Prezentare

caz clinic

Coordonator:
Dr. Ioan Gabriel Rosu Dr.Roxana Plescuta
Medic primar Medic rezident anul 2
Medicina interna Gastroenterologie
 Pacienta A.E., 83 ani, mediul rural, internata in
regim de urgenta cu urmatoarele acuze:
✗ alterarea starii generale;
✗ dispnee de repaus cu ortopnee;
✗ declarativ un episod de frison la domiciliu
(netermometrizat);
✗ discrete edeme gambiere.

Anamneza dificila!

2
Antecedente heredocolaterale :
 mama decedata la varsta de 77 ani – patologie cardiaca ;
 tatal decedat la varsta de 80 ani;

Antecedente personale patologice:

 ATEROSCLEROZA CEREBRALA – 2014
 ANGINA PECTORALA - 2014
 PROLAPS GENITAL GRADUL III COMPLICAT
 CARDIOMIOPATIE HIPERTENSIVA + ISCHEMICA
 INSUFICIENTA CARDIACA CRONICA CLASA II NYHA
 ARITMIE EXTRASISTOLICA ATRIALA SI VENTRICULARA
 HEMIBLOC ANTERIOR STANG 2016
 INSUFICIENTA MITRALA MODERATA
 ATEROMATOZA AORTEI
 VARICE MEMBRE INFERIOARE STD. 2 CEAP
 HIPERCOLESTEROLEMIE

3
Conditii de viata si munca :
 pensionara (agricultoare)

Comportamente :
 neaga fumatul
 fosta consumatoare cronica de alcool

Medicatie de fond:
 nu poate preciza

! medicatie conform documentelor medicale :

Zomen 30 mg, 1cp/zi, zilnic; Nitromint 2,6 mg, 1 cp x 2/zi, zilnic;
Atorvastatina 20 mg, 1cp/zi, zilnic.

4
ISTORIC

Pacienta in varsta de 83 ani cu anamneza dificila, neglijata de

familie, aflata in evidenta clinicilor medicale cu cardiomiopatie
hipertensiva si ischemica, insuficienta cardiaca clasa II NYHA,
aritmie extrasistolica atriala si ventriculara, hemibloc anterior
stang, insuficienta mitrala moderata, ateromatoza aortei,
aterosteroscleroza cerebrala, varice membre inferioare std. 2
CEAP, hipercolesterolemie si prolaps genital gradul III complicat
(cu indicatie chirurgicala in 2016),evaluata ultima data in ? ?
2016, este internata in regim de urgenta pentru alterarea starii
generale, dispnee de repaus cu ortopnee si un episod de frison la
domiciliu declarativ (netermometrizat).

5
EXAMEN CLINIC OBIECTIV

Stare generala : grava;

Greutate : 45 kg ; Inaltime : 1.55 m; IMC=18,75 kg/mp
Stare de nutritie: subponderala;
Stare de constienta : pastrata;
Facies : escoriatie la nivelul piramidei nazale post traumatism prin
cadere de la acelasi nivel;
Tegumente si mucoase : icterice, deshidratate, pliu cutanat persistent;
Fanere: leuconichie;
Tesut conjunctiv-adipos : slab reprezentat;
Sistem ganglionar: superficial nepalpabil;
Sistem muscular : hipoton, hipotrof, hipokinetic;
Sistem osteo-articular: aparent integru;

6
EXAMEN CLINIC OBIECTIV

Aparat respirator : pacienta aflata sub O2 terapie pe canula nazala; torace

normal conformat, excursii costale simetrice bilateral, raluri ronflante
diseminate pe ambele arii pulmonare, raluri crepitante audibile la
nivelul ambelor baze pulmonare;

Aparat cardiovascular: arie precordiala normal conformata, bataia varfului

inimii in spatiul V i.c. pe LMC, zgomote cardiace aritmice, suflu de
ateromatoza la nivelul focarului aortic, suflu sistolic grad III/VI in
focarul tricuspidian, suflu sistolic grad III/VI in focarul mitral cu
iradiere axilara, TA=90/50 mmHg, FC= 110/min.

Aparat digestiv : abdomen suplu, depresibil, mobil cu miscarile respiratorii,

nedureros spontan si la palpare, ficat cu marginea inferioara la 3 cm sub
rebordul costal, splina nepalpabila, TI – prezent pentru MF si gaze.

7
EXAMEN CLINIC OBIECTIV

Aparat urogenital : loje renale nedureroase, sonda á demeure,

diureza aprox 2000 ml/24 h.

Sistem nervos, endocrin, organe de simt : pacienta constienta, partial

orientata temporo-spatial, bradilalica, bradipsihica, absenta
semnelor de iritatie meningeana.

8
SUPOZITIE DE
DIAGNOSTIC
PNEUMOPATIE INTERSTITIALA CU
ALTERAREA STARII GENERALE
CARDIOMIOPATIE MIXTA
INSUFICIENTA CARDIACA CONGESTIVA
GLOBALA
FIBRILATIE ATRIALA APARENT RECENT
INSTALATA
ATEROSCLEROZA SISTEMICA
INSUFICIENTA VENOASA CRONICA A
MEMBRELOR INFERIOARE STD 2 CEAP
CONTUZIE FACIALA PRIN CADERE

10
 EXAMENE
PARACLINICE
 EXAMEN BIOLOGIC
BIOCHIMIE- 12.05.2018 Lipaza- 80 U/l Gamma- 24.6% AP- 27
Na- 137 mmol/l CRP- 14,84 mg/dl HEMATOLOGIE INR-2,6
K- 6,5 mmol/l Presepsina- 1638 pg/ml GA- 18 500/mmc APTT- 41.10/sec
Cl-109 mmol/l Mioglobina- 91,5 ng/ml GR- 3 820 000/mmc SUMAR URINA
Ra- 9,7 mmol/l nT Pro-BNP- 29 233pg/ml TR- 109 000/mmc Frecvente cristale de acid
Glicemie- 221 mg/dl HbA1C-6,7% HB- 11,1 g/dl uric
Uree- 220 mg/dl Amoniac 32 HT- 33,7 % Densitate-1015
Creatinina- 1,73 mg/dl Ag HBS-293.3 VEM- 88.2/fL Ph -5
TGP- 1004 U/l Ac anti HCV – 0.07 HEM- 29.1/pg
TGO- 895 U/l IgA-281 mg/dl CHEM- 32,9 g/dl
GGT- 164 U/l IgM-152 mg/dl LIMF – 8,4 %
Amilaza 50 U/l IgG- 1183 mg/dl NEUTR- 86,2%
Bilirubina totala-2,15 mg/dl PROTEINOGRAMA MONO- 5,2%
Bilirubina directa-1,19 Albumina – 44.4 % EO- 0%
mg/dl Alfa 1- 5 % BASO- 0,2%
CK- 56 U/l Alfa 2- 11.2% COAGULARE
CK-MB- 37 U/l Beta 1- 6.6 % PDF – prezenti +++
LDH- 667 U/l Beta 2- 8.2% PT- 29,60/sec
12
EKG
EKG
 RADIOGRAFIE TORACICA

 Accentuarea desenului pulmonar

bilateral de tip reticulomicronodular.

 Pahipleurita bazala si axilara dreapta.

17
ECOGRAFIE ABDOMINALA (UPU)
Lichid pleural bilateral in cantitate mica
Ficat, colecist, vena porta, splina, rinichi bilateral – aspect normal
ecografic.
Vezica urinara evacuata.
Absenta lichidului liber transonic in spatiul Morrison.
Vena cava inferioara si venele suprahepatice dilatate (VCI~ 31 mm)

ECOGRAFIE ABDOMINALA
Ficat marit, lob caudat marit. Colecist cudat, alitiazic. Pancreas
hipotrofic. Splina normala. Rinichi drept – diam. 95 mm, IP-10 mm;
rinichi stang diam. 90 mm, IP- 11mm. Lichid pleural prezent bilateral.
VCI -26 mm. Prezent lichid de ascita subfrenic.

18
19
ECOCARDIOGRAFIE
Pericard fara lichid. AS=62,8 mm, VM-ingrosata cu mobilitate
pastrata. CONCLUZII:
Insuficienta mitrala moderata cu jet oblic spre peretele posterior
al AS,calcificare nodulara de inel mitral posterior. 1. CMD cu disfunctie sistolica de VS
Aorta la inel 20,3 mm, aorta ascendenta- 32,3 mm, ateromatoza (FE= 40%)
de valva aortica si de aorta ascendenta. 2. Hipokinezie globala mai
Insuficienta aortica usoara. SIV-9,7 mm, PPVS-10,7 mm, valva
Ao-tricuspa.mobila, cuspele cu margini libere ingrosate.
accentuata la nivelul septului –
Insuficienta pulmonara usoara, hipokinezie severa de sept portiunea anterioara
anterior, hipokinezie moderata a celorlalti pereti VS. 3. Ateromatoza de valva aortica si
DTDVS-56,1 mm, DTSVS-45 mm, FE- 40%, FS-19 %, AS- aorta ascendenta
62,4/69,9 mm, AD-50/61 mm, VS-52,3/78 mm, VD-29,8/73,3
mm.
4. Insuficienta mitrala moderata
Insuficienta aortica usoara, degenerativa. V max Ao-1,53 m/sec. 5. Insuficienta aortica degenerativa
Fara formatiuni patologice intracavitare sau pe valve. TAPSE - usoara
19,5 mm.
VCI-11,4 mm, colaps normal. Dilatare importanta de AS.

20
21
 22
?
CONSULTATII INTERCLINICE

GASTROENTEROLOGIE
CARDIOOGIE
BOLI
INFECTIOASE
DIAGNOSTIC
POZITIV
PNEUMOPATIE INTERSTITIALA
STARE SEPTICA – SUFERINTA MULTIPLA DE ORGAN
CARDIOMIOPATIE DILATATIVA MIXTA
INSUFICIENTA CARDIACA CLASA IV NYHA
FIBRILATIE ATRIALA PAROXISTICA
ARITMIE EXTRASISTOLICA VENTRICULARA
ATEROMATOZA AORTEI
HEPATOPATIE ACUTA DE ETIOLOGIE MIXTA (VHB +
CARDIACA+TOXICA – ETANOLICA + MEDICAMENTOASA)
INSUFICIENTA RENALA ACUTA
INSUFICIENTA RESPIRATORIE ACUTA
DIABET ZAHARAT TIP 2 – CAZ NOU DIAGNOSTICAT

24
TRATAMENT
Hidratare 2-3 l/zi

Oxigenoterapie 4 l/min si torace

pozitionat la 45 de grade
Amoxicilina + Acid clavulanic 1200 mg la 12 ore

Ciprofloxacin 500 mg la 12 ore

DIAGNOSTIC
Biosun 1cp x 2/zi
POZITIV
Carvedilol 3,125 mg x 2/zi

Trimetazidina 35 mg x 2/zi

Spironolactona 12,5 mg/zi

Furosemid 20 mg x 2/zi
Vitamina B1 1 fiola/zi
Vitamina B6 1 fiola/zi
Heparina cu greutate 0,4 ml x 2/zi – intrerupt dupa 2
moleculara mica zile in contextul aparitie
rectoragiilor si a unui INR
spontan de ? , reluat in a 6-a zi
de spitalizare
DIAGNOSTIC
Acetilcisteina 2 fiole/zi

POZITIV
SG 10 % 500 ml
Insulina Actrapid
1 fl x 2/zi
12 UI x 2/zi

Voluven 500 ml 1 fl/zi

Ringer 500 ml 1 fl/zi
SB 100 ml 1fl/zi - initial
Acid ursodeoxicolic 1000 mg/zi
Pantoprazol 1 fiola x 2/zi
Sub tratament evolutia este
favorabila
CLINIC

• Ameliorarea starii generale

28
 PARACLINIC

12.05.2018 14.05.2018 15.05.2018 16.05.2018

HEMOGLOBINA 11.1 g/dl 10.3 g/dl

HEMATOCRIT 33.7 % 32.3 %

GA 18 500/mmc 12 890/ mmc

GR 3 820 000/mmc 3 590 000/mmc

TR 109 000/mmc 75 000/mmc

NA 137 mmol/l 148 mmol/l

K 6,5 mmol/l 3,4 mmol/l

CL 109 mmol/l 110 mmol/l

UREE 220 mg/dl 168 mg/dl 102 mg/dl 63 mg/dl

CREATININA 1,73 mg/dl 1,38 mg/dl 0.84 mg/dl 0,72 mg/dl

GLICEMIE 221 mg/dl 111 mg/dl 116 mg/dl -

29
 12.05.2018 14.05.2018 15.05.2018 16.05.2018
RA 9,7 mmol/l 28.9 - -
TGP 1004 U/l 951 U/l 668 U/l 462 U/l
TGO 895 U/l 1035 U/l 434 U/l 175 U/l
GGT 164 U/l 121 U/l 119 U/l 111 u/l
BILIRUBINA T 2.15 mg/dl 2.49 mg/dl 2.59 mg/dl 2.53 U/l
BILIRUBINA D 1.19 mg/dl 1.68 mg/dl 1.67 mg/dl 1.63 u/l
CK 56 U/l 1162 U/l 913 U/l 482 mg/dl
CK-MB 37 U/l 89 U/l 78 U/l -
CRP 14.84 U/l - - -
FIBRINOGEN - 108 mg/dl 171 mg/dl 307 mg/dl
IP 27% 34% 41% 54%
INR 2.66 2.34 1.84 1.55
AMILAZA 50 U/L 161 U/L - -
LIPAZA 80 U/L 118 U/L - -
LDH 667 U/L 532 U/L 404 U/l 355 U/l 30
PROGNOSTIC
✗ VITAL – rezervat ✗ AL STARII DE ✗ FUNTIONAL -
SANATATE – rezervat
Dictat de rezervele rezervat
biologice ale Conditionat de ingrijirile
pacientei si de acordate in regim
suferinta multipla de ambulatoriu si in
organ mediul familial

31
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