免疫抑制劑臺(tái)大醫(yī)院課件

CasereportApatientofBehcet’ssyndrome指導(dǎo)老師:賴聖如老師實(shí)習(xí)生:黃孜立CasereportApatientofBehcName:陳XXAge:47Gender:maleAdmissiondate:8/6forbloodystool病房:13C→4FI→13CBackgroundBriefhistoryBehcet’ssyndromeDiabetesmellitusOralulcerGastrointestinalbleedingName:陳XXBackgroundBriefhistor3Diagnosis入院診斷1.因Behcet‘sdisease引起口腔、末端迴腸和結(jié)腸潰瘍

，合併出血的情形。2.胃潰瘍和GERD主訴Informant:

patienthimselfBloodystoolfor3days3Diagnosis入院診斷口腔潰瘍、生殖器潰瘍和眼色素膜炎為特徵的慢性、復(fù)發(fā)性癥候群白塞病的發(fā)病機(jī)制尚未完全清楚，多數(shù)學(xué)者認(rèn)為本病為一自體免疫性疾病。藥物治療1.類固醇2.免疫抑制劑3.免疫調(diào)節(jié)劑4.白血球細(xì)胞功能抑制劑5.非醇類抗炎藥物(NSAID)Behcet’ssyndrome口腔潰瘍、生殖器潰瘍和眼色素膜炎為特徵的慢性、復(fù)發(fā)性癥候群B5GoalofbloodsugarforDM血糖控制目標(biāo)糖尿病控制原則空腹血糖：70-130mg/dl飯後兩小時(shí)血糖：小於180mg/dl糖化血色素：

<7%,最好<6.5%飲食運(yùn)動(dòng)藥物5GoalofbloodsugarforDM血糖6Nutritioncare6Nutritioncare72012/8/16SOAP1Subjective醫(yī)師照會(huì)營養(yǎng)師,血糖約在300mg/dl病人敘述平時(shí)飲食習(xí)慣：早餐：吐司2片+果醬+大燕麥片午餐：(外食)麵或便當(dāng)1個(gè)晚餐：(外食)自助餐,菜會(huì)比飯多平日飲食習(xí)慣:很喜歡吃水果,2份/天以上愛吃雜糧五穀飯多外食,每週會(huì)有一到二個(gè)晚上會(huì)自己煮不喜歡吃甜點(diǎn)優(yōu)酪乳2-3次/週經(jīng)常體重=75kg72012/8/16SOAP1SubjectiveObjectiveHt:

177cm,BW:63.5kg(IBW:68.9kg)→BMI:20.28Estimatedenergyneed:68.9x30=1950kcal/dayLabdataBloodBiochemistry8/118/16Alb(g/dL)3.1HbA1c8.4CRP2.54Medicine

Metformin1tab

Mgo2tabbid

Folicacid1tab

Solu-medrolDiet:普通飲食正餐+低油Objective8Estimatedenergynee9Bloodsugar130

mg/dl70mg/dl9Bloodsugar130mg/dl10Assessment

1.Bodyweight:正常

2.malnutrition

3.糖尿病飲食知識(shí)缺乏

4.學(xué)習(xí)態(tài)度佳5.血糖控制不佳(200-300mg/dl)Plan糖尿病飲食衛(wèi)教醣類代換方式建議少量多餐，水果可當(dāng)成點(diǎn)心建議每日六大類食物攝取量更改飲食醫(yī)囑:DM1950kcal/day+低渣+低油10Assessment餐次分配:份數(shù)醣類蛋白質(zhì)脂質(zhì)熱量奶類(低脂)11284120蔬菜3153-75水果230--120主食1421028-980蛋豆魚肉類(低脂)6-4218330油脂7--35315總計(jì)26781571940餐次分配:份數(shù)醣類蛋白質(zhì)脂質(zhì)熱量奶類(低脂)11284120腹痛,發(fā)燒,血壓=91/44mmHg轉(zhuǎn)入ICU病房:4FIDiagnosis:升結(jié)腸穿孔OperativeMethod:Laparoscopicabscessdrainage+ileostomy點(diǎn)滴:clinimix1500ml8/22轉(zhuǎn)回普通病房13C8/20ICU腹痛,發(fā)燒,血壓=91/44mmHg轉(zhuǎn)入ICU8/20IBloodBiochemistry8/168/188/208/21Alb(g/dL)3.13.12.5BUN(mg/dl)14.617.614.8Creatinine(mg/dl)0.90.90.8Na(mmol/dl)134136133132.7K(mmol/dl)4.35.13.8Ca(mmol/dl)2.15ObjectiveBloodBiochemistry8/168/188/20MedicineInsulinregular(humulin)8UscHartmann’sinjectionBloodsugar130

mg/dl70mg/dlMedicineBloodsugar130mg/dl152012/8/23SOAP2Subjective訪視術(shù)後NPO打點(diǎn)滴直到今天早上,前天晚上有吃一碗小碗稀飯自覺肌肉力氣小早上有排便

肚子痛,排便不順,喉嚨痛一到二晚上會(huì)自己煮會(huì)吃完醫(yī)院餐點(diǎn)的80%詢問:可不可以喝葡勝納?152012/8/23SOAP2SubjectiveObjectiveHt:

177cm,BW:64kg(IBW:68.9kg)→BMI:20.416Estimatedenergyneed:1950kcal/dayLabdataMedicine

InsulinNPHregular

BloodBiochemistry8/22Na(mmol/dl)137.7K(mmol/dl)3.82Diet:低油飲食Objective16Estimatedenergyne17Assessment1.Bodyweight:正常

2.malnutrition

3.腸胃道術(shù)後飲食狀況OK

PlanKeepcurrentdiet持續(xù)觀察血糖值,術(shù)後營養(yǎng)回答營養(yǎng)相關(guān)問題:葡勝納所含油脂量比例較高(49%),目前低油飲食,並不建議使用

17Assessment182012/8/30SOAP3Subjective訪視喝奶製品會(huì)脹氣胃口OK,會(huì)吃完醫(yī)院餐下午會(huì)喝自己準(zhǔn)備的鱸魚湯睡前喝半罐葡勝納182012/8/30SOAP3Subjective19

LabdataMedicine

Insulin短效(過高時(shí)打)

Metformin1tabqdpcDiet:低油飲食,不要脫脂奶BloodBiochemistry8/27Alb(g/dL)2.8BUN(mg/dl)19.2Creatinine(mg/dl)0.7Na(mmol/dl)140K(mmol/dl)4CRP2.75ObjectiveHt:

177cm,BW:60kg(IBW:68.9kg)→BMI:19Estimatedenergyneed:1950kcal/day19Lab20Bloodsugar130

mg/dl70mg/dl20Bloodsugar130mg/dl21

Assessment

非刻意體重減輕(64-60=4公斤/週)Malnutrition血糖控制不穩(wěn)定(80-300mg/dl)

Plan更改飲食為DM

2100

kcal+低油飲食可將高蛋白粉末做為點(diǎn)心高低血糖處理原則，要準(zhǔn)備糖果21Assessment222012/9/7SOAP4Subjective訪視今日做電腦斷層→NPO由造口排便,覺得消化不好,會(huì)看到菜?；蚶w維排出再度有血便的情形下午喝葡勝納半罐,因?yàn)橥砩虾葧?huì)脹氣詢問:可以食用倍力素嗎?222012/9/7SOAP4SubjectiveObjectiveHt:

177cm,BW:58.5kg(IBW:68.9kg)→BMI:1823BloodBiochemistry8/319/29/5Alb(g/dL)2.62.9Na(mmol/dl)140K(mmol/dl)3.9CRP2.20.82Medicine

Metformin1tabqdpcDiet:DM2100kcal

+晚點(diǎn)葡勝納+低油Estimatedenergyneed:68.9x30=1950kcal/dayObjective23BloodBiochemistry824Bloodsugar130

mg/dl70mg/dl24Bloodsugar130mg/dl25

Assessment

非刻意體重減輕(60-58.5=0.5公斤/週)Bodyweight:過輕(BMI=18)Malnutrition吸收狀況不佳血糖控制:OK，有改善

Plan更改飲食為DM

2100

kcal+低油飲食可補(bǔ)充高蛋白粉末或增加營養(yǎng)品密度回答營養(yǎng)相關(guān)問題:倍力素1-2瓶/天是可接受的建議可以使用元素飲食,提供創(chuàng)快復(fù)樣品給病人試喝少量多餐25Assessment262012/9/13SOAP5Subjective訪視:飲用創(chuàng)快復(fù)後接受程度?自覺消化不好,體重不斷下降可以適應(yīng)創(chuàng)快復(fù),感覺有吸收自行補(bǔ)充立攝適鈞康零脂2罐/天下午會(huì)自行補(bǔ)充排骨魚湯2次/週取消葡勝納,因?yàn)槌阅伭?62012/9/13SOAP5SubjectiveObjectiveHt:

177cm,BW:58.5kg(IBW:68.9kg)→BMI:1827LabdataBloodBiochemistry9/59/10Alb(g/dL)2.93.2CRP0.821.49Medicine

Metformin1tabqdpcDiet:DM2100kcal

+不要午晚點(diǎn)Estimatedenergyneed:68.9x30=1950kcal/dayObjective27LabdataBloodBioch28Bloodsugar130

mg/dl70mg/dl28Bloodsugar130mg/dl29

Assessment

非刻意體重減輕(60-58.5=0.5公斤/週)Bodyweight:過輕(BMI=18)Malnutrition血糖控制不佳(150-200mg/dl)

Plan晚點(diǎn)食用創(chuàng)快復(fù)1包29Assessment302012/9/20SOAP6Subjective今日出院,出院前訪視自覺沒有元?dú)?吃創(chuàng)快復(fù)有比較好體重下降15公斤,覺得需要好好補(bǔ)身體下周四(9/27)內(nèi)科門診回診302012/9/20SOAP6SubjectiveObjectiveHt:

177cm,BW:55.5kg(IBW:68.9kg)→BMI:1731LabdataBloodBiochemistry9/109/139/17Alb(g/dL)3.23.63.5CRP1.49Medicine

Glucophage1tabqdpcDiet:DM2100kcal

+不要午晚點(diǎn)

Estimatedenergyneed:68.9x30=1950kcal/dayObjective31LabdataBloodBiochBloodsugar130

mg/dl70mg/dlBloodsugar130mg/dl33

Assessment

非刻意體重減輕(減少3公斤/週)體重過輕(BMI=17)血糖控制不佳(180-200mg/dl)

Plan解釋創(chuàng)快復(fù)熱量(394.7kcal/包)和醣量(66%,49.5g)皆高，需注意會(huì)不會(huì)使血糖飆高指導(dǎo)出院後紀(jì)錄血糖、飲食繼續(xù)食用糖尿病飲食33AssessmentDM2100+創(chuàng)快復(fù)DM2100DM1950低油飲食SummaryBMIDMDMDM低油飲食SummaryBMI130

mg/dl70mg/dl130mg/dl36因Behcet‘sdisease引起口腔、末端迴腸和結(jié)腸潰瘍

，合併結(jié)腸穿孔及膿腫形成。胃潰瘍和GERDDischargeDiagnosis9/24電訪病患表示回家後沒有做飲食紀(jì)錄沒有血糖機(jī),無法記錄血糖,但下週會(huì)購買腿部肌肉無力,活動(dòng)一下子就會(huì)累1.水果2份/天2.血糖及飲食記錄的重要性36因Behcet‘sdisease引起口腔、末端迴腸和結(jié)體重沒有增加,但並沒有再減少仍舊覺得消化不佳,特別是蔬菜Diethistory早)南瓜+燕麥粥午)牛肉或魚肉1.5個(gè)手+0.5碗飯+菜少量午點(diǎn))水果1份或創(chuàng)快復(fù)1罐或立攝氏清流1罐晚)同午餐運(yùn)動(dòng))走路,但腳容易沒力尚未購買血糖機(jī),下週會(huì)買9/27內(nèi)科門診回診體重沒有增加,但並沒有再減少9/27內(nèi)科門診回診Assessment熱量攝取足夠Plan多活動(dòng)建議觀察1-2週,若是體重仍舊沒有增加,可掛營養(yǎng)門診諮詢AssessmentThankyouverymuchforlistening!39ThankyouverymuchforlistenCasereportApatientofBehcet’ssyndrome指導(dǎo)老師:賴聖如老師實(shí)習(xí)生:黃孜立CasereportApatientofBehcName:陳XXAge:47Gender:maleAdmissiondate:8/6forbloodystool病房:13C→4FI→13CBackgroundBriefhistoryBehcet’ssyndromeDiabetesmellitusOralulcerGastrointestinalbleedingName:陳XXBackgroundBriefhistor42Diagnosis入院診斷1.因Behcet‘sdisease引起口腔、末端迴腸和結(jié)腸潰瘍

，合併出血的情形。2.胃潰瘍和GERD主訴Informant:

patienthimselfBloodystoolfor3days3Diagnosis入院診斷口腔潰瘍、生殖器潰瘍和眼色素膜炎為特徵的慢性、復(fù)發(fā)性癥候群白塞病的發(fā)病機(jī)制尚未完全清楚，多數(shù)學(xué)者認(rèn)為本病為一自體免疫性疾病。藥物治療1.類固醇2.免疫抑制劑3.免疫調(diào)節(jié)劑4.白血球細(xì)胞功能抑制劑5.非醇類抗炎藥物(NSAID)Behcet’ssyndrome口腔潰瘍、生殖器潰瘍和眼色素膜炎為特徵的慢性、復(fù)發(fā)性癥候群B44GoalofbloodsugarforDM血糖控制目標(biāo)糖尿病控制原則空腹血糖：70-130mg/dl飯後兩小時(shí)血糖：小於180mg/dl糖化血色素：

<7%,最好<6.5%飲食運(yùn)動(dòng)藥物5GoalofbloodsugarforDM血糖45Nutritioncare6Nutritioncare462012/8/16SOAP1Subjective醫(yī)師照會(huì)營養(yǎng)師,血糖約在300mg/dl病人敘述平時(shí)飲食習(xí)慣：早餐：吐司2片+果醬+大燕麥片午餐：(外食)麵或便當(dāng)1個(gè)晚餐：(外食)自助餐,菜會(huì)比飯多平日飲食習(xí)慣:很喜歡吃水果,2份/天以上愛吃雜糧五穀飯多外食,每週會(huì)有一到二個(gè)晚上會(huì)自己煮不喜歡吃甜點(diǎn)優(yōu)酪乳2-3次/週經(jīng)常體重=75kg72012/8/16SOAP1SubjectiveObjectiveHt:

177cm,BW:63.5kg(IBW:68.9kg)→BMI:20.247Estimatedenergyneed:68.9x30=1950kcal/dayLabdataBloodBiochemistry8/118/16Alb(g/dL)3.1HbA1c8.4CRP2.54Medicine

Metformin1tab

Mgo2tabbid

Folicacid1tab

Solu-medrolDiet:普通飲食正餐+低油Objective8Estimatedenergynee48Bloodsugar130

mg/dl70mg/dl9Bloodsugar130mg/dl49Assessment

1.Bodyweight:正常

2.malnutrition

3.糖尿病飲食知識(shí)缺乏

4.學(xué)習(xí)態(tài)度佳5.血糖控制不佳(200-300mg/dl)Plan糖尿病飲食衛(wèi)教醣類代換方式建議少量多餐，水果可當(dāng)成點(diǎn)心建議每日六大類食物攝取量更改飲食醫(yī)囑:DM1950kcal/day+低渣+低油10Assessment餐次分配:份數(shù)醣類蛋白質(zhì)脂質(zhì)熱量奶類(低脂)11284120蔬菜3153-75水果230--120主食1421028-980蛋豆魚肉類(低脂)6-4218330油脂7--35315總計(jì)26781571940餐次分配:份數(shù)醣類蛋白質(zhì)脂質(zhì)熱量奶類(低脂)11284120腹痛,發(fā)燒,血壓=91/44mmHg轉(zhuǎn)入ICU病房:4FIDiagnosis:升結(jié)腸穿孔OperativeMethod:Laparoscopicabscessdrainage+ileostomy點(diǎn)滴:clinimix1500ml8/22轉(zhuǎn)回普通病房13C8/20ICU腹痛,發(fā)燒,血壓=91/44mmHg轉(zhuǎn)入ICU8/20IBloodBiochemistry8/168/188/208/21Alb(g/dL)3.13.12.5BUN(mg/dl)14.617.614.8Creatinine(mg/dl)0.90.90.8Na(mmol/dl)134136133132.7K(mmol/dl)4.35.13.8Ca(mmol/dl)2.15ObjectiveBloodBiochemistry8/168/188/20MedicineInsulinregular(humulin)8UscHartmann’sinjectionBloodsugar130

mg/dl70mg/dlMedicineBloodsugar130mg/dl542012/8/23SOAP2Subjective訪視術(shù)後NPO打點(diǎn)滴直到今天早上,前天晚上有吃一碗小碗稀飯自覺肌肉力氣小早上有排便

肚子痛,排便不順,喉嚨痛一到二晚上會(huì)自己煮會(huì)吃完醫(yī)院餐點(diǎn)的80%詢問:可不可以喝葡勝納?152012/8/23SOAP2SubjectiveObjectiveHt:

177cm,BW:64kg(IBW:68.9kg)→BMI:20.455Estimatedenergyneed:1950kcal/dayLabdataMedicine

InsulinNPHregular

BloodBiochemistry8/22Na(mmol/dl)137.7K(mmol/dl)3.82Diet:低油飲食Objective16Estimatedenergyne56Assessment1.Bodyweight:正常

2.malnutrition

3.腸胃道術(shù)後飲食狀況OK

PlanKeepcurrentdiet持續(xù)觀察血糖值,術(shù)後營養(yǎng)回答營養(yǎng)相關(guān)問題:葡勝納所含油脂量比例較高(49%),目前低油飲食,並不建議使用

17Assessment572012/8/30SOAP3Subjective訪視喝奶製品會(huì)脹氣胃口OK,會(huì)吃完醫(yī)院餐下午會(huì)喝自己準(zhǔn)備的鱸魚湯睡前喝半罐葡勝納182012/8/30SOAP3Subjective58

LabdataMedicine

Insulin短效(過高時(shí)打)

Metformin1tabqdpcDiet:低油飲食,不要脫脂奶BloodBiochemistry8/27Alb(g/dL)2.8BUN(mg/dl)19.2Creatinine(mg/dl)0.7Na(mmol/dl)140K(mmol/dl)4CRP2.75ObjectiveHt:

177cm,BW:60kg(IBW:68.9kg)→BMI:19Estimatedenergyneed:1950kcal/day19Lab59Bloodsugar130

mg/dl70mg/dl20Bloodsugar130mg/dl60

Assessment

非刻意體重減輕(64-60=4公斤/週)Malnutrition血糖控制不穩(wěn)定(80-300mg/dl)

Plan更改飲食為DM

2100

kcal+低油飲食可將高蛋白粉末做為點(diǎn)心高低血糖處理原則，要準(zhǔn)備糖果21Assessment612012/9/7SOAP4Subjective訪視今日做電腦斷層→NPO由造口排便,覺得消化不好,會(huì)看到菜?；蚶w維排出再度有血便的情形下午喝葡勝納半罐,因?yàn)橥砩虾葧?huì)脹氣詢問:可以食用倍力素嗎?222012/9/7SOAP4SubjectiveObjectiveHt:

177cm,BW:58.5kg(IBW:68.9kg)→BMI:1862BloodBiochemistry8/319/29/5Alb(g/dL)2.62.9Na(mmol/dl)140K(mmol/dl)3.9CRP2.20.82Medicine

Metformin1tabqdpcDiet:DM2100kcal

+晚點(diǎn)葡勝納+低油Estimatedenergyneed:68.9x30=1950kcal/dayObjective23BloodBiochemistry863Bloodsugar130

mg/dl70mg/dl24Bloodsugar130mg/dl64

Assessment

非刻意體重減輕(60-58.5=0.5公斤/週)Bodyweight:過輕(BMI=18)Malnutrition吸收狀況不佳血糖控制:OK，有改善

Plan更改飲食為DM

2100

kcal+低油飲食可補(bǔ)充高蛋白粉末或增加營養(yǎng)品密度回答營養(yǎng)相關(guān)問題:倍力素1-2瓶/天是可接受的建議可以使用元素飲食,提供創(chuàng)快復(fù)樣品給病人試喝少量多餐25Assessment652012/9/13SOAP5Subjective訪視:飲用創(chuàng)快復(fù)後接受程度?自覺消化不好,體重不斷下降可以適應(yīng)創(chuàng)快復(fù),感覺有吸收自行補(bǔ)充立攝適鈞康零脂2罐/天下午會(huì)自行補(bǔ)充排骨魚湯2次/週取消葡勝納,因?yàn)槌阅伭?62012/9/13SOAP5SubjectiveObjectiveHt:

177cm,BW:58.5kg(IBW:68.9kg)→BMI:1866LabdataBloodBiochemistry9/59/10Alb(g/dL)2.93.2CRP0.821.49Medicine

Metformin1tabqdpcDiet:DM2100kcal

+不要午晚點(diǎn)Estimatedenergyneed:68.9x30=1950kcal/dayObjective27LabdataBloodBioch67Bloodsugar130

mg/dl70mg/dl28Bloodsugar130mg/dl68

Assessment

非刻意體重減輕(60-58.5=0.5公斤/週)Bodyweight:過輕(BMI=18)Malnutrition血糖控制不佳(150-200mg/dl)

Plan晚點(diǎn)食用創(chuàng)快復(fù)1包29Assessment692012/9/20