodynamic support during/after cardiac catherization

    • cardiogenic shock

    • Weaning from cardiopulmonay bypass

    • Pre-op support with severe left main cornary arterial stenosis

    • Adjuct therapy for high risk patients with

      • Complicated angioplasy

      • Restenosis


    IABP generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    ↑ afterload + suction effect

    ↑ preload


    Contra indication of iabp
    Contra-indication of IABP generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • Aortic regurgitation

    • Aortic dissection/aneurysm

    • uncontrolled septicemia

    • bleeding diathesis


    Complication of iabp
    Complication of IABP generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    • Bleeding

    • systemic embolization

    • limb ischemia

    • amputation

    • Infection

    • Balloon rupture


    Coagulopathy
    Coagulopathy generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    Uptodate


    Causes of prolong pt ptt

    Von Willebrands (lack vWD for platelet adhesion) generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway

    Thrombocytopenia (genetic, bone marrow dz, iron)

    Vit K deficiency

    Mass transfusion (blood lack platelet, factor V)

    Liver disease

    DIC

    Antiphosplipid syndrome (ab against cell memb)

    Hemophilia

    A: VIII deficiency

    B: IX deficiency

    Protein C deficiency

    Protein S deficiency

    Antithrombin III deficiency

    Causes of prolong PT, PTT

    POMD 7th ed.


    Uptodate generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway


    Thank you generalization, no diplopia, no facial palsy, no slurred speech -> intubate to protect airway


    ad