101-03-01 ED/ICU Morbidity & Mortality Conference Presenter：洪子文 醫師 Supervisor：陳俊宇 醫師 Moderator: 林志泉 醫師

Triage Time: 2011.12.26 09:42 Age: 79 y/o Gender: male T:35.5, P:94, R:20, BP:165/95, E4V5M6 檢傷主訴：病患來診為咳嗽，慢性咳嗽，生命徵象正常 檢傷分類：5

Present illness Dizziness sometimes General malaise Post prandial epigastric tightness Chronic dry cough for months No fever

Past hisotry Hyperglycemic hyperosmolar states Type II DM poor control Hiatal herniation with grade D gastroesophageal reflux disease Normocytic Anemia Chronic kidney disease

Physical examination Conscious : E4 V5M6 , Pupil size : 3+/3+ HEENT not anemic, not icteric Neck  no jugular engorgement Chest:  BS : clear Heart : RHB , no murmur Abdomen   soft and flat          no tenderness          no rebounding pain          bowel sound : normoactive Mcburney point : negative Murphy sign : negative Extremities: free movable, no edema

What history or physical examination you will want to do ??

Dizziness Vertigo : spinning, provoking factor, aggravating factor, nystagmus, tinnitus Presyncope : black out, postural relationship, near fainting Nonspecific dizziness: mood disorder, medicine, hypoglycemia

Present illness Dizziness sometimes,Vertigo? 5 D? Presyncope? Medicine, stress ? General malaise appetite? Urine output? Dysuria? diarrhea ? Urine and stool color ? Post prandial epigastric tightness, N/V, heart-burn ? Radiation or shifting pain ? Tarry stool ?, chest pain or tightenss ? Chronic dry cough for months, sputum? Dyspnea? No fever

2011/12/26 10:10 initial order CBC/DC, Na, K, Cr, ALT troponin I finger sugar CXR and EKG

Lab data Finger sugar : 472 WBC 9.4 RBC 3.57 HB 9.9 Hct 30.7 MCV 86 MCH 27.7 RDW 14.4 Platelets 279 Seg 79.2 Lymphocyte 15 Eosinophil Monocyte 5.6 Basophil 0.2 Creatinine 1.58 Na 135 K 3.9 Troponin I 0.038 ALT 15

2011/12/26 11:53 obs order Regular insulin 12U stat SC Impression : 1. DM with Hyperglycemia 2. HTN and CKD Finger sugar Q2h x 2 times MBD if finger sugar below 250 Acetaminophen 1# qid Sucralfate 1# qid Cough mixture 15cc qid

病人從二區移到一觀，在一觀從輪椅上移到病床上時昏倒 Vital sign : T:36, P:104, R:18, BP:125/59 2011/12/26 16:05 病人從二區移到一觀，在一觀從輪椅上移到病床上時昏倒 Vital sign : T:36, P:104, R:18, BP:125/59 Consciousness clear now No shortness of breath No seizure-like episode 查一下自備藥物

Any information do you want to know ? What will you do ?

Abnormal EKG Prolonged interval (QRS,QTc) Severe bradycardia(high degree AV block), Pre-excitation Myocardial infarction Low voltage Abnormal conduction syndrome (Brugada syndrome or WPW syndrome) S1Q3T3

Syncope History : 6P Pre-prodrome activities Predisposing factor : age, chronic disease, family history of sudden death Precipitating factors : stress, postural symptom Passers by witness Post-ictal phase

Syncope Physical examination : 有無外傷 兩側上肢血壓 心音聽診 肛門指診 孕齡婦女要做懷孕測試 詳細的神經學檢查

2011/12/26 16:07 O2 nasal 3L/min On EKG monitor EKG and finger sugar stat Check troponin I and ABG Arrange Brain CT

Atrial tachy

Brain CT

Finger sugar : 197 Troponin I : 0.030 ABG : PH : 7.51 PCO2 : 42.6 PO2 : 119.7 HCO3 : 33.2 SAT : 98.6 Impression : syncope, favor postural hypotension, admission to CV ward

2011/12/26 17:19 Some brown liquid was noted from nose since yesterday No trauma No wound Plan : obs

2011/12/27 16:52 病人坐輪椅要去廁所上廁所，起身再次昏倒 Vital sign : BP :107/62 RR : 22 BT : 35.8 P : 92 Plan : arrange chest CT, r/o pulmonary embolism 你同意排Chest CT 或者還有什麼其他想法？

Chest CT

Vital sign : BP : 84/51 HR : 109 RR : 22 護士說病人有病房了 請問可以上病房嗎 ?? 2011/12/27 20:46 Vital sign : BP : 84/51 HR : 109 RR : 22 護士說病人有病房了 請問可以上病房嗎 ?? Vital sign 完整

Present history Tarry stool was noted once this morning Severe dizziness when sitting up Some brown liquid was noted again from nose Mild tachypnea No abdomen pain No vomiting No fever Conjunctiva : pale (+)

N/S challenge 1000cc stat Check Hb/Hct, PT, APTT Prepared PRBC 2u and FFP 2u Esomeprazole 40mg stat IVF On NG irrigation (1000cc/800cc all coffee ground)

Lab data PT 13.5 INR 1.3 APTT 29.1 Hb 4.4

ER course 2011/12/26 17:19 Brown liquid from nose 2011/12/27 20:46 BP : 84/51 HR : 109 Check PT,APTT,HB Fluid challenge 2011/12/26 9:42 T: 35.5 P:94 R:20 Bp: 165/95 to ER 2011/12/26 16:05 P:104 BP:125/59 Syncope Brain CT 2011/12/27 16:52 BP : 107/62 P : 92 Syncope again Chest CT

ER course 2011/12/27 22:27 Bp : 115/53 HR : 92 PRBC 6U + FFP 2U Panendoscope 2012/12/28 5:15 consult GS 2012/12/28 9:51 operation 2011/12/28 4:12 BP : 151/68 HR : 94 CC : peri-umbilical pain PE : muscle guarding Arrange abdomen CT

Operation record OP Finding: 1. turbid asictes was noted with odor smell 2. ischemic change of the small bowel with necrosis about total 200cm, 240cm distal to treize ligament and 20cm proximal to ileopcecal valve 3. the ischemic bowel was resected with side to side anastomosis 4. the colon was examed without further ischemic change 5. intro-op panendoscope was done which revealed no active bleeding from esophagus to the second portion of duodenum

Pathology GROSS D: THE WHOLE SEGMENT OF THE RESECTED INTESTINE SHOWS ISCHEMIC CHANGE WITH MULTIFOCAL MUCOSA THINING. NO OBVIOUS FIBROSIS IS NOTED ON MESENTERY. MICRO D: THE SMALL BOWEL SHOWS MARKED CONGESTION, EDEMA, DIFFUSE COAGULATIVE OR HEMORRHAGIC NECROSIS, AND ULCERATION OF THE MUCOSA. NO THROMBLI ARE FOUND WITHIN MESENTERIC VESSELS.

Hospital course 2011/12/28 Operation than transfer to ICU 2012/01/01 transfer to ordinary ward 2012/01/09 discharge

健康照護矩陣Healthcare Matrix 稱職能力 安全的醫療 SAFE 及時的服務 TIMELY 有用的處置 EFFECTIVE 效率的工作 EFFICIENT 平等的就醫 EQUITABLE 病人為中心PATIENT- CENTERED 病人照護 (是/否) PATIENT CARE 否 傷害病人之醫療行為 及早診斷或發現問題 以有用的方法治療 資源的浪費 是 提供相同品質的醫療服務 尊重病人及家屬之決定 照顧評估 醫療知識技能 MEDICAL KNOWLEDGE (應該熟知的) 知道 檢查的併發症。 藥物或治療的副作用。 手術的併發症。 出現臨床症狀至懷疑該診斷相隔多久? 出現問題至發現問題相隔多久? 依據目前實證,有哪些治療選擇? 替代療法? 各種醫療處置之成本。 (含人力物力資源) 特殊或弱勢族群常面對的疾病與醫療問題。 病人之自主權,生命權。 法定代理人之順序。 人際溝通技巧 INTERPERSONAL and COMMUNICATION SKILLS (應該表達的) 有告知 出現不良反應或病情惡化時之症狀。 診斷、檢查有結果或發現問題後至 告知與解釋病情相隔多久? 病患及家屬目前應該做的檢查和治療或可能之替代療法。 短時間內與病人及家屬達成雙方都最有利的治療計畫之共識。 以病人及家屬能了解的方式去溝通。同理病人及家屬之處境。 適時讓病人知道其病情。請病人或家屬做決定時,提供完整的醫療資訊。 專業素養倫理 PROFESSIONALISM (應該作為的) 停止有害之治療 處理併發症 預防再次發生 診斷或發現問題至 開始治療或處置相隔多久? 該做的治療或處置都做了。 不該做的治療或處置都停止了。 合理的劑量與療程之治療。 合乎適應症之的治療與檢查。 治療計畫的擬定配合病人及家屬的接受度和其特殊考量。 對於病情告知尊重其隱私權。 執行醫療行為尊重其自主權。 醫療體系行醫 SYSTEMS-BASED PRACTICE (應該支援的) 整合醫療團隊瞭解將執行之醫療行為?確實交班? 需要其他專科或醫療團隊支援時 至 開始支援協助時相隔多久? 依據病情適時會診、轉介或安置 請其他團隊協助治療。 各種檢查與治療流程可快速完成 在健保給付範圍內,維護病人的權利。 依個別需求會同各醫療團隊與病人及家屬討論病情。出院後適當的安置與追蹤。 學習改進 行醫導向之 PRACTICE-BASED LEARNING and IMPROVEMENT 如何 以團隊合作方式監測及預防不良事件發生? 更早發現該疾病或問題? 落實實證中有用的治療? 提升治療成效, 建立成本觀念? 加強同理病人及家屬的處境? 學習尊重病人的自主與隱私 © 2004 Bingham & Quinn; v.C1.5, 2008 1. Safe：避免意圖幫助病患的醫療行為反而傷害病患。 2. Timely：減少等候時間，避免因延遲而傷害病患。 3. Effective：根據醫學知識提供適當(不過當亦無不足)的服務。 4. Efficient：避免設備、藥衛材、意見或能力等資源的浪費。 5. Equitable：提供同樣品質的服務，不因性別、種族、地域或社經階層而不同。 6. Patient-Centered：依病患個別偏好及需求，提供尊重及負責任的照護，並依其價值觀作臨床決策。 A. Patient Care：具有憐憫同情心，能適當而有效率的診療病痛、預防疾病及增進健康。 B. Medical Knowledge：具備已確立及發展中的生物醫學、臨床醫學及社會科學的知識，並能將上述知識運用於照顧病患。 C. Interpersonal and Communication Skills：與病患及其家人或其他醫療照護成員建立團隊精神，維持有效的溝通管道。 D. Professionalism：表現出篤行專業責任、堅守倫理原則、尊重多樣性群體差異之行為。 E. Systems-Based Practice：有熱誠理解醫療照護體系之運作及緣由，並有能力運用體系資源，提供最適當的醫療照護。 F. Practice-Based Learning and Improvement：自我評估醫療行為，運用科學證據，提升照護品質。

Take home massage Acute blood loss related postural hypotension have to be considered as the reason of syncope.

Thank you