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When past is prologue

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MikaMaebashi

那須南病院のCPS勉強会の資料です。問題があればご連絡ください。

Health & Medicine
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When Past Is Prologue 36歳男性 下腿浮腫、進行性の倦怠感、労作時呼吸困難 N Engl Med 2009;360:1016-22
これまで • 慢性下痢、腹痛:ガストリノーマ • 難治性気管支喘息:好酸球性多発血管炎性肉芽腫症 • 高Ca血症、貧血、腎障害、骨病変:サルコイドーシス • 疲労感、遂行障害：PRES • 不明熱：血管内リンパ腫 • 頭痛、発熱後の発疹：発疹チフス • 肺胞出血、糸球体腎炎：Goodpasture’s症候群 • MVP、頭痛：IE • 慢性下痢：VIPoma • 出血傾向：多発性骨髄腫による後天性von Willebrand 病 • 腹部膨満感：好酸球性胃腸症 • 妊婦の突然発症の両側頭部頭痛と息切れ：褐色細胞腫 • 難治性VT：心サルコイドーシス • 突然の霞目、複視：好酸球増多症候群に伴う心内膜炎 • ４週間続く倦怠感：強皮症腎クリーぜ • 全身浮腫：心アミロイドーシス
前回の復習 73歳男性 全身浮腫 心アミロイドーシスはALとAAどちらが多いか？ →ALは5割の患者、AAでは5%の患者にアミロイドーシスが起こ る アミロイドーシスに対する心筋生検の特異度は？ →？ 透析アミロイドーシスでも心疾患が出るか？ →起こることもありそう
36歳男性 下腿浮腫、倦怠感、労作時呼吸困難 2週間前からの下腿浮腫、進行性の倦怠感、労作時呼吸困難 既往:10ヶ月前に屋根から落ち、頭蓋底骨折を含む多数の頭蓋骨 骨折をし、頭蓋骨形成術を受けた リハビリをして後遺症はなし 8ヶ月前に脂質異常症を指摘され、総コレステロール383、 LDL236、TG461、HDL56だった 血糖、Alb、肝機能、腎機能に異常なし アトルバスタチンが開始されたが、筋痛とCK794と上昇あり中断 ALTは正常
36歳男性 下腿浮腫、倦怠感、労作時呼吸困難 1ヶ月後から筋痛は良くなっていたが、CK1200とさらに上昇を 認めた TSH0.32（正常0.3−5.0）、抗核抗体は陰性 リウマチ科の予約がされていたが、その前に上記症状で受診 貧血に対して鉄剤と、緩下剤を処方されていた 家族歴なし、喫煙なし、アルコールなし、違法薬物なし
36歳男性 下腿浮腫、倦怠感、労作時呼吸困難 慢性的に病弱な感じ、少し息苦しそう BT36、BP80/60、PR85、RR22、SpO2 91%(RA) 頸静脈圧は14cm 両側上半分の肺野で雑音聴取 肺底部では打診で濁音 心尖拍動は触れず 心音は遠く、少しのⅢ音・ギャロップ聴取するが、雑音や摩擦音無し 肝脾腫なし、腹水無し 四肢は冷たく、両下腿に1+の末梢動脈の拍動と3+の圧痕性浮腫あり 神経学的検査では以前からあるという左上下肢の軽度の虚弱を認めた
WBC6800、Hb13.0、plt15万 Na129、K3.4、BUN10、Cre1.6（もともと0.8−1.2） AST109、ALT61、CK1110、CK-MB12、tropI検出されず 赤沈8 36歳男性 下腿浮腫、倦怠感、労作時呼吸困難
WBC6800、Hb13.0、plt15万 Na129、K3.4、BUN10、Cre1.6（もともと0.8−1.2） AST109、ALT61、CK1110、CK-MB12、tropI検出されず 赤沈8 ECG：洞調律、四肢の低電位、QT延長、poor R progression、 びまん性のT波平坦化 Xp：心拡大あり、肺うっ血あり、両側胸水 心エコー：中等量の心嚢水貯留、全体的にhypokinetic、左室拡 大、EFは10−15% 36歳男性 下腿浮腫、倦怠感、労作時呼吸困難
WBC6800、Hb13.0、plt15万 Na129、K3.4、BUN10、Cre1.6（もともと0.8−1.2） AST109、ALT61、CK1110、CK-MB12、tropI検出されず 赤沈8 ECG：洞調律、四肢の低電位、QT延長、poor R progression、 びまん性のT波平坦化 Xp：心拡大あり、肺うっ血あり、両側胸水 心エコー：中等量の心嚢水貯留、全体的にhypokinetic、左室拡 大、EFは10−15% 36歳男性 下腿浮腫、倦怠感、労作時呼吸困難
心カテ：冠動脈に異常無し 右心カテで右房圧15mmHg、右室圧43/14mmHg、肺動脈圧 40/28mmHg、平均の肺動脈楔入圧32mmHg、心係数1.8 IABP挿入、ドブタミンとドパミン開始 多形性、単形性VTあり、複数回除細動を施行された 36歳男性 下腿浮腫、倦怠感、労作時呼吸困難
本症例は心係数1.8 PCWP32 病気がみえる 循環器内科より引用
HIV、ライム病、A型肝炎、B型肝炎、C型肝炎、EBウイルス、CMV、 コクサッキーウイルス 陰性 免疫電気泳動は正常（ALアミロイドーシス除外目的） 鉄動態も正常 抗核抗体陰性 筋電図、神経伝導検査は異常無し 繰り返し行われたTSHは0.21、fT4は低値（0.3）、fT3も検出範囲以 下 鑑別診断は？ 36歳男性 下腿浮腫、倦怠感、労作時呼吸困難

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When past is prologue

Editor's Notes

  1. 甲状腺機能低下症、心筋梗塞、DVT、脂肪塞栓、
  2. 甲状腺機能低下症、心筋梗塞、DVT、脂肪塞栓、心不全、
  3. 甲状腺機能低下症、心筋梗塞、DVT、脂肪塞栓、心不全、ウイルス性心筋炎、副腎不全、ミトコンドリア異常症、
  4. 甲状腺機能低下症、心筋梗塞、DVT、脂肪塞栓、心不全、ウイルス性心筋炎、副腎不全、ミトコンドリア異常症、 low voltage、真の雨水貯留
  5. 甲状腺機能低下症、心筋梗塞、DVT、脂肪塞栓、心不全、ウイルス性心筋炎、副腎不全、ミトコンドリア異常症、 low voltage、真の雨水貯留 コードなに？
  6. 甲状腺機能低下症、心筋梗塞、DVT、脂肪塞栓、心不全、ウイルス性心筋炎、副腎不全、ミトコンドリア異常症、結核、悪性腫瘍、先天性心疾患、悪性リンパ腫 low voltage、心嚢水貯留 コードなに？
  7. 甲状腺機能低下症、心筋梗塞、DVT、脂肪塞栓、心不全、ウイルス性心筋炎、副腎不全、ミトコンドリア異常症、たこつぼ low voltage→心嚢水貯留 コードなに？
  8. 肺動脈圧正常値30/2−8、平均20以上だとPH 心係数は2.2で正常 フォレスター分類
  9. 甲状腺機能低下症、心筋梗塞、DVT、脂肪塞栓、心不全、ウイルス性心筋炎、副腎不全、ミトコンドリア異常症、たこつぼ、DCM low voltage→心嚢水貯留 コードなに？
  10. 中枢性甲状腺機能低下症、腫瘍？ 心筋梗塞、DVT、脂肪塞栓、心不全、ウイルス性心筋炎、副腎不全、ミトコンドリア異常症、たこつぼ low voltage→心嚢水貯留 コードなに？