1 / 16

“ Surpriza ” de la miezul noptii

Scoala de vara a Tinerilor Internisti – Sibiu 2014. “ Surpriza ” de la miezul noptii. Dr. Razvan Mihalcea Medic rezident an III, Medicina Interna Spitalul Clinic Coltea. D.M. ,F, 37 ani , Urban. Se prezinta pentru :

lara-morse
Download Presentation

“ Surpriza ” de la miezul noptii

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Scoala de vara a TinerilorInternisti – Sibiu 2014 “Surpriza” de la miezulnoptii Dr. RazvanMihalcea Medic rezident an III, MedicinaInternaSpitalul Clinic Coltea

  2. D.M. ,F, 37 ani, Urban • Se prezintapentru: • Durere cu caracter de junghi (stanga>dreapta), debutata de aprox. 2 luni, accentuataca intensitate in ultimaperioada • Tusecu expectoratiemucopurulenta • Pacientafumatoare(13 pachete-an) • Neaga:febra la domiciliu, consumul de anticonceptionaleorale. • Dec 2013: CT toracic(in ambulator): TEP cronicla nivelularterelorlobare, segmentaresisubsegmentareinf stg simodificariemfizematoasepulmonar bilateral, maiimportantepepartea stg.

  3. Examen clinic • normoponderala(IMC=19,5kg/m2) • tegumentehiperpigmentateconstitutional • scoliozadorsaladextro-concava

  4. Paraclinic • - Usoaraleucocitoza (11.000/mmc) cu neutrofilie • - Faraanemiesautrombocitopenie • - Sindrominflamatorusor • - D-dimerinegativi • - functierenala/ hepatica in limitenormale • - ionogramaserica in limitenormale • - cultura sputa, urocultura - negative • - Markeritumorali: CEA=7.31 ng/mL, CA 15-3=22.9 u/mL, CA-125=26.5u/mL, CA 19-9=43.3 u/mL

  5. Paraclinic • Rx torace:usoaraaccentuare a desenului interstitial difuzbilateral si minima obstrucite a sinusuluicostofrenicdrept. • Spirometrie: in limitenormale. • ECG: RS, AV=64b/min, ax QRS=60 grade, faramodificari de fazaterminala. • Ecografie cordsi abdomen in limitenormale. • CT torace(ian.2014): TEP bilateral

  6. Paraclinic • Ecografie Doppler membreinferioare: venefemurale, poplitee, tibio-peronierecompresibile bilateral, fara TVP, venefemurale cu variatie de flux cu respiratia • Endoscopiedigestivainferioara: faratumori la acestnivel, dolicocolon. • HolterECG: RS, frecventamedie=86b/min. Tahicardiesinusalapana la 148b/min, aproximativ 3 ore/inregistrare. Frecventacardiaca min=48b/min. Rare extrasistoleventriculare. Faraaltearitmii, faramodificaripatologice ST-T.

  7. paraclinic • Ex. Babes-Papanicolau: negativpentruleziunimaligneintraepiteliale • Ecografiemamara: modificari de mastozafibrochisticabilateral • Consult psihiatric: sindromdepresiv sever. • Consult ORL: otitamediebilaterala. • Consult neurologic: Faralateralizareneurologica, farasemnemeningealesau de HIC. Arnold sensibil bilateral.

  8. Teste de trombofilie • Proteina C = 94% (70-130%) • Proteina S = 62% (60-140%) • APCR = 3,01 (>2,9) • Anticoagulant lupic= negativ • Anti-trombina III = 90% (80-120%) • Factor von Willebrand = 108% (50-150%) • D-dimeri = 230 ug/L (0-550ug/L) • PDF = absenti • PAI-1 = 3,2 UI/L (0,3-3,5 UI/L) • Homocisteina = 15,3 umol/L (3,7-13,9 umol/L) • Ac. Anti-Cardiolipina = 5,3 U/ml (<10 U/ml) -negativ • Ac. Anti-beta2 glicoproteina = 11,3 U/ml (<10 U/ml) –pozitiv

  9. Diagnostic • TROMBEMBOLISM PULMONAR CRONIC BILATERAL • SINDROM ANTIFOSFOLIPIDIC • BRONSITA CRONICA TABAGICA • INSUFICIENTA VENOASA CRONICA A MEMBRELOR INFERIOARE STADIUL CEAP C3 • OVARE MICROPOLICHISTICE • MASTOZA FIBROCHISTICA BILATERALA • SINDROM DEPRESIV SEVER • BOALA DE REFLUX GASTRO-ESOFAGIAN

  10. Sindromul anti-fosfolipidic • Boalasistemicaautoimunacaracterizataprin: • Trombozearteriale/venoase • Evenimenteobstetricale • Prezentaanticorpilorantifosfolipidici (anticoagulant lupic, Ac anticardiolipina, Ac anti β2 glicoproteina) • Trombozavenoasaprofundaesteceamai des intalnitamanifestare, de obiceirecurentasiinsotitauneori de emboliepulmonara. • Ocluziaarterelorintracranieneesteceamaifrecventamanifestarevascularaarteriala. • Altetipuri de manifestari: neurologice, cutanate, pulmonare, cardiace, hematologice, musculo-scheletale, endocrine.

  11. Diagnostic diferential • Coagulare intravasculara diseminata • Endocardita infectioasa • Purpura trombotica trombocitopenica

  12. Tratament • Anticoagulant cu heparinafractionata (Dalteparinum5000 UI x 2/zi), ulterior la 3 luni, continuat cu antivitamina K (Acenocumarol) • Antisecretor gastric – inhibitor de pompa de protoni (Omeprazol 20mg/zi) • Prokinetic (Domperidona 30mg/zi) • Antidepresiv cu inhibitor al recaptariiserotoninei/epinefrinei (Duloxetin, 30mg/zi) sianxiolitic (Lorazepam 1mg/zi) • Interzisconsumul de contraceptiveorale !

  13. Evolutie • Pacientarevina in martie 2014 pentru: • - dureretoracicaanterioara, cu iradiereposterioara (interscapulo-vertebrala), cu durata de <5min, cu caracter de junghi, cu debut de aproximativ 2 saptamani, agravata ca frecventasiintensitatecu douazileinainteaprezentarii • - dispneela eforturiminine • - tusecu expectoratiemuco-purulenta • Explorarilepulmonaresi CV nu au evidentiatmodificari fata de prezentareaanterioara

  14. Vamultumesc ! • Vamultumesc !

More Related