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发布者:鑫达医学翻译 发布时间:2013-04-09 8:50:52 阅读:

原文:
诊治经过:入院后持续心电监护,肝素化治疗,并加用冠心病二级预防药物治疗,监测心肌酶谱,起病后8小时起病8小时后,心肌酶谱达峰,1002u/L。患者持续肝素泵入,11月25 日拔除鞘管,当日予低分子肝素克塞0.6ml q12h抗凝治疗。局部穿刺处未见明显渗血。同时完善相关检查:脂全:TC5.28mrnoi,TG 1.1mmollL, HDL 0.93mrn)ilL, LDL3.74mmoiFL;肾全:K查iinolfL, Cr 69 unollL, CK 560LiJL。肝全未见明显异常。血常规:WBC 10.88'109/L> neut% 75.6 %,HGB 119g/L, PLT 199*109/L。粪便常规+潜血:(-)。

另查ANA、抗dsDNA, ANCA 结果未回。 PCI回报:RCA全程斑块,近段100%闭塞,LM, LAD未见斑块、狭窄,LCX可见斑块。于RCA植.入Cypher支架1枚,术后下TIMI血流3级。

 


译文:
Diagnosis and treatment:
Continuous ECG monitor was performed. Pumping of heparin was conducted. Secondary prevention of coronary heart disease was performed. Myocardial enzymes detection was performed, which indicated the peak level of myocardial enzyme (1002ul) was detected 8h after onset of the disease. Continuous pumping of heparin was conducted. The sheathing canal was removed on Nov 25. Then low molecular heparin (Clexane, 0.6ml, q12h) was administrated for the anticoagulant therapy. No severe capillary hemorrhage was noted in the puncture site. The partial auxiliary examination was as follows:
Fat detection: TC 5.28mmol/L, TG 1.1 mmol/L, HDL 0.93mmol/L, LDL. 3.74mmol/L;
Kidney function: K3.5mmol/L, Cr 69umol/L, CK 560U/L
No abnormality was observed in the liver function determination.
Routine blood test: WBC 10.88*109/L, neut% 75.6%, HGB 199g/1, PLT 199*109/L
The detection for stool routine and occult blood was negative. Pathological lesion in the right coronary artery was noted. Complete occlusion was noted in the proximal right coronary artery. Plaques were noted in the left circumflex coronary artery (LCX). A stent (CYPHER®) was implanted. After surgery, the thrombolysis in myocardial infarction (TIMI) was at level 3.
 


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