Caz Clinic Biochimie IV

8/18/2019 Caz Clinic Biochimie IV

1/38

CAZ CLINICBIOCHIMIE CLINICA

IONESCU VALERIAN STEJAREL

Gr. 5, Seria A


2/38

Pacienta A.G., in varsta de 10 ani

edi! r!ra"Se #re$inta in !r%enta


3/38

&tive"e internarii

'!reri retr&sterna"e c! iradierein !(ar!" dre#t

'is#nee !s&ara, a#ar!ta c! )

$i"e inaintea internarii


4/38

Antecedente *ered&+c&"atera"e siantecedente #ers&na"e #at&"&%ice

nese(nicative


5/38

C&nditii de viata si de

(!ncae"eva


6/38

Ist&ric!" -&"iiPacienta A.G. in varsta de 10 ani, din (edi!"

r!ra", c! antecedente*ered&+c&"atera"e siantecedente #ers&na"e #at&"&%icenese(nicative, se internea$a avand!r(at&are"e ac!$e d!reri retr&sterna"e c!iradiere in !(ar!" dre#t, dis#nee !s&ara.Si(#t&(at&"&%ia a a#ar!t in a#r&/i(ativ c! )$i"e inaintea internarii.


7/38

E/a(en c"inic "a

internareGre!tate + 5%

Inai"ti(e + 151 c(

IC+ 25

Stare de n!tritie s!#ra#&ndera-i"itate severa

Stare %enera"a a"terata, s!-3e-ri"a ),5 C

4acies si(etric, erite( "a nive"!" #&(eti"&r

Te%!(ente n&r(a" c&"&rate

!c&ase n&r(a" c&"&rate


8/38

E/a(en c"inic "a internare4anere n&r(a" i(#"antate

Tes!t c&n!nctiv+adi#&s -ine re#re$entat

Siste( %an%"i&nar 3ara adenatii dece"a-i"ec"inic

Siste( (!sc!"ar n&r(&t&n, n&r(&tr&3,n&r(&inetic

Siste( &ste&+artic!"ar inte%r!, artic!"atii"i-ere, ned!rer&ase, 3ara t!(eeri artic!"are


9/38

E/a(en c"inic "a

internareA#arat res#irat&r

'is#nee (i/ta !s&ara

!r(!r ve$ic!"ar !s&r di(in!at "a -a$a*e(it&race"!i stan%

4ara ra"!ri

A#arat cardi&vasc!"ar

AV 6a"!ra ventric!"ara7 c! 100 -atai8(in9%&(&te cardiace rit(ice, -ine -at!te, 3ara

s!:!ri

TA; 1108


10/38


11/38

E/a(en -i&c*i(ic=e(&"e!c&%ra(a dece"ea$a tr&(-&citenie,

"e!c&cit&$a c! ne!tr&e"ie, 3ara sindr&(ane(ic

=- ; 11,2%8d" 6VN 12+15%8d"7

=t ; )),1> 6VN )5+?5>7

VE ; @5,?: 6VN @+5:7

=E ; 2@,


12/38

E/a(en -i&c*i(icLB ; 1 6VN 50+0>7

N ; 6VN 25+?0>7

Tr ; 1510008((c 6VN 150000+?000008((c74r&ti! #eri3eric ne!tr&"e c! n!c"e! #&"i"&-at

VS= ; 52((81*, 6VN+1181*7

4i-rin&%en ; ?(% 61?0+)


13/38

Investi%atii i(a%isticeRadi&%rae #!"(&nara

Trans#arenta #!"(&nara in "i(ite n&r(a"e

C&rd!" c! dia(etr!" transvers !s&r cresc!tEc&%rae a-d&(ina"a

S#"ina (arita c! dia(etr!" "&n%it!dina" de1),5 c(, 3ara "ic*id in cavitatea #erit&nea"a


14/38

Investi%atii i(a%isticeEc&%rae cardiaca

4E ; 50>, 4S ; )0>, se#t interatria" si

interventric!"ar intacte, "a(a na de "ic*id in#ericard 65 ((7

Pericardita

EG ta*icardie sin!sa"a, 3ara (&dicari a"e

se%(ent!"!i ST si !ndei T


15/38

'ia%n&stic #re$!(tivPericardita ac!ta c! !r(at&are"e ar%!(ente

e/a(en!" c"inic D d!reri #rec&rdia"e, dis#nee,ta*icardie sin!sa"a

E/a(ene #arac"inice D sindr&( i(:a(at&r,dia(etr! transvers a" c&rd!"!i !s&r (arit #eradi&%raa #!"(&nara, #re$enta de "ic*id#ericardic "a ec&%raa cardiaca in cantitate(ica D 5((


16/38


17/38

'ia%n&stic!" di3erentia"a. &"i in3ecti&ase end&cardita in3ecti&asa

ac!ta sa! s!-ac!ta 6a-senta s!:!ri"&rcardiace7, #ericardita TC 6inr(ata #e -a$aI'R ne%ativ si a radi&%raei #!"(&naren&r(a"e7, #ericardite vira"e, -acteriene,(Bc"as(e etc.

-. Pericardite #rin c&nti%!itate 6in -&"i #"e!ra"e,#ne!(&nii7F


18/38

c. &"i de c&"a%en der(at&+(i&$ita,sc"er&der(ie, "!#!s erite(at&s siste(ic n!s+a e/c"!s dat&rita #re$entei a d&!a criteriierite( "a nive"!" #&(eti"&r, "a(a na de"ic*id in #ericard7F

d. Artrita re!(at&ida !veni"a 6e/c"!sa #e -a$aa-sentei sindr&(!"!i 3e-ri" #re"!n%it siartritei7F

e. Vasc!"ite i(!ne, #&"iarterita n&d&asaF3. Pericardita din re!(atis(!" artic!"ar


19/38

S+AU RECOLTAT PENTRU'IAGNOSTICUL 'I4ERENTIAL

Antic&r#i antin!c"eari #re$enti, #attern #atat

n 6in "!cr! "a (&(ent!" e/ternarii7,3act&rre!(at&id 11 UI8(" 6N107,

C&(#"e(ent C) 1),? (%8d" 6N;0+1@07,

Antic&r#i anti+cc# 6anti#e#tide cic"icecitr!ni"ate7 0,5 U8(" 6ne%ativ #ana "a U8("7


20/38

'ia%n&stic #&$itiv initia"Cardita re!(atis(a"a D 3&r(a !s&ara

Ar%!(ente

Criterii J&nes !n criteri! (a&r D cardita c!#ericardita, d&!a criterii (in&re reactanti de3ara ac!ta #&$itivi 6VS=, CRP, -rin&%en7,d&vada in3ectiei stre#t&c&cice 6titr! ASLO

cresc!t7


21/38

TRATAENTUL CURATIV1. Eradicarea in3ectiei stre#t&c&cice

#enici"ina G [email protected] UI "a < &re i.v.7+ 10$i"e

2. Trata(ent!" carditei c&rtic&tera#ie DPrednis&n


22/38

Ev&"!tia s!- trata(ent ainvesti%atii"&r #arac"iniceVS= ; 10((8* 6VN10((8*7

CRP ; 0.)@(%8d" 6VN 0,5(%8d"7

ASLO ?5 UI8(" 6VN )20 UI8("7

Ec&%rae cardiaca 3ara "ic*id in #ericard


23/38

'ISCUTIIS+a inter#retat ca$!" ca ind cardita ac!ta

re!(atis(a"a 3&r(a !s&ara 6#ericardita i$&"ata

3ara se(ne de ins!cienta cardiaca, titr! ASLO

cresc!t, sindr&( -i&"&%ic in:a(at&r7N! s+a #!t!t e/c"!de #er!cardita din cadr!"

c&"a%en&$e"&r 6AAN #&$itivi+ H#attern #atat s+

a! re"!at, "a (&(ent!" e/ternarii nd in "!cr!7.

S!- trata(ent a ev&"!at c! re(isiasi(#t&(at&"&%iei c"inice, a sindr&(!"!i -i&"&%ic

in:a(at&r si dis#aritia "ic*id!"!i #ericardic "a

e/a(inarea ec&%raca.


24/38

RECOAN'ARI LA ETERNARERe%i( 3ara sare

C&ntin!area trata(ent!"!i c&rti$&nic, c!scaderea #r&%resiva a d&$e"&r, trata(entad!vant c&rtic&tera#ei 6aa"&/, CaK vita(ina'), As#acardin7

Pr&"a/ia end&carditei


25/38

'!#a 5 "!ni s+a reinternat #entr! d!reri "a

nive"!" *e(it&race"!i stan%, 3ati%a-i"itate,si(#t&(at&"&%ie c! de-!t de & $i

E/a(en!" c"inic "a internare

G ;


26/38

In ev&"!tie 6a d&!a $i de "a

internare7A"terarea starii %enera"e, #r&c&rdia"%ii6sen$atie de

#resi!ne t&racica c! iradiere in !(ar!" stan%7,dis#nee (&derata, cian&$a discreta

SaO2; 0> 3ara O24R;)08(in

AV;


27/38

TRATAENTS+a initiat tera#ie c!

S&"!(edr&" 125 (% "a < &re i.v.

edr&" )2(% 1K1K0

Trata(ent c! Penici"ina G 61 UI "a < &re7

< $i"e (ai tar$i! a #re$entat

Peri&ade c! -radicardie sin!sa"a )@8(in inc"in&statis(, "a ridicarea in &rt&statis( AV;63ara O27, accent!area erite(!"!i 3acia", EG c!-radicardie sin!sa"a, RS n&r(a"


28/38

INVESTIGATII

IUNOLOGICEC&(#"e(ent C) D 2,)2 %8" 6N0,+1,@7

C&(#"e(ent C?+ 0,5 %8" 6N0,1+0,?7

4act&r re!(at&id )@ UI8(" 6N 0+257Antic&r#i antin!c"eari #&$itivi, #attern #atat,

titr!181


29/38

N! s+a #!t!t e/c"!de "!#!s!" erite(at&ssiste(ic dat&rita #re$entei a ) criterii erite("a nive"!" #&(eti"&r, ser&$ita 6#ericardica7,antic&r#i antin!c"eari #&$itivi.

S!- trata(ent ev&"!tia a 3&st 3av&ra-i"a c!re(isia si(#t&(at&"&%iei c"inice, re(isiasindr&(!"!i -i&"&%ic in:a(at&r, dis#aritia"ic*id!"!i #ericardic "a e/a(inarea ec&%raca

Pe #arc!rs!" !r(at&are"&r trei internari #entr!-i"ant c"inic&+-i&"&%ic n! a #re$entat sindr&(in:a(at&r, #r&tein!rie 0,2%82?*, 3ara "ic*id#ericardic "a ec&%raa cardiaca


30/38

Pat&"&%ic s+a evidentiat dis"i#ide(ie in cadr!"

sindr&(!"!i C!s*in% iatr&%en, care s+a re(iss!- dieta si trata(ent c! aci$i %rasi O(e%a )

In ev&"!tie a #re$entat t!se cr&nica #entr!care s+ae3ect!at c&ns!"t #ne!(&3ti$i&"&%ic,

test !anti4ERON ne%ativ 6s+a e/c"!s TC7CT t&racic (ini(a in%r&sare de #ericard,

(ini(a in%r&sare #"e!ra"a stan%a

? "!ni (ai tar$i! s+a internat #entr! (&tive"edis#nee (i/ta, d!rere t&racica c! iradiere in!(ar!" stan%, t!se iritativa, #a"#itatii, ras*(a"ar. Se a:a in trata(ent c! edr&"1


31/38

La ) &re d!#a internare a #re$entatA"terarea starii %enera"e, 3e-ra )@C, verti,

#a"#itatii, dis#nee (&derata, (&tive #entr!care s+a trans3erat in sectia de tera#ie

intensivaInre%istrarea EG a evidentiat !nde T

ne%ative

In AVL, AV4 si V2+MV<

Ec&%raa cardiaca e3ect!ata a evidentiat na"a(a de "ic*id #ericardic 5 ((.

S+a instit!it #!"s+tera#ie c! S&"!(edr&" 1% i.v.) $i"e c&nsec!tiv


32/38

Ev&"!tie 3av&ra-i"a s!- trata(ent

Re(isia sindr&(!"!i in:a(at&r 6"a internareL;1


33/38

Revi$!irea dia%n&stic!"!iPe -a$a date"&r ana(nestice, c"inice si

#arac"inice a 3&st revi$!ita incadrarea incriterii"e ARA #entr! "!#!s erite(at&s siste(ic,

ada!%and!+se a" #atr!"ea criteri!+#r&tein!ria6inter(itenta in ca$!" n&str!7, a"at!ride ce"e"a"te ) criterii ras*(a"ar, ser&$ita6#ericardita7,antic&r#i AAN #&$itivi 6#attern

#atat7'e&arece tr&(-&citenia n! s+a (ai re#etat,

n! s+a c&nsiderat necesara rec&"tareaantic&r#i"&r antitr&(-&citari.


34/38

RECOAN'ARI LA

ETERNARERe%i( 3ara sare

N&r(&+"i#idic

N&r(&+%"!cidicEvitarea e/#!nerii "a s&are

Evitarea (edica(ente"&r care inc"!de LES,edr&"61(8%c,c! scaderea tre#tata a

d&$e"&r7 Trata(ent ad!vant c&rtic&tera#iei


35/38

CONCLU9II'&vada in3ectiei stre#t&c&cice si a #ericarditei a

&rientat initia" dia%n&stic!" catre carditare!(atis(a"a.

La de-!t!" -&"ii n! a! e/istat ce" #!tin ? criterii

#entr! a deni dia%n&stic!" de "!#!" erite(at&s

siste(icA" #atr!"ea criteri! #&$itiv #entr!

LES6#r&tein!ria7 este in ca$!" n&str! inter(itentasi n! #ersistenta D in viit&r #r&-a-i" va necesita

#!nctie -isie rena"a. 'at&rita tera#ieic&rti$&nice a de$v&"tat C!s*in% iatr&%en

C&nsidera( acest ca$ c! c&(#"icatii #&tentia"

severe dat&rita a3ectarii cardi&vasc!"are si rena"e


36/38


37/38

LUPUS ERITEATOS

SISTEICEste & -&a"a a!t&i(!na (!"tisiste(ica de

eti&"&%ie nec!n&sc!ta

LES este rar inta"nit "a cii, re!nind 15> dint&ta"!" ca$!ri"&r, c! #red&(inanta a3ectariise/!"!i 3e(inin

LES c! de-!t in ci"arie este (ai sever decat"a ad!"t, c! & incidenta (ai (are a ne3ritei,#ericarditei, *e#at&s#"en&(e%a"iei


38/38

ILIOGRA4IE. . J. nr. 2 + 2011

Caz Clinic Biochimie IV

Documents

Transcript of Caz Clinic Biochimie IV