新英格兰双语病例讨论1

BilingualcasediscussionA54-Year-OldWomanwithAbdominalPain,Vomiting,andConfusionICU——LingshengMengPresentHistory3daysago,shebegantofeelunwell,withweakness,chills,andskinthatwasabnormallywarmtothetouch.Sheself-administeredaspirin,withoutimprovement.2daysago,heroralintakedecreased.Approximately22hoursbeforepresentation,vomitingoccurred.PresentHistory7hoursago,increasingabdominalpainoccurred,associatedwithvomitingandshortnessofbreath,andshetookadditionalaspirinforpain.Approximately2hoursbeforepresentation,abdominalpainmarkedlyworsened,vomitingincreased,andshebecameconfusedandunresponsive.Thecapillarybloodglucoselevelwas6.4mmolperliter.PastHistoryType2diabetesmellitusHypertensionNephrolithiasis肾结石ChronickidneydiseaseMedicationEnalapril依那普利Metformin二甲双胍Glimepiride格列美脲Nimesulide尼美舒利(非甾体抗炎药)Imipramine丙咪嗪（一种抗抑郁药）Aspirin阿司匹林Ibuprofen.布洛芬Personal&FamilyHistoryNoallergies；didn’tsmoke，drinkalcohol,oruseillicitdrugsandtherewasnohistoryofunusualingestions.Shewasmarriedandhadchildren.ShelivedinItalyanddidnotspeakEnglish.ShehadvacationedinNorthAmericafor10days,travelingtourbanareas.PhysicalExaminationT36.7P52RR26BP120/70Thepupilswere3mmindiameterandminimallyreactivetolight;Theoralmucousmembranesweredry,andtheneckwassupple.Theabdomenwassoft,withoutdis-tention,reboundtenderness,orguarding.Theskinwascool.Theremainderofthegeneralexaminationwasnormal.PhysicalExaminationTheoxygensaturation95%whileshewasbreathingambientair.Theneurologicexaminationwaslimitedbecauseofthepatient’sinabilitytofollowcommands;Shewithdrewallextremitiestopain,andcranialnervesstrengthappearednormal.Anelectrocardiogramrevealedatrialfibrillationatarateof115beatsperminuteandaQRSdurationof94msec,withatremulousbaselinepossiblyobscuringST-segmentdepressionintheinferiorleads.Achestradiographshowednoevidenceofpneumoniaorpleuraleffusion.Therewereill-definedcalcificationsinthesofttissueoftheleftbreast.Laboratorytests1Laboratorytests2Laboratorytests3Bloodgasanalysis:PH6.62PCO218mmHgPO273mmHgHCO3-2mmol/LBE-35.1AG61mmol/LBloodlevelsofcalcium,triglycerides,glycatedhemoglobin,andhaptoglobinwerenormal,asweretheresultsofliver-functiontests;Approximately3hoursafterthepatient’sarrival,therectaltemperaturedecreasedto31.7°C，andthebloodpressureto84/43mmHg.Dark-browngastricsecretionsthatwerepositiveforoccultbloodwereaspiratedthroughanorogastrictube;ThegastricpHwas5.7.Thepatientwasanacutelyill54-year-oldwomanwithamedicalhistoryoftype2diabetes,hypertension,kidneystones,andchronickidneydiseaseofunknownseverity.Shepresentedtotheemergencydepartmentwithdeterioratingmentalstate,respiratorydistress,andworseninggastrointestinalsymptoms.Laboratoryevaluationshowedaincreasedleukocytosis,anincreaseinpancreaticenzymelevels,severemetabolicacidosiswithamarkedlyelevatedserumlactatelevel,profoundhyperphosphatemia,andoligurickidneyfailure.ACTscanoftheabdomenandpelvis,revealspancreaticedemaandperipancreaticfatstrandingandfluid.thecharacteristicsofdiseaseDiagnoses？1.lacticacidosis?2.pancreatitis?3.renalfailure?Bloodgasanalysis:PH6.62PCO218mmHgPO273mmHgHCO3-2mmol/LBE-35.1AG61mmol/Lmetforminoverdoseoraccumulationasthecauseoflacticacidosisishighlylikelyinanypatientwhohasmostorallofthefollowingfivecriteriaevenifthemetforminlevelisnotknown:1.ahistoryofmetforminadministration，2.amarkedlyelevatedlactatelevel(15mmolperliter)and3.alargeaniongapsevereacidemia(pH7.1),4.averylowserumbicarbonatelevel(10mmolperliter),and5.ahistoryofrenalinsufficiency.whatcauseelevatedserumlactate?typeA——lacticacidosisisimpairedtissueperfusionthattypicallyhappensinpatientswithsepticorcardiogenicshockorduringcardiopulmonaryarrest.typeB——occurinassociationwiththeadministrationofcertainmedications(e.g.,metformin,salicylate水杨酸,isoniazid异烟肼,andzidovudine齐多夫定)orinassociationwithcertaincancers(e.g.,lymphomaandleukemia)二甲双胍水平是23ug/ml（正常值1-2）二甲双胍为降血糖药。可降低II型糖尿病患者空腹及餐后髙血糖，HbAlc可下降1%〜2%，降血糖的机制可能是：1.增加周围组织对胰岛素的敏感性，增加胰岛素介导的葡萄糖利用。2增加非胰岛素依赖的组织对葡萄糖的利用，如脑、血细胞、肾髄质、肠道、皮肤等。二甲双胍3．抑制肝糖原异生作用，降低肝糖输出。(FBG下降20%-30%)；4．抑制肠壁细胞摄取葡萄糖，5．抑制胆固醇的生物合成和贮存，降低血甘油三酯、总胆固醇水平。与胰岛素作用不同，本品无促进脂肪合成作用、对正常人无明显降血糖作用，对II型糖尿病单独应用时一般不引起低血糖。Toxiceffectsofmetformin二甲双胍结构稳定，几乎不与白蛋白结合。主要以原形经肾脏排泄，血中二甲双胍浓度主要取决于肾功能状态。肾功能不全为禁忌症男性：血肌酐水平≥1.5mg/dl（133umol/L）女性：血肌酐水平≥1.4mg/dl（124umol/L）DiagnosesoralintakeACEI、NSAIDSRenalfailurelacticacidosispancreatitisMetforminaccumulationThankyouverymuch!