1 / 53

CV-CVS-Nephro Conference

CV-CVS-Nephro Conference. Presented by F1 潘恆之 Commented by Dr. 謝宏昌 2012/04/18. CASE 1: 8480511 CASE 2: 21508337 CASE 3: 8853407. CASE 1: 8480511. General Data. Age: 40-year-old Gender: Female Ethnic: Taiwanese Marital status: Married. Past history. Hypertension

lundy
Download Presentation

CV-CVS-Nephro Conference

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. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CV-CVS-Nephro Conference Presented by F1 潘恆之 Commented by Dr.謝宏昌 2012/04/18

  2. CASE 1: 8480511CASE 2: 21508337CASE 3: 8853407

  3. CASE 1: 8480511

  4. General Data • Age: 40-year-old • Gender: Female • Ethnic: Taiwanese • Marital status: Married

  5. Past history • Hypertension • Systemic lupus erythematous with lupus nephritis • Chronic kidney disease, lupus nephritis related • Vasculitis related enteritis • Hypothyroidism

  6. Medication history • 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

  7. Personal History • Allergy to Sulindac • She denied smoking, alcohol, or betel nut chewing.

  8. Family history • Younger sister: SLE • Father: lung cancer • Grandmother: Arrythmia

  9. Course G a 2011/02/08 ~ 2011/03/15 Admission • Urosepsis • Acute on chronic kidney disease • On FDL for H/D • Arrange Hickman insertion and AVF creation* • Discharge on 03/15 2011/03/22 Nephro OPD • S/S: local heat and swelling around left AVF • Cefuroxime 1# BID x 7 days 2011/03/31 Nephro OPD • S/S: local heat and swelling around left AVF • Vancomycin 1g st, Dicofenac, Neo-cortisone cream • Return to CVS OPD on 05/30

  10. Course 2011/05/30 CVS OPD • S/S: left forearm swelling • Arrange Duplex of AVF * 2011/06/13 CVS OPD • S/S: left forearm swelling • Consider repair the stenotic basilic vein • Arrange revision of A-V shunt with intering Graft* 2011/07/11 CVS OPD • S/S: no local swelling, heat nor tenderness around AVF • Arrange Duplex of AVF*for follow up

  11. Course 2011/10/22 ~ 2011/11/12 Admission • 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 2012/03/06 Nephro OPD • S/S: Left forearm swelling, severe pain over the left hands for 2 months • Arrange Duplex of AVF*

  12. 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

  13. Diagnosis • Left 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 • Hypertension • Left ovarian cyst and multiple uterine myoma

  14. Discussion

  15. CASE II: 21508337

  16. General Data • Age: 56-year-old • Gender: Female • Ethnic: Hakkanese • Marital status: Married • Admission date: 2011/10/31

  17. Chief Complaint • Poor appetite for one month

  18. Present 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.

  19. 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.

  20. Past history • Hypertension • Chronic kidney disease • Asthma

  21. Personal History • No known allergy history to drug or food • She denied smoking, alcohol, or betel nut chewing.

  22. Family history • No family history of diabetes mellitus, hypertension, malignancy, chronic kidney disease or other systemic diseases.

  23. Physical Examination • BH: 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 mmHg • General appearance: fair looking • Consciousness: alert but disoriented, E4V4M6 • HEENT: conjunctiva: not pale, sclera: anicteric • Chest: symmetrical expansion, bilateral clear breathing sounds. • Heart: regular heart beats, no audible murmurs.

  24. Abdomen: soft and flat normal bowel sounds, no local tenderness • Back: 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: 5/5 • Skin: no rash, no petechiae nor ecchymosis fair skin turgor

  25. Laboratory Findings

  26. 2011/10/30 CXR

  27. 2011/11/02 Cardiac 2D echo • IVS: 19 mm; LVEDD: 34 mm; LVESD: 14 mm; PW:15 mm; EF by M-mode: 87 % • Pericardial effusion: nil, tamponade: nil • LV systolic function: adequate • Vavular lesions: TR -- Vmax: 4.0m/s, max gradient: 64 mmHg • Asynergy: no regional wall motion abnormality • Conclusion: Thick IVS & LVPW, mild MR, TR&PR, pulmonary hypertension maybe due to CRF (group 5)

  28. 2011/11/03 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 anecho-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

  29. 2011/11/03 Peripheral Doppler 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.

  30. 2011/11/05 Hickman insertion and left distal forarm AV fistula creation • Left 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.

  31. 2011/11/10 TCD/CCD • B-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.

  32. 2011/11/16 CTA of Brain 1. 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.

  33. 2011/11/16 CTA of Brain 4. 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.

  34. 2011/11/16 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.

  35. 2012/01/19 Peripheral Doppler of Lower Extremities • Segmental blood pressures: ABI: Right 1.11 normal Left 1.08 normal • A mild to mod narrowing at Rt distal ATA

  36. 2012/02/09 P.T.A • Osital 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.

  37. 2012/03/15 CTA of Left Upper Extremities • Great 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.

  38. Medication • Amlodipine 5mg/tab -------------- 1 PC QD • Clonazepam 0.5mg/tab ----------- 1 PC HS • Colchicine 0.5mg/tab ------------ 1 PC QD • Imipramine 25mg/tab ------------- 1 PC HS • Aspirin 100mg/cap -----------------1 PC QD • Cilostazol 50mg/tab ---------------1 PC BID

  39. Diagnosis • Left subclavian artery stenosis and left vertebral artery hypoplasia. • End-stage renal disease • Hypertension • Asthma

  40. Discussion

  41. CASE III: 8853407

  42. General Data • Age: 49-year-old • Gender: Female • Ethnic: Taiwanese • Occupation: Counselor

  43. Past History • Hypertension • End stage renal disease, s/p CAPD during 1995~2002, complicated with CAPD peritonitis, shift to H/D since 2002 • Peptic ulcer disease

  44. Medication • Famotidine (20mg) ------------------------ 1# QOD • Bisoprolol hemifumarate(1.25mg) ---- 0.5# QD • Irbesartan (300mg) ----------------------- 0.5# QOD • Alprazolam (25mg) ------------------------ 1# HS • Metoclopramide (5mg) ------------------ 1# QD

  45. Personal History • No known allergy to drug or food • Smoking: denied • Alcohol: denied • Betel nut chewing: denied • No recent travel history • No contact history

  46. Family history • Father: hypertension, stroke • Mother: hypertension, ESRD

  47. Course G a 2010/10/11 ~ 2010/10/25 Admission (SKH) • Left AVF infection • On FDL for H/D • Remove left AVF • Transffered to LinKou CGMH on 10/25 2010/10/28 ~ 2010/11/16 Admission • Arrange right AVF creation* • Discharge on 11/16 2010/11/29 CVS OPD • S/S: local heat, swelling with painful sensation around right AVF • Arrange duplex of AVF* • Arrange revision of AV shunt with intering jump graft*

More Related