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Çàãàäî÷íûé ïàöèåíò
Ïàöèåíò 73 ëåò ïîñòóïèë ñ âõîäíûì äèàãíîçîì ÎÍÌÊ â êîìå. Íàéäåí ðîäñòâåííèêàìè áåç ñîçíàíèÿ â ñâîåé êâàðòèðå. Íà ëèöå è ðóêàõ - êðîâîïîäòåêè, âåðîÿòíî, âñëåäñòâèå ïàäåíèÿ. Ïðîëåæàë òàê, âåðîÿòíî, îêîëî ñóòîê. Ïî äàííûì ÌÐÒ (2 ðàçà) ÎÍÌÊ íåò. Âûñêàçàíî ïðåäïîëîæåíèå îá îòðàâëåíèè áåíçîäèàçåïèíàìè. Ââåäåí àíåêñàò - ïàöèåíò ïðèøåë â ñîçíàíèå. Íî ïî ïðåêðàùåíèè äåéñòâèÿ àíåêñàòà ñíîâà âïàë â êîìó. Óäèâëÿåò ñëåäóþùåå: óæå ïðîøëî áîëåå íåäåëè ñ ìîìåíòà ïðåäïîëàãàåìîãî îòðàâëåíèÿ. Òåì íå ìåíåå áåç èíôóçèè àíåêñàòà ïàöèåíò ãðóçèòñÿ äî êîìû 7 áàëëîâ. Íà ôîíå àíåêñàòà - ðàçãîâàðèâàë (ïðàâäà îäíîñëîæíî) ñ ïñèõèàòðîì. Ñåé÷àñ ïðîäîëæàåòñÿ èíôóçèÿ 0,2 ìã/÷àñ.  ëèêâîðå - íè÷åãî.  àíàëèçå êðîâè íåáîëüøîé ëåéêîöèòîç (âåðîÿòíî, ìî÷åâàÿ èíôåêöèÿ), ãèïîêàëèåìèÿ - 2,7-2,9, ãèïîêàëüöèåìèÿ - 0,6-0,7 èîíèçèðîâàííûé, ÊÔÊ-äî 7800!!!. Îñòàëüíîå - â íîðìå. Ùèòîâèäíàÿ æåëåçà óäàëåíà 100 ëåò íàçàä, ïüåò ë-òèðîêñèí, ãîðìîíû â íîðìå. Ãîä íàçàä îáñëåäîâàí - êàëüöèé, ïàðàòãîðìîí - â íîðìå.
Áåíçîäèàçåïèíû â êðîâè è ìî÷å ñåé÷àñ íå îïðåäåëÿþòñÿ. Èçâèíèòå çà íåêîòîðóþ ñóìáóðíîñòü èçëîæåíèÿ. Ìû â äèàãíîñòè÷åñêîì òóïèêå. |
#2
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full electrolytes, anion gap, serum osmolarity if avail
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#3
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îñîáåííî èíòåðåñóåò íàòðèé, ôîñôàò è áèêàðáîíàò, à òàêæå êðåàòèíèí. Ñïèñîê ïðåïàðàòîâ, âêëþ÷àÿ åïèçîäè÷åñêè ïðèíèìàåìûå, âêëþ÷àÿ îáåçáîëèâàþøèå è ñðåäñòâà îò çàïîðîâ.
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#4
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ÝÝÃ, ãàçû êðîâè? Òèàìèí äàâàëè?
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#5
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Êñòàòè, ÿ òóò ñëåãêà âñòðÿíó.
Èíôóçèÿ àíåêñàòà ïðåêðàùåíà â÷åðà ~ â 19-00. Ïàöèåíò íà óòðî ñåãîäíÿøíåãî äíÿ áûë â ñîçíàíèè, êîíòàêòåí (õîòÿ áîëüøóþ ÷àñòü âðåìåíè "äðåìëåò"). Òàê ÷òî íà 11 ñóòêè ïîñëå ïðåäïîëàãàåìîãî îòðàâëåíèÿ äåéñòâèå ôåíàçåïàìà, ïîõîæå, íàêîíåö-òî çàêàí÷èâàåòñÿ... |
#6
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Öèòàòà:
Èëè ,íàïðèìåð, îøèáêà ëàáîðàòîðèè â îïðåäåëåíèè ÒÒà â ñî÷åòàíèè ñ ïðåêðàùåíèåì ïðèåìà ïàöèåíòîì òèðîêñèíà äîìà. Ïðè ãèèïîòåðèîçå è ÊÔÊ ïîâûøàåòñÿ è ãèïîêàëèå-êàëüöèåìèÿ ìîæåò áûòü.  îáùåì íå âñå òàê îäíîçíà÷íî.
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Êîãäà çíàåøü ïî÷åìó íåëüçÿ, òî óæå ìîæíî (ñ) Ñ óâàæåíèåì, Ãóñåéíîâ Òèìóð Þñóôîâè÷ Ñàéò dr-timur.ru |
#7
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Ìîæíî ôàíòàçèðîâàòü, íî âðÿä ëè ïðî ãèïîêîìó.. Ãèïîòèðåîèäíàÿ êîìà - î÷åíü ïîçäíåå îñëîæíåíèå ïðèìåðíî ñ 80% ëåòàëüíîñòüþ, ïåðåä êîòîðûì äëèòåëüíî ñóùåñòâóåò ÿâíûé è ãðóáûé ãèïîòèðåîç. Âèä ó òàêèõ áîëüíûõ âåñüìà õàðàêòåðíûé, à ëå÷åíèå ñîñòîèò íå â àíåêñàòå. Äà è òàêóþ îøèáêó ëàáîðàòîðèè (ÒÒà 1 âìåñòî ÒÒà 100) òðóäíî ñåáå ïðåäñòàâèòü..
Íî, êîíå÷íî, ïðè ïîñòóïëåíèè ïîñìîòðåòü ÒÒà è ñâÒ4 ñòîèëî.
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Àííà, âðà÷-ýíäîêðèíîëîã Âîðîíåæ, êëèíèêà Íåïëàöåáî |
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#8
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Öèòàòà:
Íà ôîíå ãèïîêàëèåìèè ïå÷åíî÷íàÿ ýíöåôàëîïàòèÿ óñóãóáëÿåòñÿ è ðàáäîìèîëèç ñ áîëüøåé âåðîÿòíîñòüþ ðàçîâüåòñÿ (ïëþñ êîìïðåññèÿ ìûøö/ïðîëåæíè). Íà ôîíå ðàáäîìèîëèçà è ãèïîêàëüöèåìèÿ áóäåò. |
#9
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Àíòîí, íèêàêèõ ãðóáûõ îòêëîíåíèé â ýòèõ ïîêàçàòåëÿõ íå áûëî.
Êîñòü, à çà÷åì ÝÝÃ? Ãàçû êðîâè - ìåòàáîëè÷åñêèé àëêàëîç â áîëüøèíñòâå ïðîá. Óâàæàåìûé Òèìóð! Ãèïîòèðåîç ìîæíî ñìåëî èñêëþ÷èòü. È â íàøåì àíàëèçå è â àíàëèçàõ ãîäè÷íîé äàâíîñòè âñå íîðìàëüíî. Äà è ðîäñòâåííèêè èçìåíåíèé íå çàìå÷àëè, â îáùåì âñå ðàçâèëîñü äîâîëüíî âíåçàïíî. Ïå÷åíî÷íîé ýíöåôàëîïàòèè íåò. Ïðîëåæíåé òîæå. Êñòàòè, ì. á. êòî çíàåò. Àíåêñàò ïðè äðóãèõ âèäàõ êîì (êðîìå ïå÷åíî÷íîé) ìîæåò ïîìî÷ü? |
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Íå îáÿçàòåëüíî èìåòü ïðîëåæíè. Äëÿ ðàáäîìèîëèçà äîñòàòî÷íî ãèïîêàëèåìèè + êîìïðåññèè ìûøö (ïðîëåæàâ ñóòêè íà ïîëó). À ïå÷åíî÷íóþ ýíöåôàëîïàòèþ, ÈÌÕÎ, èíîãäà òîëüêî ìåòîäîì èñêëþ÷åíèÿ óñòàíàâëèâàþò. Àíòèáèòèêè íå íàçíà÷àëè? Áûâàåò äîñòàòî÷íî "ïðîñòåðèëèçîâàòü" êèøå÷íèê, ÷òîáû áîëüíîé ïðèøåë â ñîçíàíèå.
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#11
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#12
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#13
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Öèòàòà:
Ç.Û. À õóæå âñåãî æåëóäî÷íîå êðîâîòå÷åíèå. Êðîâü â êèøå÷íèêå ó òàêèõ áîëüíûõ ìãíîâåííî óñóãóáëÿåò ýíöåôàëîïàòèþ. |
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Öèòàòà:
Öèòàòà:
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 êà÷åñòâå ýêçîòèêè:
Brain. 1998 Jan;121 ( Pt 1):127-33. Endozepine stupor. Recurring stupor linked to endozepine-4 accumulation. Lugaresi E, Montagna P, Tinuper P, Plazzi G, Gallassi R, Wang TC, Markey SP, Rothstein JD. Institute of Clinical Neurology, University of Bologna, Italy. Abstract Recurring stupor can be caused by repeated metabolic, toxic or structural brain disturbances. Recently, cases of recurring stupor, with fast EEG activity were shown to display increased endogenous benzodiazepine-like activity during the episodes of stupor. Patients with recurring stupor underwent extensive metabolic and toxicologic screening, EEG and brain imaging. Endozepines and exogenously administered benzodiazepines were assayed in plasma and CSF by means of mass spectrometry. Flumazenil, a benzodiazepine antagonist was administered and the behavioural and EEG responses monitored. Treatment with oral flumazenil was attempted in selected cases. Twenty patients were found with recurring stupor. Episodes had begun between ages 18 and 67 years, and in nine patients, had disappeared spontaneously after 4-6 years with symptoms. Stupor lasted hours or days. Onset of the episodes and frequency were unpredictable. Patients were normal between attacks. Stupor was characterized by initial drowsiness, staggering and behavioural changes, followed by deep sleep and spontaneous recovery with post-ictal amnesia. Biochemical screening and brain imaging were always normal. Ictal EEG showed fast background activity, and flumazenil transiently awoke the patients and normalized the EEG. In the nine cases examined, endozepine-4 levels were increased during the stupor. Oral flumazenil reduced the frequency of the attacks in three of these nine patients. Recurring episodes of stupor may be due to increased endozepine-4. We propose the term 'endozepine stupor' for such episodes. Endozepine-4 is an endogenous ligand for the benzodiazepine recognition site at the GABAA receptor, with unknown molecular structure. Íàëè÷èå ïîðòîñèñòåìíîãî øóíòà (òîæå êàê áû ýêçîòèêà) ñ ðàçâèòèåì ïå÷¸íî÷íîé ýíöåôàëîïàòèè áåç íàëè÷èÿ çàáîëåâàíèÿ ïå÷åíè? |