Spitalul Universitar de Urgenta Bucuresti Gmpa

Alergic la:
CARDIOLOGIE 1
Telefon:

BILET DE EXTERNARE

Nr. foaie internare: 43947

Cod prezentare: 28873SS N

Vdrsta: 35 ani Sex; Masculin

LocalUate: Macin Judet/Sector: TULCEA

Adresa.- Str. TRAIAN, Nr. 16, BI., Ap. Telefon:

Data intemarii: 1/5/2011 Data extemarii: 13/5/2011

DiaSfiosiic externare:
ICC CLASA 11 NYHA
DSA DE TIP OSTIUM SECUNDUM
BRD MAJOR
HTAP SECUNDARA MODERATA
REGURGITARE I RIC LS PI DI AN A MODERATA
REGURGITARE MITRALA USOARA
PNEUMONTE ALVEOLOINTERSTITIALA APICALA STANGA TN REZOLUTIE

Dias ft OS tic secuttdari

Enicrizat
Motivele iaternarii: dispnee, febra, tuse cu espectoratie mucoasa
Istorlcul bolii: pacient de 35 de ani, fost fiimator, aparent cunoscut cu DSA (fara documents medicale^ fara alti FR cardiovasculari
cunoscuti, se intemeaza pentru dispnee usoara, febra, frison, tuse cu expectoratie mucoasa, fenomene debutate cu 3-4 zile anterior
intemarii. cu agravare progresiva.
Obiectiv la internare: pacient corstiert, cooperant, MV prezent, inasprit in baze, dirninuat apical slang, fara staza sisTemica
saupubnonara, TA=105'60mmhg, AV=90/min^ regulat, suflu sistolic grad III/VI in focarul tricuspidian, Erb si aortic, fara galop,
puls periferic prezent, fara cianoza, abdomen nedureros, mobil cu respiratia.
ECG la internare: RS, AV=100/mm, ax QRS la 90 de grade, BRD major cu modificari secondare de faza terrainala- neevolutiv.
Eco cord: DSA de tip OS de dimensiuni man (maxim 5cm), fara margini laterale senmificativel; cu flux bilateral (stg-drp; drp-
stg), cu consecinte hemodinamice semnificative; raport Qp/Qs=l,8, fara alte anomalii congenitale asociate; cavitati drepte dilatate
(VD=57mm, AD=58romX TAPSE=18rnra, insuficienia tricuspidiana severa, semne de HTP severa; PAPS=65inraHg, subevaluat;
cu miscare apiatizata SIV; VS de dimensiuni mici, cu functie sistolica normala; fara dilatate de aorta ascendenta, flux aorta
normal; VCI dilatata, colaps sub 50%, pericard liber.
RxCP: cord si aorta in limite radiologice; AP dreapta de calibru crescut; opacitate neomogena parahilar drept imprecis delimit ata
de intensitate costala, desen infrahilar drept accentuat.
CT torace: defect de umplere intraluminal la ntvelul ramurii segm apicale stangi, asoclaia cu modificare de tip condensare
alveolointcrstitiala cu bronhograma aerica la nivel segment apical slang; trunchiul AP=36mm, AP dr=35mm, APstg=36mm, ramui
principale lobare si segmentare dilatate; aorta cu diemnsiuni nomale: pahipleurita bazala dreapta; sechele fibroasa apicale
bilateral; microadenopatii nespecifice paratraheale dreapta. Biologic: vezimaijos
Evolutie si concluzii: internare pentru pneumonie alveolointcrstitiala apicala stanga cu heraoculturi pozitive cu
sufiioc coagulazo negativ (probabilitate
mare contaminare de la nivel tegumentar) la pacient tanar, aparent fara
FRcardiovasculari cunoscuti.
Ecografic (transtoracic si ulterior transesofagian) se deceleaza DSA de tip OS de 5cm
vegetatu,cu Qp/Qs >1,5, cu HTP secundara severe. fara imagine sugestiva de
Se instituie tratament antibiotic (cefalosporina), antitemnic, TNR
terapeudc. mucoexpectorant, HGMM suprapus cu ACO pana la

De pe data de 9.05 prezinta sindrom de citoliza hepatica important (peste lOxN), fara colestaza; ecografic cu ticat cu
ecosiructura hiperecogena, granulara, cu aspect de ficat de staza- vezi anexa. Consultul gastroenterologic iniirma existenta
unei hepatixa medicamentoase, inierptetand sdr de citoliza hepatica in context de ICC, Evolutia pe parcursul spitaiizarii este
favorabila, cu remiterea sindromului febril, reducerea tusei productive, fara alte acuze. Se extemeaza ameliorat, cu
recomaudarile:

Analizc de laboralor:
01.05 11 11:02 : Gl.tJ-76mg/dl ,UREA-31 mg/dl ,CREA-1.0mg/dl ,ALT=26U/L , AST-21 U/L TBIL=09mz/dl NA+=l40inmolZl .K+-
4.0BHnoW ,lNR=l.l9mR .PT(%)-71«% ,PT(scc)=14,0«c . APTr(sec)-35.8scs: 02 05.11 09:53 :Bll=ncg .BLO=neg AlLlJ^neg , KRT-
neg ,LEU=15 ,Nrr=neg ,pH=6 .PRO-neg SG-103 , UROl , SEDIMENT URINAR (MlCROSCOPlEXclulc Gpitdiale: RELATIV FRECVENTE
Cilindn'
Fosfai atnorf:
Celule renale. UraiAmcrf: RELATIV FRCCVENT Fos&taraoniacomagnciian;
Leucocite; RARE Acid uric; Flora;
Hcmaiii; Oxalat de calciu: Mucus:
02.05.11 10:11 :PROTEINACREACTIVA=REACTIV
02 05.11 10:13 ;GLU=S5 mg/dl , UREA=33rag/dl .CREA=0-8mgfdl ,Tl’=7.2g/dl ,FE=j4jig/dl .TB1L=O62mg/dl DRlL=0.18mg/dl , NA+=n9 mmol/1 ,
K+-4.3 mmolA , CL-='.04ranon ,ALKP-521J/L .CK=43U/L , CKMB=1Q J.'L ,AST=17U/L ,ALT-31U/L ,LDH=140UA .GGT-49U/L , CTLF=219
tng/dl
02.03.11 10:15 AgHBs calitativ-NON REACTIV , HCV calttativ=NON REACTIV .HIV Ag/Ab calitativ=NON REACTTV 02.05.11
10:36 ;11CMOCIJLTURA FLACON AEROBCULTURA , HEMOCDLTDRA FLACON ANAEROB=NEGAT1VA LA 5 ZILE . IIEMOCULTURA
FLACON AEROD=NEGATIVA LAS ZlLE . HEMOCULTURA FLACON ANAF.ROB-NEGATIVALA 5 ZILE
02.05.11 10:39 :FIBRINOGEN=474.38 mg^dl .BASO#-0i022 *10’/^L , BASO%-O.44l % ,EO#=0.035 ’lO’/^L ,EO%=0.697 % .HCT-37.4% .
HGB=l3g'dl , LYMPH#=1.82’lO’/pL ,LYMPH%-36% ,MCH=32.1pg , MCHC=34.8 g/dl , MCV-92.21L ,MONO#=0.773 *10’VL .MONO
%=15.3% ,MPV=7.34fL , NEUT#=2.42 *10VnL ,NEUT%M7.6% , PCT=O.12% ,PDW=17.9fL , PLT-163‘lO’/gL . RBC=4.06 10%/^L .RDW-
13.1% , WBC=5.07 *10’/nL ,VSH=12 mm/h
02.05.11 12:20 EXAMEN SPUTAKRILTURA: FLORA SAPROFITA .FROTIU GRAM=- Cclule epiieltale- rare
- Leucocite - Dumeroase polimorronuclcare ; Heniatu -
- Fibrina •; Detritus -
' Flora Gram pozitiva - ran coci in diplo si lantun
- Flora Gram negativa - rari bacili
FROTIU ZlEHL-NEELSEN=Nus-au evidentiat bacili acido-alcoolo-rezistenti.
02.05.11 12:38 BILIRUBIN A IN DIRECT A=Q .44 mg/dl
02.05.11 12-.45 CS=15.5%
02.05.11 13:09 ;CRP=57.2 mg/l
02,05.11 14:03 •.UROCULTtJRA=NEGATIVA
03.05.11 09:51 :A/Q=l-68 , ALBUMIN %=62.7 ,ALPHAl%=2.8 , ALPHA2%=l0.0 ,BCTA%=8.0 ,GAMMA%-16.S
04 05 11 09 54 IDENTIFICARE BACTER1ANA=STAFILOCOC COAGULAZO-NEGATIV , ANTIB[OGRAMA=
ACID NALIDIXIC CEFPIROME -----
ERTAPENEM OFLOXACIN
AMIKACIN A CEFTAZIDIM FURAZOLltXJN OXACILINA S
AMOXlCttJNA CEFTRIAXON CENTAMlClNA R PENICILTNA
AMOXI.+CLAV. S CEFUROX1M IMIPENEM PIPERAC.+TAZ.
AMPICILINA CIPROFLOXACIN KANAMICINA R1FAMP1CINA S
AMPIC.+SULB, CLARITROMlCiNA LEVOFLOX ACIN TEICOPLANINA S
CEFALEXIN CLINDAMICINA LINCOMICINA TETRACICLINA
CEFAZOLIN CLORAMFENICOL LINEZOLID TICARC.+CLAV.
CEFEPIME COLISTIN MEROPENEM VANCOMICINA
CEFOPERAZONA CO’TRIMOXAZOL NEOMICINA AZTREONAM
CEFOPER.+SULB. DOXICICLINA NITROFURANTOIN PIPERACILINA
CEFOTAXIM ERITROMICINA NORFLOXACIN MOXIFLOXACIN
CEFOXnTN S TIGECICLINA
R'Tezislent. S=sensibil. l=imermediar . FROTIU GRAM=FLACON AEROB ;
Flora Gram poziliva - coci in teoade si grameai 04.05.11 12:24
TestbemoTagiioculte=Q^tiv i
EO%=2.3% .HCT-39.0% ,HGB=13.0 g'dl
05 05 11 ll:32:BASO#®n.03 *10VpL .BASO%=0.7% ,EO«-0.10 lOVuL 1G%=O 2 %
LYMPH#=1.82 *10VpL , LYMPH%=42.0 % , MCH®30.7 pg MCHC=33.3 gMl ,MCV=92.2fL
,NEtTr%=44.6% , P-LCR=25.9 %
■VSH=20 mm/h z>ncA-i 1 at I U/L AST=42UyL ,TBIL-0.57mg/4t- ,
05 05 11 11-33. QLU«87mg/dl , UREA=27 mg/dl ,CR£A=l.lm^ .^T-5IU/L
DWL^^.U^dl .AMYL=43U/L .CK1-55U/L ,CKMB-13U/L ,LDH-:44L7L
05 05 11 ! L58 ;NA+-143 nunol/l ,K+-4.2mmon
05'.05.1ll2:23;BlLIRUBlNAlNDIRECTA=0.45m&/^ APTT r^«:^25 6s«
0S.05.in6:28 -.INR=^lNR % .EO«l'.f=3.0% ,HCT=3S.8% . HGB-12,6g/dl
 MONO#=0.48*lOVgL ,MONO%-9,0% .MPV=102X .NEVT#=2.98‘l(P/uL ,NELrT%=55.5% , P-LCR-25.8% .
PCT’=O,29ft. ,PDW=ll.6fl , PLT=290‘10^zjiL , RaC=4.l6’lOO’/jiL , RDW-CV=!2.8 % . RDW.SD=41.9fl ,WBC=5.33 *1O’/UL
09.05.11 13:13 ;GLlJ=78nig/dl . UREA-30 mg/dl ,CR£A-12Tngz'dl , ALT-558 U<L .AST=355 LI/L ,CKI=96U/L ,
CKMB=12TJ/L .NA+-137minol/l , K+-4 5 mnwll ,VSH=’22mm/h , F1BIUNOGEN=211.2 mg/di
09.05.11 16:25 ;ALT=498 U/L . AST-294 U-O- , TBIL-0.25 mg'dl .CKI=57U/L ,CKMB=12U/L .LDH-233 U/L , ALKP-69WL .GGT-79U^
C9.OS.11 16:26 :INR=1,72INR ,PT(%)=42.5% ,PT(sec)=20.1 . APTT (sec)=34.9 see ,ALT=551U/L ,AST-301 U/L . TBlL-0.4
l0.05.il 06.11 ;GLU=«0mg/'dl see ,UREA=28 n^'dl ,CREA=l.O mg/dl ,
AMYL-47UZL ,CK=30U/L mg/dl .CKMB=6 U/L , NA+-y9 mmoVl , . K+-5.0 mmoLl .GGT-6SU/L ,1NR=1.521NR , PT
{%)=55 % , PT (see)= 18.2 sec APTT (sec)=36.6 sec .PT(%K4.7%
1O.O5.1IO9:27:INR-1.64INR .PT(S«)=19.2 5OC , LRtA-24 , APTT (sec)=35.2 sec
11.05.11 10:39 :GUJ=77ing/dl mg/dl .CREA-0.fi mg’d! , CKMB=9 U-1 , , ALT-602 U/L ,AST=253 U/L ,TBlL=0.5 mg/dl .
DBlL-0.2 mg/dl , CK=38 WL NA+=139 mmol/1 ,K+=4.9mmoV1 ,CL-=l04mm>l/l .ALKP=47U/L .
GGT=6fiU/L , BIURUBINA [NDrRECTA=0.3 mg/dl , AMYL-48 UL
11.05.11 13:00 ;[NR=2.34 INR ,PT(%H1% , PT (sec 1=28.6 see , APTT (secl=34.5 sec , FIBRINOGEN-265 mg'dl
13.05 I! 06:24 :GLU=78 mg/dl . UREA-35 mg/dl . CREA-1.1 mg/dl ,ALT-415U/L ,AST=113U/L , TDIL=0.7mg/dI , DBlL-0 3 mg/dl
.AMYL-49U/L .CK.-30U/L .CKMD-8U/L .NA+-139 mmol/l ,K+=5 0 mmol/1 .ALKP-52U/L , OQT-63U/L ,lNR=144rNR ,PT(%)=59% . PT (sec)=l7 3
sec , APTT lsec)=30.4 sec

Recomandari:
1. Evita eforturile fizice mari, medii, stresul, lemperaturile extreme.
2. Dieta moderat hiposodata, saraca in grasimi saturate de origine animala. hidratare cel putin 21/zi.
3. Tratamenl medicamentos cu:
STNTROM 4MG (Vt JotU" CU INR PESTE 10 ZTLE

4. Repeta peste 7zile TGO, TCP, QQT, Fostaza alcalina, BT, BD, Bl, HEG, fibtsnogen, VSH.
5. In tirapul tratamentului cu Sintrom se vor evita injectiile intramusculare, traumatismele, interventiile chirurgicale; daca
apar sangerari (urina rosie, scaun negru sau cu sange rosu, var&atura in zat de cafea $au cu sange rosu, sangerari nazale
importante) pacientul va opri traiamentul cu Sintrom si se va prezenta de urgenta la Spitak
6. Dispensarizare periodica cardiologica. Consult chirurgie cardiovasculara.
Sef sectie; Medic curant;
Dr. CINTE7A MIRCEA Dr. FLORESCU MARIA
MEDIC PRIMAR MEDIC SPECIALIST
CARDIOLOGIE CARDIOLOGIE

/
u-

I
n

Ooemtor de date cu caractcn>ersonal nr. 9351 Pagina 3 din 3

UtiHzator Lucica Tanislav Slade: CARDIOLOGIEA5 Data lipanni: 13.05.11 08:51