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\Large E. B. (f.) * 1939 - Hauptdiagnose Herzinsuffizienz
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\begin{document} 
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Alexander Ölzant (9301547), Medizinische Universät Wien\\

\MYTITLE{Patientin E. B.}

\begin{itemize} 
\item geboren 1939 (72 a)
\item Kinderkrankheiten
\item keine Beschwerden bis 1994
\item Ex-Raucherin
\end{itemize}	


\BS
\MYTITLE{Sozialanamnese}

\begin{itemize} 
\item Familie: verheiratet, 2 erwachsene Kinder
\item bis 1999 (60 a) gerne berufstätig (Lehrberuf), seither in Pension
\end{itemize}	
\MYTITLE{Familienanamnese}
\begin{itemize} 
\item Beide Eltern hatten Herzerkrankungen, die auch als Todesursache angegeben
werden (Bluthochdruck, CMP, DM2)
\item Ein Bruder leidet ebenfalls an Diabetes Mellitus Typ 2
\item keine Krebserkrankungen in der Familie bekannt
\end{itemize} 

\BS
\myTITLE{Frühere Erkrankungen}
\vspace*{-.3in}
\begin{itemize} 
\item Kinderkrankheiten: Scharlach, Röteln, Masern, Mumps
\item bis 2001 keine Operationen
\end{itemize}	
\pause
\myTITLE{Vegetative Anamnese}
\vspace*{-.3in}
\begin{itemize}	
\item trinkt moderat Alkohol ($<$ 1/8 Wein pro Tag)
\item Rauchen: ca. 1953 - 1993 1 Paket/d (ca. 40 pack years)
\item gynäkologisch nach eigener Angabe unauffällig (2 Geburten, unregelm. Kontrollen)
\item Harn, Stuhl keine Beschwerden
\end{itemize} 
V. a. KM-Allergie

\BS
\MYTITLE{aktuelle Aufnahme}

COPD-Exazerbation, Luftnot

Nach Einstellung Simdax (Levosimendan = Ca++ Sensitizer) i. v. angedacht

\pause
\MYTITLE{Untersuchung}
Herztöne rein, rhythmisch, keine Geräusche in den Carotiden

Atemgeraeusche: dorsal vesikulaere Atemgeraeusche, frontal leichtes Giemen

körperliche Untersuchung abgebrochen (``unangenehm''), daher Herzvergrösserung nicht exakt bestimmt.

\BS
\MYTITLE{Krankheitsentwicklung}

\begin{itemize}	
\item 1994 intermittierend Herzrasen, Herzklopfen, Übelkeit, kaum Schmerzen - nach eigener Angabe keine eindeutige Dia\-gnose
\item 1995 Diagnose Vorhofflimmern 
\item 2001 erster Schrittmacher mit 1 Sonde
\item 2002 zweiter Schrittmacher mit 2 Sonden
\item parallel Coumarine (Marcoumar \textregistered)
\end{itemize}	
Diagnose: dilatative Cardiomyopathie, NYHA Grad III

seit 2 Jahren exazerbiert

\BS\mytitle{EKG}\includegraphics[width=\textwidth]{ekg_ges_small.jpg}

\BS
\myTITLE{EKG Detail}\includegraphics[width=3in]{ekg_detail.jpg}
deutlich Schrittmacherzacken statt P-Wellen, QRS verbreitert

\BS
\vspace*{-.5in}Labor\\
\includegraphics[width=\textwidth]{labor1.jpg}

\BS
\MYTITLE{Sonstige Erkrankungen}
dil. CMP NYHA III 
\begin{itemize}
\item COPD (FEV1 55 \% (Soll 80))
\item Vorhofflimmern
\item PM (bivent. seit 2002)
\item	NIDDM (Nuechterngluc. 166 mg/dl)
\item pAVK
\item CNI (chronische Niereninsuffizienz) - Krea 1.78 mg/dl, GFR ca. 30 ml/min/1.7
\item nach eigenen Angaben Adipositas (1.60 m, 66 kg = BMI 25?)
\item SD-Unterfunktion
\end{itemize} 

\BS
\vspace*{-.5in} 
\myTITLE{Medikation}
\begin{tabular*}{\textwidth}[t]{p{0.7\textwidth}|p{0.1\textwidth}|p{0.1\textwidth}|p{0.1\textwidth}}
Medikament & morgen & mittag & abend \\
\hline
Pantoloc (Pantoprazol) 40 mg & 1 & 0 & 0 \\
Marcoumar (Phencrocoumon) 3 mg & \multicolumn{3}{|c}{2/w 1/4, 5/w 1/2 } \\
Thrombo-ASS (Acetylsilicylsäure) 100 mg & 0 & 1 & 0 \\
Thyrex 50 $\mu$g & 1/2 & 0 & 0 \\
Concor (Bisoprolol) 10 mg & 1 & 0 & 0 \\
Atacand plus 16 (Candesartan 16 mg/HCT 12.5 mg) & 1 & 0 & 0 \\
Renitec (Enalapril) 20 mg & 1 & 0 & 1 \\
Diamicron (Gliclacid) 30 mg & 1 & 0 & 0 \\
Lanitop (Digoxin) 0.1 mg & 0 & 1 & 0 \\
Rocaltrol (Calcitriol) 0.25 $\mu$g & 0 & 1 & 0 \\
Indapamid/Fludex 1.5 mg & 0 & 1 & 0 \\
Spirono 50 mg & 0 & 1/2 & 0 \\
Atacand (Candesartan) 16 mg & 0 & 0 & 1 \\
Sortis (Atorvastatin) 40 mg & 0 & 0 & 1 \\
\end{tabular*}
\BS % FARBE
\vspace*{-.5in} 
\myTITLE{Medikation}
\begin{tabular*}{\textwidth}[t]{p{0.7\textwidth}|p{0.1\textwidth}|p{0.1\textwidth}|p{0.1\textwidth}}
Medikament & morgen & mittag & abend \\
\hline
Pantoloc (Pantoprazol) 40 mg & 1 & 0 & 0 \\
Marcoumar (Phencrocoumon) 3 mg & \multicolumn{3}{|c}{2/w 1/4, 5/w 1/2 } \\
Thrombo-ASS (Acetylsilicylsäure) 100 mg & 0 & 1 & 0 \\
Thyrex 50 $\mu$g & 1/2 & 0 & 0 \\
Concor (\color{Red}{Bisoprolol}) 10 mg & 1 & 0 & 0 \\
Atacand plus 16 ({\color{Red}{Candesartan}} 16 mg/{\color{Red}{HCT}} 12.5 mg) & 1 & 0 & 0 \\
Renitec ({\color{Red}{Enalapril}}) 20 mg & 1 & 0 & 1 \\
Diamicron (Gliclacid) 30 mg & 1 & 0 & 0 \\
Lanitop ({\color{Red}{Digoxin}}) 0.1 mg & 0 & 1 & 0 \\
Rocaltrol (Calcitriol) 0.25 $\mu$g & 0 & 1 & 0 \\
Fludex ({\color{Red}{Indapamid}}) 1.5 mg & 0 & 1 & 0 \\
Spirono 50 mg & 0 & 1/2 & 0 \\
Atacand ({\color{Red}{Candesartan}}) 16 mg & 0 & 0 & 1 \\
Sortis (Atorvastatin) 40 mg & 0 & 0 & 1 \\
\end{tabular*}
\BS
\myTITLE{Medikation}
+ Bedarfsmedikation/beim Bett:
\begin{itemize} 
\item Berodualin (Fenoterol/Ipratropium = Parasympatholytikum + Beta2- Sympathomimetikum) 1 - 1 - 1 
\item Spiriva (Tiotropium bromid - AntiCh) 18 $\mu$g 1 - 0 - 0 
\item Aprednislon (Prednisolon) für 6 Tage 50/25 mg 
\end{itemize}	


\BS
\MYTITLE{Danke für die Aufmerksamkeit}

Ende



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