A patient of Behcet's syndrome

1、 A patient of Behcets syndrome指導(dǎo)老師:賴聖如 老師實(shí)習(xí)生:黃孜立Name:陳XXAge:47Gender: maleAdmission date:8/6 for bloody stool病房: 13C4FI 13C1. Behcets syndrome2. Diabetes mellitus3. Oral ulcer4. Gastrointestinal bleeding3入院診斷1. 因Behcets disease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: patient himselfBloody sto

2、ol for 3 days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)5Goal of blood sugar for DM 血糖控制目標(biāo)糖尿病控制原則空腹血糖：70-130 mg/dl 飯後兩小時(shí)血糖：小於180 mg/dl 糖化血色素： 7 %, 最好6.5% 飲食 運(yùn)動(dòng) 藥物 67SubjectiveSubjective醫(yī)師照會(huì)營(yíng)養(yǎng)師,血糖約在300mg/dl1.病人敘述平時(shí)飲食習(xí)慣： 早餐：吐司2片

3、+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2.平日飲食習(xí)慣:1)很喜歡吃水果,2份/天以上2)愛吃雜糧五穀飯3)多外食,每週會(huì)有一到二個(gè)晚上會(huì)自己煮4)不喜歡吃甜點(diǎn)5)優(yōu)酪乳2-3次/週6)經(jīng)常體重=75 kgObjectiveHt: 177cm, BW: 63.5 kg (IBW: 68.9 kg) BMI: 20.28lEstimated energy need:68.9x30= 1950kcal/day Lab dataBlood Biochemistry8/118/16Alb(g/dL)3.1HbA1c8.4CRP2.54Medicine Metfo

4、rmin1 tab Mgo 2 tab bid Folic acid 1 tab Solu-medrolDiet:普通飲食正餐+低油9lBlood sugar130 mg/dl70 mg/dl10AssessmentAssessment 1.Body weight: 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)PlanPlan糖尿病飲食衛(wèi)教1.醣類代換方式2.建議少量多餐，水果可當(dāng)成點(diǎn)心3.建議每日六大類食物攝取量4.更改飲食醫(yī)囑:DM1950kcal/day+低渣+低油餐次分配:份數(shù)醣類蛋白質(zhì)脂質(zhì)熱量奶類(低脂)1

5、1284120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腹痛,發(fā)燒,血壓=91/44 mmHg轉(zhuǎn)入ICU病房:4FIDiagnosis:升結(jié)腸穿孔Operative Method: Laparoscopic abscess drainage + ileostomy點(diǎn)滴:clinimix 1500 ml8/22轉(zhuǎn)回普通病房13CBlood Biochemistry8/168/188/208/21Alb(g/dL)3.13.12.5BUN(mg/dl)14.617.614.8Creatinine(m

6、g/dl)0.90.90.8Na(mmol/dl)134136133132.7K(mmol/dl)4.35.13.8Ca(mmol/dl)2.15ObjectiveMedicineInsulin regular(humulin) 8U scHartmanns injectionlBlood sugar130 mg/dl70 mg/dl15SubjectiveSubjective訪視1.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2.自覺肌肉力氣小3.早上有排便 4.肚子痛,排便不順,喉嚨痛5.一到二晚上會(huì)自己煮6.會(huì)吃完醫(yī)院餐點(diǎn)的80%詢問:可不可以喝葡勝納?ObjectiveHt:

7、 177cm, BW: 64 kg (IBW: 68.9 kg) BMI: 20.416lEstimated energy need:1950kcal/dayLab dataMedicine Insulin NPH regular Blood Blood BiochemistryBiochemistry8/228/22Na(mmol/dl)137.7K (mmol/dl)3.82Diet:低油飲食17AssessmentAssessment 1.Body weight: 正常 2.malnutrition 3.腸胃道術(shù)後飲食狀況OK PlanPlanKeep current diet持續(xù)觀察血

8、糖值,術(shù)後營(yíng)養(yǎng)回答營(yíng)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 18SubjectiveSubjective訪視1.喝奶製品會(huì)脹氣2.胃口OK,會(huì)吃完醫(yī)院餐3.下午會(huì)喝自己準(zhǔn)備的鱸魚湯4.睡前喝半罐葡勝納19 Lab dataMedicine Insulin 短效(過高時(shí)打) Metformin 1 tab qdpcDiet:低油飲食,不要脫脂奶Blood Biochemistry8/27Alb(g/dL)2.8BUN(mg/dl)19.2Creatinine(mg/dl)0.7Na(mmol/dl)140K(mmol/dl)4CRP2.75ObjectiveH

9、t: 177cm, BW: 60 kg (IBW: 68.9 kg) BMI: 19lEstimated energy need:1950kcal/day20lBlood sugar130 mg/dl70 mg/dl21 Assessment 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) PlanPlan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22SubjectiveSubjective訪視1.今日做電腦斷層NPO2.由造口排便,覺得消化不好,會(huì)看到菜梗或纖

10、維排出3.再度有血便的情形4.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?ObjectiveHt: 177cm, BW: 58.5 kg (IBW: 68.9 kg) BMI: 1823Blood Biochemistry8/319/29/5Alb(g/dL)2.62.9Na(mmol/dl)140K(mmol/dl)3.9CRP2.20.82Medicine Metformin 1 tab qdpcDiet:DM2100kcal +晚點(diǎn)葡勝納+低油lEstimated energy need:68.9x30= 1950kcal/day24lBlood sugar130 mg/d

11、l70 mg/dl25 Assessment Assessment 非刻意體重減輕(60-58.5=0.5公斤/週)Body weight :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(yíng)養(yǎng)品密度回答營(yíng)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26SubjectiveSubjective訪視:飲用創(chuàng)快復(fù)後接受程度?1.自覺消化不好,體重不斷下降2.可以適應(yīng)創(chuàng)快復(fù),感覺有吸收3.自行補(bǔ)充立攝適鈞康零脂2罐/天4.下午會(huì)自行補(bǔ)充排骨魚湯

12、2次/週5.取消葡勝納,因?yàn)槌阅伭薕bjectiveHt: 177cm, BW: 58.5 kg (IBW: 68.9 kg) BMI: 1827Lab dataBlood Biochemistry9/59/10Alb(g/dL)2.93.2CRP0.821.49Medicine Metformin 1 tab qdpcDiet:DM2100kcal +不要午晚點(diǎn)lEstimated energy need:68.9x30= 1950kcal/day28lBlood sugar130 mg/dl70 mg/dl29 Assessment Assessment 非刻意體重減輕(60-58.5=0

13、.5公斤/週)Body weight:過輕(BMI=18)Malnutrition血糖控制不佳(150-200mg/dl) PlanPlan晚點(diǎn)食用創(chuàng)快復(fù)1包30SubjectiveSubjective今日出院,出院前訪視1.自覺沒有元?dú)?吃創(chuàng)快復(fù)有比較好2.體重下降15公斤,覺得需要好好補(bǔ)身體3.下周四(9/27)內(nèi)科門診回診ObjectiveHt: 177cm, BW: 55.5 kg (IBW: 68.9 kg) BMI: 1731 Lab dataBlood Biochemistry9/109/139/17Alb(g/dL)3.23.63.5CRP1.49Medicine Glucop

14、hage 1tab qdpcDiet:DM2100kcal +不要午晚點(diǎn) lEstimated energy need:68.9x30= 1950kcal/daylBlood sugar130 mg/dl70 mg/dl33 Assessment 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) PlanPlan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DM2100+創(chuàng)快復(fù)DM2100DM1950低油飲食BMI130 mg/dl70 mg/dl361. 因Behcets disease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。2. 胃潰瘍和GERDDischarge Diagnosis9/24電訪1. 病患表示回家後沒有做飲食紀(jì)錄2. 沒有血糖機(jī),無(wú)法記錄血糖,但下週會(huì)購(gòu)買3.