Scrisoare Medicala Razvan 08.11.2012
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Transcript of Scrisoare Medicala Razvan 08.11.2012
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I]OI,I' I] RA IJMATOLOGI IA
CASA AUSTRIA
Curta Razvan 113 anicNP 1790226i\54782Timisoara, Localitatea Ghirodalnternat in 5.1 1.2012 cu FO: 37193
Dg la internare:
Politraumatism prin accident rutier (pieton lovit de masina )- Traumatism cranio-cerebral cu contuzie cererbrala P dr, cerebral, suspiciunecontuzie hemipunte dreaptaTraumatism thoracic cu : hemotorax stang drenat, i pulmonare bilateral,Fracturar spinal T11 (chance) - scor ASIA neobiectivabilFracturar bifocal pedrohanteriana si 1/3medie diafiza f stangFracturar cominutiva platou tibial dreptFracturar platou tibial stangPlaga contuza delabranta semicirculara genunchi stang.SIRSInsuficienta respiratorie acuta protezata mechanicCoagulo,patie de consum cu trombocitopenie, fibrinoliza Cl D), acidoza metabolicasevera corectata, anemie posthemoragica corectata, si de hemoliza acuta
S-a practicat in urgent (la internare)- Spondilclsindeza posterioara transpediculara TgjA,T12, 1 cu laminectomie
decornpresiva T11, patch defect dural fara sutura + dremon itori,zarea presiun ii.
i LCR lombar extern cu
- Toaleta debridare, lavaj, drenaj sutura plaga contuza branta semicircular spatiulpopliteu stang, reducere pe focar inchis si osteotacsietibie pro,ximala bilateral, sifemur stang.
fixator extern pentru fractura
Starea prezenta:FC 60 baVmin, TA 160/80 mmHg,- IOT respiratie asistata, FiO2 50%, SpO2 ggo/o, afebril,
diureza 2400 mll24 h, dren pleural stang 230 mll24 h, LCR 100 mll24 h.
Nume: CURTA RAZYAN AURELIAN Varsta:33 Sex:M Medic: MIRELA SARANDANc.N.P: 7790226354782 codpacient:370900000255286 Sal0n:Sl
Bd.InsilB ulbuca nr,l50, R0 3[[i30 Timislara, ]el: r4 025$ 4$1001, iilr60Z, rqtllt,/ [
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POLTI] RA UIVI AT'OI-OGIECASA AUSTRIA
Nume: CURTA RAZVAN AURELIAN Varsta: 33
C.N.P: 1790226354782 Cod pacient: 37090000025528
Sex: M Medic: MIRELA SARANDAN
Salon:S1
APTT (Sinthasyl) @LIICTRA 1400C) 22.'l 22-35 I s
GLTCEMm (GOD/PA}) (VrrROS_FSs.1) 't+sil 74-106 lmgldl
SODIU SDRIC (potentiiometric*)(vrrRos_Fss.1) 145 135 - 145 /mmol/\
POTASIU SERIC (potentiometric*)(vrTRos_Fss.1) 42 3.5 - 5 /mmoVl
CK (kinetic*) 0TITROS_FS5.1) 6655 d 30 - t70 tutL
CKMB (imunoinhibitie, kinetic*)(vrrRos_FSs.1) 113 iil 0 - 16 /u/L
LDH SERIC (kinetic P-L*) (VITR.OS_FS5.1) '1641 5 3r3 - 6t8 tUtL
0t|.lrsilIrliuranr R0 t[0i3fi +4 [25[ 403[0], int ff 02, tltl|tl/.h