泌尿课件：肾内科-临床病例解析完整版.pptxVIP

肾内科-临床病例解析;简要病例;接诊该患者后首先需要考虑的临床问题是什么？; 高钾血症 有没有误差？;需要行哪些紧急处理以减少高钾血症致心律失常的风险？;;这份心电图结果提供什么信息？;根据心电图结果需做哪些处理？;钾从细胞内转移至血液 Movement of K + out of cells 1.酸中毒：H+转入细胞内，K +移出 Acidosis: H+ transported into cells at the expense of K+ efflux 2.细胞死亡，细胞内钾释放如：横纹肌溶解、溶瘤综合征 Cell death causes release of K+, e.g. rhabdomyolysis, tumour lysis syndrome 肾脏排钾减少（远曲小管） Failure of K + excretion by kidney (distal convoluted tubules） 3.肾衰竭 Renal failure 4.醛固酮不足 Aldosterone deficiency 5.保钾利尿剂的使用，如螺内酯 Potassium-sparing diuretics 6.ACEI、ARB 钾摄入过多 Excess intake of K+ from gut;;高钾血症的处理; 该患者的静脉血气分析示血钾7.7mmol/L，经过静脉注射葡萄糖酸钙及高糖胰岛素后，复查患者的血钾5.9mmol/L，心电图的高钾改变消失，至此，该患者的高钾血症的紧急处理已完成，现在，我们可以详细询问该患者的病史。 Venous blood gas sample showed a potassium of 7.7 mmol/L. Following the calcium gluconate and insulin-dextrose, a repeat measurement shows that his K+ is now 5.9 mmol/L. His ECG changes have resolved. Now that you have tackled the immediate urgent issue of his potassium, you are able to get some more history from the patient.;详细的病史询问需要着重了解哪些内容？;肾功能不全是急性还是慢性？ Is this acute or chronic renal failure? 肾功能不全的原因？肾前性（低血压/低血容量），肾性还是肾后性（梗阻性）因素？ Why does he have renal failure? A pre-renal (hypotension/ Hypovolaemia), renal or post - renal (obstruction) cause? 患者是否有提示肾损害的任何症状？ Does he have any symptoms as a result of his renal impairment?;本例患者是急性还是慢性肾衰，或者慢性肾衰合并急性肾衰？Is this acute or chronic renal failure, or perhapsacute-on-chronic renal failure?;肾衰的原因是什么？;肾前性因素？近期是否有呕吐、腹泻等导致血容量减少、低血压等相关疾病 Pre-renal cause? Has he had any recent illnesses which might cause volume depletion or hypotension, e.g. vomiting, diarrhoea? 家族史(Family history)：遗传性疾病(inherited causes )导致CKD，例如APKD、Alport综合征、FSGS，多见于年轻人 药物史(Drug history)：引起CKD（NSAID、CsA、锂制剂）；急性间质性肾炎（PPI、抗生素） 吸烟史(Smoking history)：患者是否吸烟（与动脉粥样硬化有关）；患者是否酗酒（慢性肝脏疾病、肝衰竭）;Cause of AKI;患者是否已出现肾衰竭并发症的相关症状？;哪些临床征象提示该患者需要进行急诊透析？; 体检：无血容量不足体征，脉搏90次/分，血压160/90 mmHg。心脏听诊无心包摩檫音，但双肺底可闻及吸气末湿罗音。腹部检查，脐下2cm似可触及患者的膀胱。直肠指检可触及患者前列腺明显增大，尚光滑。患者双踝部轻度水肿。 On examin