20151007
臨床決策
血液净化 Chief. 黃AP
Case: 32 y/o male with subacute jaundice
一個病人18秒就要問完重點
- ascites通常比jaundice先出現，不需要問
- vomit, nausea, malaise, liver span, splenomegaly都是non-specific，沒有幫助診斷，不需要問
Approach to Jaundice
Charcot's triad:
- RUQ pain; right upper quadrant pain
- Jaundice
- and fever.
Reynolds' pentad:
4. Hypotension
5. Confusion
Murphy sign (cystic duct)
Charcot's triad+Murphy(+) cholecystitis
Charcot's triad+Murphy(-) cholangitis
Mirizzi syndrome (cholecystitis造成jaundice原因)
External compression causes compression of the common bile duct (CBD) or common hepatic duct, resulting in obstruction and jaundice.
DDx
- tumor, cancer
- acute hepatitis
- ...
依照位置：
- Pre-hepatic
- hepatic
- post-hepatic
問Stool color
- Dark: Pre-hepatic (Unconjugated hyperbilirubinaemia)
- Pale (caly-color stool):
- hepatic(Mixed)
- post-hepatic (Conjugated hyperbilirubinaemia)
Urine Dipstick
Bilirubin
The system’s cells convert the protoporphyrin into unconjugated bilirubin that passes through the circulatory system bound to protein, particularly albumin. The kidney is unable to filter out this bilirubin as it is bound to protein, however, it is conjugated with glucuronic acid in the liver to form water-soluble conjugated bilirubin.
Conjugated bilirubin appears in urine when the normal degradation cycle is altered due to the obstruction of the biliary ducts or when the kidney’s functional integrity is damaged. This allows the escape of conjugated bilirubin into the circulation as occurs in hepatitis and hepatic cirrhosis). https://www.wikiwand.com/en/Urine_test_strip
Urobilinogen
Intestinal bacteria reduce the bilirubin to urobilinogen
Urobilinogen is a colourless by-product of bilirubin reduction.
Low urine urobilinogen may result from complete obstructive jaundice or treatment with broad-spectrum antibiotics, which destroy the intestinal bacterial flora. (Obstruction of bilirubin passage into the gut or failure of urobilinogen production in the gut.)
Low urine urobilinogen levels may result from congenital enzymatic jaundice (hyperbilirubinemia syndromes) or from treatment with drugs that acidify urine, such as ammonium chloride or ascorbic acid.
Elevated levels may indicate hemolytic anaemia (excessive breakdown of red blood cells), overburdening of the liver, increased urobilinogen production, re-absorption - a large hematoma, restricted liver function, hepatic infection, poisoning or liver cirrhosis.
http://www.wikiwand.com/en/Urobilinogen
Haptoglobin
Under normal conditions the formation of haptoglobin-hemoglobin complexes prevents glomerular filtration, but if the hemolysis is extensive haptoglobin’s uptake capacity is exceeded and hemoglobin can appear in urine. Hemoglobinuria can be caused by hemolytic anaemia, blood transfusions, extensive burns, the bite of the recluse spider(Loxosceles), infections and strenuous exercise.https://www.wikiwand.com/en/Urine_test_strip
Heme
無法區分hemoglobin (hemolysis)還是myoglobin (rhabdomyolysis）造成的，要進一步測試
Chemical tests for blood use the pseudoperoxidase activity of hemoglobin to catalyze a reaction between the heme component of both hemoglobin and myoglobin and the chromogen tetramethylbenzidine to produce and oxidized chromogen, which has a green-blue colour.https://www.wikiwand.com/en/Urine_test_strip
PBS; Peripheral blood smear
看Erythrocyte有沒有怪怪的
malaria 通報拿三千元 (找schizont, trophozoite)
問TOCC
不過沒經驗的人PBS並不容易做，可以考慮以下更簡單的區分方法
Blood放著等clotting
看serum 顏色
pink 四級結構 hemolysis
opaque 三級結構 rhabdomyolysis (7kg以上才有顏色，基本上已經救不回來了)
轉診考量？住院？
helicopter 50萬NTD/次
看Vital sign決定
Vice Superintendent
遇到不理性病人
展現專業度(vital sign...)
