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Texto de origen - español INFORME DE ALTA
MOTIVO CONSULTA: Disnea
ANTECEDENTES:
Varón 71 años. No alergias conocidas. Hábitos tóxicos: Ex-fumador desde hace 3 años con DTA 45 paq/años.
criterios BC. No bebedor (última cerveza hace 1 año)-
Antecedentes patológicos:
Factores de riesgo cardiovascular DM tipo 2 en tto con ADO. HTA. Dislipemia.
Cardiopatía Isquémica crónica: IAM en enero 03 con ingreso en HSD, stent en enero 03.
EPOC severo con bullas en LSD,
* Control en CCEE NML. No ingresos en nuestro Hospital. No ingresos en UCI. Última PFR de Mayo 2006: FEV1 40% FEV1/FVC 39% (alteración ventilatoria obstructiva de intensidad severa; sin cambios significativos en FEV1 y/o FVC tras la inhalación de Salbutamol).
* Ha realizado tto de Fisioterapia respiratoria,
* Último control en Consultas de NML en Oct 2006: Sat02: 93%. Retinopatía Diabética tratada con láser en junio 04. PNP diabética con lesión en talón en enero 04. Eritromelalgia (lesiones pigmentadas en piernas en junio 03). Pancreatitis aguda biliar ingreso en Mayo 06. IQ: Colelitiasis en Octubre 06.
Tto habitual: Omeprazol 20mg, Carduran neo 8mg, Diamben.650 1-0-1, spiriva 18mg.
Situación basal; Independíente para las AVD. Disnea a medianos-mínimos esfuerzos
ENFERMEDAD ACTUAL:
Paciente que con los antecedentes descritos es remitido desde atención primaria tras valoración de agudización de su EPOC, Se le ha administrado tanda de Ventolín 1cc + Atrovent 500mcg + Dacortin 30mg v/o y con SAT 93% es remitido para valoración.
Refiere cuadro de aumento de la tos con expectoración blanca + disnea a mínimos el esfuerzos hasta casi de reposo + fiebre termometrada desde hace 3 días. No dolor torácico pleurítico ni precordial.
EXPLORAClÓN FISICA:
TA: 179/98 FC: 117 FR: 24 Ta.: 38.2
SatO2: 90%. GCS:15. Aspecto general: Taquipneico. Disnea de reposo. Febril. NH, NC. Cardíocirculatorío: ligera taquicardia sin soplos. Ligeros edemas con fóvea en EEII. Respiratorio: Hipofonesis generalizada. Abdomen: globuloso no doloroso sin peritonismo. Neurológico: consciente y orientado sin focalidad,
EXPLORACIONES COMPLEMENTARIAS: Hemograma: pte Bioquímica: pte RX Tórax: pte
E.C.G.: RS a 95 1pm sin alteraciones de la repolarización aguda. GSA: Ph 7.43 P02 71 PC02 38.1 HC03- 24.9 SAT 94.8%.
EVOLUCIÓN: La clínica impresiona de agudización de su patología EPOC de base en el contexto de proceso
infeccioso respiratorio. Se solicita Hemograma, Bioquímica, ECG, GSA. Rx tórax,
Se administran 2 tandas de Ventolín 0.5cc + Atrovent 500mcg + Urbason 60 mg iv + Seguril 20mg iv + 02 con VMK
DIAGNÓSTICO PRINCIPAL:
EPOC severo agudizado. Infección respiratoria de vías bajas.
DIAGNÓSTICO SECUNDARIO:
1. Diabetes tipo 2 con polineuropatía y retinopatía
2. HTA
3. Dislipemia
4. Cardiopatía isquémica crónica revascularizada
TRATAMIENTO Y RECOMENDACIONES:
Ver órdenes médicas
DESTINO AL ALTA:
Resultados pendientes.
Traducción - inglés DISCHARGE SUMMARY
PRESENTING COMPLAINT: Dyspnoea
HISTORY:
71-year-old male. No allergies to medication known. Toxic Habits: Ex-smoker since 3 years ago: 45 packets/year.
Alchohol criteria: Does not drink (last beer 1 year ago).
Pathological history:
Cardiovascular risk factors: Type-II Diabetes Mellitus under treatment with Anti-diabetic Oral Drugs (AODs) Arterial Hypertension (AHT), Dyslipidaemia.
Chronic Ischaemic Cardiopathy: Acute Myocardial Infarction (AMI) in January 2003, admitted in XXXXXX Hospital, stent in January 2003.
Chronic Obstructive Pulmonary Disease (COPD) with sounds in Right Upper Lobe (RUL).
* Follow-up by Pneumology Outpatients Department. No admissions in our Hospital. No admissions in our Intensive Coronary Unit (ICU). Last Respiratory Function Test (RFT) in May 2006: Forced Expiratory Volume (FEV1): 40%. Forced Expiratory Volume (FEV1) / Forced Vital Capacity (FVC): 39% (severe obstructive ventilation disorder; no significant changes in Forced Expiratory Volume (FEV1) and / or Forced Vital Capacity (FVC) after inhaling Salbutamol.
* Patient underwent respiratory physiotherapy treatment
* Last follow-up at Pneumology Outpatients Department in October 2006: Oxygen Saturation (Sat O2): 93%. Diabetic Retinopathy (DR) treated with laser in June 2004. Diabetic Polyneuropathy (PNP) with lesion on heel in January 2004. Erythromelalgia (pigmented lesions on legs in June 2003). Acute biliary pancreatitis admitted in May 2006. Surgical Intervention: Cholelithiasis in October 06.
Regular treatment: Omeprazole 20mg, Carduran neo 8mg, Diamben 650 1-0-1, Spiriva 18mg.
Baseline situation: Independent for Daily Live Activities (IDLA) Dyspnoea of moderate-small effort.
HISTORY OF PRESENTING COMPLAINT:
Patient with the above mentioned history referred from primary care after an impairment of his Chronic Obstructive Pulmonary Disease (COPD). The patient has been administered Ventolín 1cc + Atrovent 500mcg + Dacortin 30mg (oral) and saturating at 93%, he is referred for assessment.
The patient reports a syndrome of increasing cough with whitish expectoration + dyspnoea of small effort almost at rest + temperature monitored over the last three days. No pleural or precordial chest pain.
PHYSICAL EXAMINATION:
Blood Pressure: 179/98 Cardiac Frequency: 117 Respiratory Frequency: 24 Temperature: 38.2
Oxygen Saturation (SatO2): 90%. Glasgow Coma Scale (GCS): 15. General condition: Tachypnoeic. Dyspnoea at rest. Febrile. Well hydrated, normal colour. Cardiocirculatory: Mild tachycardia without murmurs. Mild oedemas with pitting in Lower Limbs (LLs). Respiratory: General hypophonesis. Abdomen: Bloated, not painful, no peritoneal signs. Neurological: conscious and oriented without focality signs.
OTHER INVESTIGATIONS:
Haemogram: pending. Biochemistry: pending. Chest X-ray: pending.
Electrocardiogram (ECG): Sinus Rhythm (SR) at 95 bpm, without acute alterations of the repolarisation. Arterial Gasometry: pH: 7.43. PO2: 71. Oxygen Partial Pressure (PO2): 38.1. HC03: 24.9. Oxygen Saturation (SAT): 94.8%.
PROGRESS: Clinical picture suggests acuteness of the basal Chronic Obstructive Pulmonary Disease (COPD) in the context of a respiratory infectious process. Haemogram, Biochemistry, Electrocardiogram (ECG) and Gasometry are requested. Chest X-ray.
Two fractions of Ventolin 0.5cc + Atrovent 500mcg + Urbason 60mg (intravenous) + Seguril 20mg (intravenous) + Oxygen with Venturi Mask (VMK) are administered.
MAIN DIAGNOSIS:
Acute impairment of Chronic Obstructive Pulmonary Disease (COPD). Respiratory infection of the lower tracts.
SECONDARY DISGNOSIS:
1. Type-2 diabetes mellitus with polyneuropathy and retinopathy.
2. Arterial Hypertension (AHT)
3. Dyslipidaemia:
4. Revascularised chronic ischaemic cardiopathy
TREATMENT AND RECOMMENDATIONS:
Please see prescriptions
DESTINATION ON DISCHARGE:
Results pending.
francés al inglés: Vascular Medicine
Texto de origen - francés Cher Collègue,
Voici des nouvelles de votre patient. Monsieur XXXXXX, né le XXXX, hospitalisé dans notre Service du 27 mai au 1er juin 2006 puis du 16 juin au 18 juin 2006 pour ischémie critique du membre inférieur droit.
Il s'agit d'un patient aux antécédents récents de revascularisation coronarienne, angioplastie stenting iliaque gauche associée à un pontage fémoro-jambier gauche, pris en charge dans notre Service pour une ischémie critique du membre inférieur droit dans un contexte d'hémorragie digestive très sévère avec choc hypovolémique sur une duodénite multi-ulcérée pour laquelle un traitement local par adrénaline a été réalisé. A noter un syndrome coronarien au décours de cet épisode.
Les lésions au niveau du duodénum responsables de cette hémorragie ont contre-indiqué de manière absolue toute anticoagulation jusqu'à huit jours de l'épisode (Professeur XXXXXX). De ce fait, noua n'avons pu proposer aucun geste â Monsieur XXXXXX. En effet, une désobstruction à la sonda de Fogarty est un geste fortement thrombogène et une anticoagulation efficace est indispensable les jours qui suivent l'intervention.
La tolérance clinique s'est révélée satisfaisante au début de son hospitalisation, c'est pourquoi nous avons transféré Monsieur XXXXXXX en Service de GERIATRIE.
Nous avons réhospitalise le patient quinze jours après, devant l'aggravation de l'état local au niveau du membre inférieur droit avec une ischémie cette fois-ci dépassée chez un patient dont l'état général s'altérait. Nous avons réalisé une amputation de jambe droite. Les suites immédiates se sont révélées satisfaisantes et nous avons retransféré Monsieur XXXXXX dans le Service de GERIATRIE pour la suite de la prise en charge. La cicatrisation était globalement satisfaisante.
Traducción - inglés Dear Colleague,
Your patient, Mr. XXXXXX, was hospitalised in our Department from 27th May to 1st June 2006 and later from 16th June to 18th June 2006 for critical right lower limb ischaemia.
The patient recently underwent coronary revascularisation, angioplasty and placement of stent in the left iliac artery with a left femoral bypass. He was treated in our Department for critical ischaemia of the right lower limb, very severe digestive tract haemorrhages and hypovolemic shock. Multiple ulcers of the duodenum were treated with adrenaline. During this episode the patient experienced a coronary syndrome.
The presence of lesions in the duodenum, which led to the haemorrhage absolutely precludes administration of anticoagulation drugs until 8 days following the episode (Prof. XXXXXX). For this reason, no intervention could be performed. In fact, the removal of the blood clot with a Fogarty probe is a strongly thrombogenic event and the administration of anticoagulants is indispensable during the days following the procedure.
At the beginning of the hospitalisation of the patient, clinical conditions were satisfactory and Mr. XXXXX was transferred to the GERIATRIC Department.
The patient was re-admitted in our Department fifteen days later as a result of ischaemia of his right lower limb. The overall condition of the patient deteriorated as well. We performed the amputation of his right lower limb. The immediate outcome of the surgery appeared satisfactory and Mr. XXXXX was referred to the GERIATRICS Department for further treatment. Wound was healing satisfactorily.
portugués al inglés: Clinical Trial
Texto de origen - portugués ASSUNTO: FACTOR ANTI-HEMOFÍLICO (RECOMBINANTE), MÉTODO SEM PLASMA, ALBUMINA (rAHF-PFM): ESTUDO MULTICÊNTRICO DE FASE 4, PROSPECTIVO, CONTROLADO E ALEATORIZADO, PARA COMPARAR A EFICÁCIA E A SEGURANÇA DA PERFUSÃO CONTÍNUA (CI) VERSUS PERFUSÃO EM BOLUS (BI) INTERMITENTE EM DOENTES COM HEMOFILIA A GRAVE OU MODERADAMENTE GRAVE, SUBMETIDOS A SUBSTITUIÇÃO TOTAL PRIMÁRIA UNILATERAL DO JOELHO
ESTUDO XXXXXXXX
EudraCT #: XXXXXXXX
Como requerente autorizada e representante legal da XXXXXXX do protocolo número XXXXXX intitulado “Factor Anti-hemofílico (Recombinante), Método Sem Plasma, Albumina (rAHF-PFM): Estudo Multicêntrico de Fase 4, Prospectivo, Controlado e aleatorizado, para Comparar a Eficácia e a Segurança da Perfusão Contínua (CI) versus Perfusão em Bolus (BI) Intermitente em Doentes com Hemofilia A Grave ou Moderadamente Grave, Submetidos a Substituição Total Primária Unilateral do Joelho”, venho por este meio notificar que o promotor do estudo acima mencionado preparou uma actualização da Brochura do Investigador.
Assim, junto envio a versão actualizada da Brochura do Investigador datada de 27 de Setembro de 2006.
Traducción - inglés SUBJECT: ANTIHAEMOPHILIC FACTOR (RECOMBINING), METHOD WITHOUT PLASMA, ALBUMIN ((rAHF-PFM): RANDOMISED, CONTROLLED PROSPECTIVE MULTICENTRE STUDY, PHASE 4, TO COMPARE THE EFFICACY AND THE SAFETY OF CONTINUOUS INFUSION (CI) VERSUS INTERMITTENT BOLUS INFUSION (BI) ON PATIENTS WITH MODERATE SEVERITY OR SEVERE HAEMOPHILIA, SUBMITTED TO A PRIMARY UNILATERAL TOTAL KNEE REPLACEMENT.
STUDY XXXXXXXXX
EudraCT #: XXXXXXXXXX
As the authorised requester and legal representative of Baxter AG of the protocol number 060402 entitled “Antihaemophilic Factor (Recombining), Method Without Plasma, Albumin (rAHF-PFM): Randomised, Controlled Prospective Multicentre Study, Phase 4, to Compare the Efficacy and the Safety of Continuous Infusion (CI) versus Intermittent Bolus Infusion (BI) on Patients with Moderate Severity or Severe Haemophilia, Submitted to a Primary Unilateral Total Knee Replacement", would like to inform you that the above mentioned study sponsor has prepared an updated version of the Investigator’s Brochure.
Therefore, I am enclosing the updated version of the Investigator’s Brochure dated 27th September 2006.
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