Caz clinic Biochimie

P. I., M, 66 ani, Iai: 17.03.2017

29.03.2017
M.I.: - Durere toracic anterioar cu caracter de arsur
- Dispnee de repaus
- Transpiraii
- Vertij

AHC: - nu declara
APP: - HTA i aritmie (ESV ) - 1997
- DZ tip 2 - 2004
- I episod de AP instabil 2008
- al-II lea episod de AP instabil 2012
- infec. resp. intercurent feb. 2016
CVM: - maistru auto-moto
- fumtor timp de 18 ani (5 igarete/zi)
- consumator cronic de alcool (aprox. 1 L/zi)
- neag consumul de cafea
MF: - Rawel 1.5 mg/zi
- Leridip 10 mg/zi
- Tenaxum 10 mg/zi
- Zenra 10 mg x 2/zi
- Bisogamma 2.5 mg /zi
- Rytmonorm 150 mg x 3/zi
- Simvacard 20 mg/zi
- Siofor 850 mg x 3/zi
Examen obiectiv:
Stare de nutriie obezitate gr. II
= 177 cm G = 110 kg IMC = 32 kg/m2
Aparat CV: - oc apexian sp V I.C. Stg. pe LMC
- zg. cardiace aritmice, bine btute, fr
sufluri
- artere periferice pulsatile
TA = 165/90 mmHG FC = 72 bpm
Aparat digestiv: - abdomen mrit de volum n plan xifo-
pubian
- hepatomegalie 1 cm sub rebordul costal
Aparat urogenital: - miciuni polakiurie
17.03.2017
TGO = 18 UI TGP = 20 UI
CK = 64 U/L CK-MB = 15 U/L

TS = 110/min AQRS = -30 R amputat V2-V4

Ischemie ant-lat
ESV isolate

IPOTEZA DE DIAGNOSTIC CLINIC:

1) SINDROM CORONARIAN ACUT
- ANGINA PECTORALA INSTABILA (DE NOVO)
- INFARCT MIOCARDIC ACUT
2) DURERE TORACICA CARDIACA NON-ISCHEMICA
3) DURERE TORACICA NON-CARDIACA
18.03.2017
TGO = 90 UI TGP = 27 UI
CK = 729 U/L CK-MB = 157 U/L

70/min
T neg 0,5-3 mm n DI, aVL, V5, V6
19.03.2017
TGO = 89 UI TGP = 29 UI
CK = 399 U/L CK-MB = 68 U/L

RS = 66/min
T neg 3 mm n V4, V6
T aplatizat n DI, aVL
20.03.2017
TGO = 26 UI TGP = 17 UI
CK = 90 U/L CK-MB = 20U/L
RS = 70/min

T neg 2 mm n V5, V6 Relativ frecv ESV izolate polimorfe

T aplatizat n DI, aVL
21.07.2012

Relativ frecv. ESV izolate polimorfe

EXAMENE PARACLINICE 1.04.2017
VSH 37/72 1h/2h Fibrinogen 520 mg/dL
Hb 15 g/dL Ht 45,1%
GA 8330 FL: L-27,5%, M-14.5%, N-51.5%
Trombocite 219.000
Uree 30 g/dL Creatinin 0,95 md/dL
RA 29 mEq/L Na 142 mEq/L K 4,6 mEq/L
Colesterol = 169 mg/dL TGL = 223 mg/dL
LDL = 77 mg/dL HDL = 47 mg/dL
TGO 26 UI TGP 17 UI
Glicemie 114 mg/dL
Bilirubin T 0,82 mg/dL D 0,33 mg/dL
APTT 36.4 sec
 ECOCARDIOGRAFIE:
Bulb Ao 34 mm PPVS 9 mm
SIV 10 mm SIV BAZAL 14 mm
FE 45% FS 23%
AS 49/46/52 mm AD 49/45 mm
VS 60 mm VD 40 mm
- Gradient VS-Ao 7 mmHg
- Valv mitral - ecodens
- regurgitare mitral gradul II
- Crosa aortei ateromatoas
- Kinetic VS - hipokinezie septo-apical i a apexului
- zon diskinetic la nivelul apexului
- Lichid pericardic - absent
Rx Toracica
ICT = 0.46 Cord orizontalizat, normal pulmonar
 DIAGNOSTIC POZITIV:
CARDIOPATIE HIPERTENSIVA
INFARCT MIOCARDIC ACUT SUBENDOCARDIC ANTERO-LATERAL
TRATAMENT:
17.03.2017 26.03.2017 26.03.2017 29.03.2017
Heparin 1000 UI/h Clexane 80 UI x 2/zi
Clopidogrel 75 mg/zi
Accupro 10 mg x 2/zi
Furosemid 40 mg/zi
ISONIT 20 mgx2/zi
Bisoprolol 2.5 mgx2/zi
Siofor 850 mg/zi
29.03.2017
RS = 60/min
AQRS = 0
T negativ 1-2 mm n DI, aVL, V5, V6
 DIAGNOSTIC LA EXTERNARE

INFARCT MIOCARDIC ACUT SUBENDOCARDIC

ANTERO-LATERAL
CARDIOPATIE HIPERTENSIV
INSUFICIEN CARDIAC CRONIC CLS II HYHA
ARITMIE EXTRASISTOLOC VENTRICULAR
DIABET ZAHARAT TIP 2
HIPERLIPOPROTEINEMIE TIP IV
ATEROSCLEROZ SISTEMIC
 TRATAMENT LA EXTERNARE

Enalapril 10 mg/zi
Bisoprolol 5 mg/zi
ISONIT 20 mg x 2/zi
Furosemid 20 mg/zi
Clopidogrel 75 mg/zi
Lipofib 160 mg/zi
Siofor 850 mg x 3/zi
Nitromint spray S.L. la nevoie