PASSPORT SECTION
Sidorov Vladimir Petrovich, 66 years old.
Secondary technical education.
Profession: machine tool adjuster.
Place of residence: Vitebsky pr., 31, building 2, apt.22.
Diagnosis at admission: ischemic heart disease.
Pain behind the sternum of a pressing character, radiating to the back,
lasting about 2 hours, non-stop nitro drugs
tami, cold sweat, dizziness, loss of consciousness.
Associates with prior exercise.
HISTORY OF THE PRESENT DISEASE
character, radiating to the back, lasting about 1.5 hours,
not stopped by nitro drugs, cold sweat, dizziness,
loss of consciousness. With these symptoms he was hospitalized in a cardiac
department of the hospital N 26. The following diagnostics were carried out
IC research:
ECG showing sinus bradycardia, left hypertrophy
ventricle, subepicardial changes;
echocardiography, where dilatation of the left gland cavity was detected
chest x-ray showing enlarged
shadow of the left ventricle;
general and biochemical blood test, urinalysis.
Based on the research results, the diagnosis was made:
ischemic heart disease, acute large-focal myocardial infarction
from 5.10.92. Treatment: heparin therapy, analgesic injections
on, diphenhydramine, isodinite, corinfar; complex drops with dionin, tri-
ampur, panangin, hypothiazide, aspirin, butadion. After the
within a month of the course of treatment, an improvement was noted: symptoms disappeared
volumes of angina pectoris, the patient could fully serve himself, was in
able to climb 1-2 flights of stairs, every day
was discharged.
In the period from November 1992 to October 1996, the patient was disturbed
attacks of angina pectoris (pressing pains behind the sternum, radiating to
left hand, lasting about 10 minutes), mainly associated
with physical exertion, sometimes at rest, having successfully stopped
with nitrosorbide.
Tinsk hospital with complaints of pain behind the sternum of a pressing character
tera, radiating to the back, cold sweat, suffocation, dizziness
condition, loss of consciousness. After resuscitation procedures, it was noted
improvement of the patient's condition and he was transferred to a heart attack
branch.
In 1981, during an examination at a district clinic, where
the patient complained of palpitations, it was revealed that
increase in blood pressure for several days (160/95 mm Hg). ECG
tensile drugs. Between 1981 and 1986, the patient did not
was examined. In the fall of 1986, he again turned to a regional therapist.
onnoy polyclinic with complaints of palpitations. When examining
a periodic increase in blood pressure up to 160/95 mm Hg was found.
followed by lowering to 120/80 mm Hg, slight accent
II tone above the aorta, ECG without changes, on the basis of which the
vili diagnosis: hypertension, grade I, borderline artery
mental hypertension. The patient was prescribed antihypertensive drugs.
In October 1992, based on the results of a survey in
hospital N 26, where the patient was being treated in connection with coronary artery disease
(BP = 160/100 mm Hg for several weeks, on an ECG from
6.10.92 signs of left ventricular hypertrophy; on echocardiogram
from 10.10.92 signs of left ventricular dilation; on the roentgenogram
enlarged shadow of the left ventricle), was diagnosed with hyper-
tonic disease of the II degree, mild arterial hypertension. Pain-
Noma was prescribed antihypertensive drugs: beta-blockers
(anaprilin), diuretics (furosemide), peripheral vasodilators
(apressin, hydrolazine, minoxidil), calcium antagonists (nifedipine,
Nitsch was registered BP = 120/80 mm Hg.
In the spring of 1994, due to complaints of cold extremities
the patient was admitted to the surgical department of the clinic
1st Medical Institute, where the following
diagnostic studies: radiography of the lower extremities,
general and biochemical blood test, general urine analysis and sample by
Zimnitsky. Based on the results obtained,
diagnosis - obliterating atherosclerosis of the arteries of the lower extremities.
As a surgical treatment, amputation of the left
thighs, after which intravenous injections of the vasodilator are prescribed
agents, agents that improve microcirculation and blood rheology
(trental, adelfan, reopolyglyukin). After the treatment
there was an improvement and the patient was discharged.
LIFE STORY OF THE PATIENT
From early childhood he grew and developed normally. Mentally and
physical development did not lag behind their peers. In 1936 g.
moved to Leningrad. From the age of 8 I went to school.
Meals are regular, high-calorie.
After graduating from high school and receiving a technical education-
Niya went to the army, where he served for 8 years.
In 1954 he returned to Leningrad, went to work at the factory
named after Zhelyabov as an adjuster of machine tools, then moved to the factory "Krasny
lighthouse ", where he worked in 3 shifts. Occupational hazard - noise.
He retired at the age of 65.
Married. A healthy baby was born at the age of 28.
I rarely had colds.
Epidemiological history. Infectious diseases, contact with
infectious patients, as well as tuberculosis and venereal diseases
denies. The regions of Russia that are unfavorable in terms of epidemiology do not travel
Family history: Mother and sister suffered from hypertension.
Bad habits: the patient smokes for 54 years, 20 cigarettes per
day. He does not use alcohol and drugs. The tea drinks are moderate
Post, coffee in the morning.
Insurance history. Retired, does not work. Disabled group II.
Allergic history. Allergic reactions to any
drugs were not observed.
OBJECTIVE STATUS
The patient's condition is satisfactory. Consciousness is preserved. Tem-
body temperature is normal. Height 176 cm, weight 65 kg, constitutional
type is normosthenic.
Active position, facial expression was normal. Skin pink
of that color, normal humidity, turgor is preserved. Rash, hemorrhage
there are no streaks or scars. The subcutaneous tissue is moderately expressed. Edema
no. The mucous membranes are clean, pale pink in color.
Lymph nodes are not palpable except for the inguinal.
Thyroid gland of normal size, soft consistency.
Muscular system: general development is moderate. Soreness when feeling
singing no. Joints of normal configuration, mobile, with palms
The treatments are painless.
The shape of the skull is mesocephalic.
The shape of the chest is normal; posture is normal.
The cardiovascular system. When feeling the elbow, radial,
axillary, subclavian and carotid arteries, pulsation is noted.
Pulsation of the femoral, posterior tibial, dorsal artery of the foot is exposed
failed to fire. Pulse rate 46 beats per minute, rhythmic,
good filling. BP - 120/70 mm Hg.
The apical impulse is not palpable.
Borders of relative cardiac dullness: right - in the IV interre-
berier - the right edge of the sternum; upper - III intercostal space; left -
in the V intercostal space 0.5 cm medially from l.mediaclavicularis sinistra.
The boundaries of absolute cardiac dullness: right - in the IV intercostal space -
the left edge of the sternum. Upper - along the lower edge of the IV costal cartilage.
Left - V intercostal space along the parasternal line.
Auscultation: I tone at the apex is weakened, systole is heard
cic noise conducted into the left axillary fossa. Based
II tone louder than I.
Respiratory system. Breathing through the nose. There is no discharge from the nose.
The boundaries of the lungs during percussion: the upper point of standing of the apices of the special
redi - 3 cm above the clavicle, behind - at the level of the VII cervical vertebral
Lower bounds:
right left
l.parasternalis VI rib -
l.mediaclavicularis lower edge of the VI rib -
l.axillaris anterior VII rib VII rib
l.axillaris media VIII rib IX rib
l.axillaris posterior IX rib IX rib
l.scapularis X edge X edge
l.paravertebralis XI rib XI rib
Kroenig fields 4 cm 4 cm
Mobility
pulmonary margin 6.5 cm 9 cm
There is no change with comparative percussion. Auscultatory service
hard breathing. There are no breathing noises and wheezing.
Bronchophonia is determined.
Digestive system. The tongue is not coated. Oral mucosa
pink, tonsils are not enlarged. The belly is of the correct shape.
The skin is pale pink. The vessels are not dilated.
The abdomen takes part in the act of breathing. With superficial pal-
pation is soft, painless.
With deep sliding palpation according to the Obraztsov method in the left
the iliac region over 15 cm palpable sigmoid
intestine in the form of a smooth, moderately dense strand; it is painless
easily displaces, does not gurgle, sluggishly and rarely peristalsis. In the right
the iliac region, the cecum is palpable in the form of a smooth
mild-peristaltic, slightly widened downwards cylinder;
it is painless, moderately mobile, and hums when pressed. In-
the descending and descending parts of the colon are palpated accordingly
venously in the right and left flanks of the abdomen in the form of mobile moderately
dense, painless cylinders. The transverse colon is defined
divided in the umbilical region in the form of a transverse, arcuate
curved downwards, moderately dense cylinder; it is painless
easily slides up and down. 2-4 cm above the navel is felt
greater curvature of the stomach in the form of a smooth, soft, inactive,
painless roller running transversely along the spine in both
sides of it.
The liver is palpable at the edge of the costal arch.
Borders according to Kurlov are 10-9-7 cm.
The spleen could not be palpated. Percussion: Top
lus - IX rib; lower pole - X edge.
Urinary system. Lumbar region without protrusions and
swelling. The skin is pale pink. The kidneys are gone
the feast failed; when tapping on the lower back, the kidney area
painless.
PRELIMINARY DIAGNOSIS AND ITS JUSTIFICATION
for 15 years;
axillary region, -
hearts to the left, -
you can make a preliminary diagnosis of the underlying disease:
workplace noise;
it is possible to make a preliminary diagnosis of a concomitant disease
Preliminary diagnosis:
Main disease:
Ischemic heart disease: acute repeated myocardial infarction from 5.10.96. Postinfarction
cardiosclerosis (acute myocardial infarction from 5.10.92).
Accompanying illnesses:
left thigh from 1994
SURVEY PLAN
Laboratory: general and biochemical blood tests, urinalysis;
Instrumental: ECG, echocardiography, chest X-ray
DATA OF LABORATORY AND INSTRUMENTAL STUDIES
General blood test from 5.10.96: erythrocytes - 4.0 * 10 / l,
Hb - 117 g / l, leukocytes - 8.3 * 10 / l, ESR - 10 mm / h, CP - 0.93.
Rod neutrophils - 5%, segmented - 65%,
eosinophils - 4%, lymphocytes - 21%, monocytes - 9%.
General blood test from 8.10.96: erythrocytes - 4.0 * 10 / l,
Hb - 120 g / l, leukocytes - 6.4 * 10 / l, ESR - 16 mm / h, CP - 0.9.
Rod neutrophils - 5%, segmented neutrophils - 60%,
eosinophils - 4%, lymphocytes - 25%, monocytes - 6%.
Biochemical blood test from 5.10.96: ALT - 0.5 mmol / l;
AST - 0.4 mmol / l; bilirubin: total - 9 μmol / l;
direct - 3 μmol / l, indirect - 6 μmol / l; sugar - 2.8 mmol / l;
urea - 6.5 mmol / l; creatinine - 188 μmol / l;
fibrinogen - 4.5 g / l; prothrombin - 79%; thrombotest - IV Art.
Biochemical blood test from 8.10.96: ALT - 0.1 mmol / l;
AST - 0.4 mmol / l.
Biochemical blood test from 9.10.96: sugar - 4.4 mmol / l.
Urine analysis from 5.10.96: specific weight 1020; the reaction is acidic; protein - 0;
the epithelium is flat - 1; leukocytes - 0-2 in the field of view.
ECG from 5.10.96: AVL - negative T wave; V2 - T is isoelectric;
V4 - T is weakly positive; V1, V2 - R negative; QRS expanded;
ST - oblique descending.
Sinus bradycardia; left bundle branch block.
ECG from 6.10.96: deep S in lead II.
Against the background of sinus bradycardia, an episode of LBBB, with frequent
group ventricular extrasystoles (2-3).
ECG from 8.10.96: P - 0.10 s; R-R 1.10 s; P-Q - 0.16 s;
QRS - 0.11 s; QT - 0.42 s. Heart rate = 55 beats / min.
In leads V2-V5 negative T; V6 - T is isoelectric.
Sinus bradycardia; left ventricular hypertrophy, dynamics
acute focal penetrating changes in the anterior-lateral localization.
ECG from 10/9/96: P - 0.10 s; R-R 1.32 s; P-Q - 0.20 s; QRS -
0.11 s; QT - 0.46 s. Heart rate = 47 beats / min.
In leads V2-V4, T negative changed to positive;
V5 - T is isoelectric; V6 - T is weakly positive.
ECG from 10.10.96: P - 0.10 s; R-R 1.42 s; P-Q - 0.20 s;
QRS - 0.10 s; QT - 0.46 s. Heart rate = 40 beats / min.
Indistinct regular
dynamics of acute focal penetrating changes in the side wall.
ECG from 10/15/96: P - 0.10 s; R-R 1.60-1.30 s; P-Q - 0.16 s;
QRS - 0.10 s; QT - 0.48 s. Heart rate = 38 beats / min.
Deepening of the Q wave in V3-V6. Sinus bradycardia.
Episodes of sinoauricular blockade of the II degree.
FINAL CLINICAL DIAGNOSIS AND ITS RATIONALE
Based on the patient's complaints of pain behind the sternum, pressing character
ra, radiating to the back, lasting about 2 hours, do not buy
nitro drugs, cold sweat, dizziness;
based on the history of the disease, which indicates that
that the patient already had similar symptoms in October 1992, he
was taken to the clinic, where he was diagnosed with myocardial infarction;
based on the data of the anamnesis of life, which says that the pain
Noah worked 3 shifts, smoked a lot, was exposed to noise
at the workplace, the patient has arterial hypertension on
for 15 years;
based on the data of an objective examination: weakening of the I tone by
apex, systolic murmur at the apex, conducted to the left
axillary region;
based on laboratory data: leukocytosis in the first
day (5.10.96 leukocytes - 8.3 * 10 / l), increased ESR on day 3
(8.10.96 ESR - 16 mm / h);
based on data from instrumental studies: negative
T wave on the ECG from 5.10.96, 8.10.96, 9.10.96; negative R wave
on the ECG from 5.10.96; expansion of the QRS complex on the ECG from 5.10.96;
oblique ST interval on the ECG from 5.10.96, -
Based on data from instrumental studies: expansion
R-R interval on ECG from 10/8/96 to 10/15/96, -
the final diagnosis of complications can be made: sinoauricular
blockade of the II degree.
Based on the patient's complaints of dizziness, palpitations;
based on the history of the disease, which says that
that the patient has been suffering from hypertension for 10 years
(BP = 160/100 mm Hg), and from 8.10.96 and on the following days it was
registered blood pressure = 120/80 mm Hg;
based on a history of life, which says that the mother and
the patient's sister suffered from hypertension;
based on the data of an objective examination: expanding the boundaries
hearts to the left;
based on the data of instrumental studies:
the next ST interval on the ECG from 5.10.96; negative T wave on ECG
from 5.10.96, 8.10.96, 9.10.96, -
you can make a final diagnosis of the underlying disease:
hypertension, grade III, mild arterial hypertension.
Based on the patient's complaints about cold extremities;
based on the history of the disease, where it is said that
the patient was previously diagnosed with obliterating atherosclerosis of the arteries
the lower extremities, in connection with which the amputation of the thigh was carried out;
based on the history of life, which says that the patient
worked 3 shifts, smoked for 54 years, was impacted
workplace noise;
based on the data of physical examination: weakening of the pulsation
femoral, posterior tibial, dorsal artery of the foot, -
it is possible to make a definitive diagnosis of a concomitant disease
niya: obliterating atherosclerosis of the arteries of the lower extremities; am-
left hip swelling from 1994
Final clinical diagnosis:
Main disease:
Ischemic heart disease: acute recurrent anterior non-penetrating myocardial infarction from
5.10.96. Postinfarction cardiosclerosis (acute myocardial infarction from
Hypertensive disease, grade III, mild arterial hypertension.
Complication:
Sinoauricular block II degree
Concomitant disease:
Obliterating atherosclerosis of the arteries of the lower extremities; amputation
left thigh from 1994
To clarify the diagnosis, it is necessary to conduct echocardiography,
genography of the chest. Survey data were not carried out.
DIFFERENTIAL DIAGNOSIS OF THE DISEASE
Myocardial infarction should be differentiated from angina pectoris,
sloughing aortic aneurysm and some other diseases.
1. Differential diagnosis of myocardial infarction and angina pectoris.
Myocardial infarction Angina pectoris
The nature of the pain Frequent attacks or With physical exertion
prolonged attack and at rest
The action of nitro is ineffective or effective
drugs are ineffective
Duration
pain for 30 minutes or more 5-10 minutes
Decrease in blood pressure + -
Blood test:
leukocytosis up to 8 * 10 / l 1-2 days no
ESR, mm / h increases to 20 but does not increase
Hyperfermentemia of CPK - no after 6-8 hours
LDH - after 24-48 hours
LDG1 - after 8-12 hours
AST - after 8-12 hours
Signs on the ECG with penetrating: ischemic changes:
the appearance of pathology - ST increases or decreases -
iic Q, disappears, reversal of T
change or decrease
R; ST on the isoline.
with non-penetrating:
RST higher or lower
isolines and (or) raz-
no-like pathologies
ical changes in T
2.Differential diagnosis of myocardial infarction and dissecting aneu-
aortic rhizma.
Myocardial Infarction Exfoliating
aortic aneurysm
Action of nitro- Ineffective or Ineffective
drugs are ineffective
Anamnesis data Attacks of angina pectoris High and persistent artery
Rial hypertension
Pain Pressing or constricting Behind the sternum, migrating
behind the breastbone in the back, lower back,
abdominal cavity
Shortness of breath Severe in asthma- Often
the technical version
Vomiting May Be Rare
Physical data- Muting tones, lowering blood pressure, systolic-
on examination, disruption of the rhythm, lower diastolic murmur on
aortic blood pressure, disappearance
heart rate on a.radialis
Signs on the ECG with penetrating: Decreased ST segment,
the appearance of a T wave pathology
ical Q, disappeared
change or decrease
R; ST on the isoline.
with non-penetrating:
RST higher or lower
isolines and (or) raz-
no-like pathologies
ical changes in T
Hyperenzymemia CPK - after 6-8 hours Absent
LDH - after 24-48 hours
LDG1 - after 8-12 hours
AST - after 8-12 hours
X-ray data - Uncharacteristic Expansion of one of
gical research - departments of the aorta
PATHOLOGICAL ANATOMY
Morphological examination of the heart in patients who died from a heart attack
myocardium, confirms the different severity of atherosclerosis of the
arteries.
There are three main zones of myocardial changes in infarction:
the focus of necrosis, the prenecrotic zone and the area of the heart muscle, from-
far from the zone of necrosis. 6-8 hours after the onset of the disease,
are edema of interstitial tissue, swelling of muscle fibers,
expansion of capillaries with blood stasis in them. After 10-12 hours, these
changes become more distinct. They are joined by the regional
standing of leukocytes, erythrocytes in the vessels, diapedetic hemorrhages
on the periphery of the affected area.
By the end of the first day, muscle fibers swell, their outlines disappear
zyute, sarcoplasm acquires a clumpy character, the nuclei swell,
become pyknotic, dense, structureless. The walls of the arteries in
the zone of myocardial infarction swell, the lumen is filled with homogenized
noisy mass of erythrocytes. At the periphery of the necrosis zone, an exit is noted
from the vessels of leukocytes forming the demarcation zone.
In the prenecrotic region of the myocardium, dystrophic diseases predominate.
changes in muscle fibers, manifested by intracellular edema,
destruction of the energy-generating structures of mitochondria.
Within 3-5 hours after the development of myocardial infarction in the heart muscle
severe, irreversible changes in the structure of muscle fibers occur
end with their death.
The outcome of myocardial necrosis is the formation of connective tissue
th scar.
ETIOLOGY OF THE DISEASE
Among the direct causes of the development of myocardial infarction should be
name a prolonged spasm, thrombosis or thromboembolism of the coronary arteries
ry of the heart and functional overstrain of the myocardium in conditions
atherosclerotic occlusion of these arteries. Etiological factors
atherosclerosis and hypertension, primarily psychoemotional
nal tension leading to angioedema disorders, such
they are also etiological factors of myocardial infarction.
PATHOGENESIS OF THE DISEASE
Most often, there are several pathogenic factors of the "vicious
th circle ": spasm of the coronary arteries -> platelet aggregation ->
thrombosis and increased spasm or thrombosis -> release of vasoconstriction -
rictor substances from platelets -> spasm and increased thrombosis.
Platelet aggregation increases with atherosclerotic lesions -
nii vessels. An additional factor contributing to thrombosis is
slowing down of blood flow velocity in stenotic coronary
arteries or with spasm of the coronary arteries.
With myocardial ischemia, sympathetic nerves are stimulated
endings followed by norepinephrine release and stimulation
the adrenal medulla with the release of catecholamines into the blood.
Accumulation of under-oxidized metabolic products during myocardial ischemia
children to irritation of myocardial interoreceptors or coronary
dov, which is realized in the form of a sharp pain attack,
accompanied by activation of the adrenal medulla with maximum
a simultaneous increase in the level of catecholamines during the first hours
diseases. Hypercatecholaminemia leads to disruption of processes
energy production in the myocardium. Increased sympaoadrenal activity
system, acquiring in patients with acute myocardial infarction
at first compensatory in nature, soon becomes pathogenic in
conditions of stenosing atherosclerosis of the coronary arteries of the heart.
BASIC PRINCIPLES OF THERAPY
Mode N 2; restricted diet
calorie content due mainly to easily digestible carbohydrates and
animal fats. Eliminate cholesterol-rich foods
sterol and vitamin D. Into the food ration to enter: products with-
lipotropic, vegetable oil with a high
the consumption of polyunsaturated fatty acids, vegetables, fruits and berries (vit-
min C and vegetable fiber), seafood rich in iodine.
Diet: 5-6 times a day in moderation, dinner for 3 hours
Physiotherapy. Pharmacological therapy: to eliminate
pain syndrome - narcotic analgesics; fentanyl with droperi-
dolom, nitrous oxide anesthesia, epidural anesthesia; thrombolytic
ical and anticoagulant therapy; streptase, streptodecase, hepa-
rhin and indirect anticoagulants; to prevent the area from enlarging
necrosis, along with thrombolytic drugs and anticoagulants
use nitrates, beta-blockers; for emergency -
cardiac glycosides; vitamin therapy - ascorbic, nicotine
In the subacute period, focus on measures aimed
to improve coronary circulation and cardiac activity,
use prolonged-release nitrates and indirect anticoagulants
TREATMENT OF THE PATIENT
Mode N 2; diet N 10c. Pharmacological therapy:
Drug Purpose
1.Rp .: Tab.Nitroglicerini 0.0005 For relief of an attack
D.t.d.N. 40 angina pectoris
S. 1 tablet under the tongue
2.Rp .: Tab.Nitrosorbidi 0.005 To improve blood supply
D.t.d.N. 50 and myocardial metabolism
S. 1 tablet 2-3
once a day
3.Rp .: Heparini 5 ml (25000 ED) To reduce aggregation
D.S. 1 ml intramuscularly platelet capacity, ac-
4 times a day tivization of fibrinolysis
4.Rp .: Tab.Phenigidini 0.01 For the treatment of hypertensive
D.t.d.N. 50 diseases
S. 2 tablets 3 times
5.Rp .: Tab.Acidi ascorbinici 0.1 Vitamin
S. 1 tablet 2-3 times
FORECAST OF THE DISEASE
For life - favorable;
for recovery - unfavorable;
for working capacity - unfavorable.
DISEASE PREVENTION
Primary: physical activity; food rich in polyunsaturated
fatty acids, anti-atherogenic substances; avoid emotional
overvoltage, stress; fight against risk factors (obesity,
diabetes mellitus, etc.); quitting bad habits (smoking);
moderate alcohol consumption (for prevention, 30-40 g per day);
Secondary: physiotherapy exercises; avoid hard physical
loads, emotional stress, stress; low diet
vegetable fiber, seafood; complete rejection of harmful
habits - smoking and drinking alcohol; living in ecology
clean area, frequent walks in the fresh air, sanatorium
spa treatment. For the prevention of angina attacks,
change nitro drugs (nitrosorbide, nitroglycerin).
Patient Sidorov Vladimir Petrovich, 66 years old, was admitted to Elizavetins-
kuyu hospital 5.10.96 with complaints of pain behind the sternum pressing ha-
rakter, radiating to the back, lasting about 2 hours, not
stopped by nitro drugs, cold sweat, dizziness,
loss of consciousness. From the anamnesis it is known that the patient for 4 years
suffers from ischemic heart disease, 5.10.92 suffered an acute myocardial infarction. During
while in the hospital, the following diagnostic
research: blood test, general and biochemical, urinalysis,
ECG. Based on the results obtained, acute
repeated myocardial infarction from 5.10.96. Therapy was carried out:
pharmacological - nitrosorbide, aspirin, corinfar;
intravenous injections of analgin, sibazon, aminophylline, glucose,
sodium chloride, potassium chloride; physiotherapy.
As a result of the treatment, the patient's well-being was noted
there was an improvement: the symptoms of angina pectoris disappeared, the patient could
self-service, was able to climb 1-2
flights of stairs, daily walks through the territory
loads, emotional stress, stress; low diet
polyunsaturated fatty acids, anti-atherogenic substances,
vegetable fiber, seafood; complete smoking cessation;
living in an ecologically clean area, frequent walks on
fresh air, spa treatment. Periodically observed
given by a cardiologist. If you experience symptoms of angina pectoris, take
nitrosorbide.
FINAL DIAGNOSIS
Main disease:
Ischemic heart disease: acute recurrent anterior non-penetrating myocardial infarction from
5.10.96. Postinfarction cardiosclerosis (acute myocardial infarction from
Hypertensive disease, grade III, mild arterial hypertension.
Complication:
Sinoauricular block II degree
Concomitant disease:
Obliterating atherosclerosis of the arteries of the lower extremities; amputation
left thigh from 1994
LIST OF USED LITERATURE
1. Komarov F.I., Kukes V.G., Smetnev A.S. et al. Internal bo-
get sick. M., "Medicine", 1991.
2. Karpman V.L. Phase analysis of cardiac activity. M., 1985.
3. Lang G.F. Hypertonic disease. M., 1950.
4. Strukov A.I., Serov V.V. Pathological anatomy. M., "Medicine
5. Lectures on Internal Medicine. SPb, 1996.
Curator's signature:
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Department of Propedeutics
internal diseases
head of department
professor, DMN
Voznesensky N.K.
assistant
Savinykh E.A.
disease history
in pulmonology and
cardiology
Patient: Vaneeva Antonina Isakovna
Diagnosis: ischemic heart disease, angina pectoris II FC,
Hypertensive heart disease II, encephalopathy.
Curator: medical student
faculty group L-317
Zhurakovskaya O.V.
General information about the patient:
1. Full name Vaneeva Antonina Isakovna
02/2/1923 year of birth.
3.nationality - Russian.
4. education - secondary.
5. place of work - does not work.
6.Home address - Kirov, Metallurgov str. 9-12
7. was admitted to the clinic on 24.11.00 (at 12.00) with an ambulance.
Patient questioning data:
I. Main complaints:
The patient complains of an increase in blood pressure up to 300 (working pressure 160/100), headaches, trembling, vomiting, flashing of flies before the eyes, tinnitus.
Pain in the region of the heart pressing, dull. During an attack, stabbing pains, spilled, long, intense. The pains are accompanied by dizziness. After the injection (which, the patient does not know), the pain disappears in about 40 minutes.
II.General complaints:
Weakness, malaise.
III. There are no complaints from other bodies and systems.
1.Since 1972, she considers herself ill, when she first felt pain in the region of the heart. During the last 5 years, there were 3 attacks with a sharp increase in blood pressure, dizziness, flashing of flies before the eyes, weakness. During the last attack, she called an ambulance and was admitted to the clinic for treatment.
2. The patient associates the appearance of the main complaints with a stressful situation (death of her husband).
3. She did not seek medical help, she was treated at home, taking validol.
4. Was admitted to the clinic for treatment during an attack.
She was born in the Svechinsky region, where she lived until 1944. The family had 8 children, and began working at the age of 12. Since 1944 she has been living in Kirov, worked as an accountant. At the time of supervision, it does not work.
Marital status: widow, has a daughter.
Housing and living conditions: the apartment is comfortable, eats at home, regularly.
She suffered from colds, dysentery.
She denies sexually transmitted diseases, tuberculosis, hepatitis, AIDS.
The younger sister has a similar disease.
Allergy to penicillin, no food allergy.
Hemotransfusion has not been previously performed.
Data from physical research methods.
I. General examination of the patient.
1. General condition - satisfactory.
2. Consciousness is clear.
3. The patient's position is active.
4. The Constitution is a hypersthenic.
5. Body type - correct.
6.Height - 162 cm.
weight - 75 kg.
Height-weight indicator-46
Skin.
Pale in color, clean, normal moisture content, reduced elasticity.
Visible mucous membranes
Physiological color, clean.
Subcutaneous tissue
Developed normally, the fat layer is evenly distributed,
The lymph nodes
Submandibular, cervical, supraclavicular, axillary, inguinal - not increased.
Musculoskeletal system
Palpation is normal, the spine has physiological curves.
Joints
Palpation is normal.
Temperature- normal.
II. Respiratory system.
Upper respiratory tract condition- breathing through the nose.
Chest examination.
Static inspection:
The shape of the chest is normal
· Supra- and subclavian fossa are expressed slightly;
· Symmetry of the clavicles;
· The severity of the angle of Ludovitsa;
· The direction of the ribs is moderately oblique;
· The epigastric angle is approximately 90 °;
· The shoulder blades are symmetrically spaced from the chest.
Dynamic inspection:
• type of chest breathing;
· Movement of the chest during breathing is uniform;
Palpation:
· Resistance of intercostal spaces;
Percussion:
· The height of standing of the tops of the lungs in front of the right and left - 4 cm, behind - on the right and left at the level of the spinous process of the VII cervical vertebra.
· Kroenig's field width - 8 cm;
The location of the lower borders of the lungs.
Mobility of the lower edges of the lungs
Auscultation:
· Over the entire surface of the lungs - vesicular respiration.
· No pathological wheezing.
· The ratio of the phases of inhalation and exhalation is preserved.
III The cardiovascular system:
Examination of the area of the heart and peripheral vessels.
· visible pulsation of the temporal, carotid, in the jugular fossa, no arteries of the extremities, no venous pulse.
· there are no protrusions of the region of the heart.
· there is no visible pulsation of the pulmonary trunk, aorta, cardiac impulse and epigastric pulsation.
· The apical impulse is located in the intercostal space 1 cm medially from the SCL.
· No abdominal enlargement.
Palpation:
· The condition of the temporal, carotid, aortic arch, brachial artery is normal.
Arterial pulse:
1) symmetrical; 5) full;
2) rhythmic; 6) large;
3) frequency - 57; 7) high and fast.
4) solid;
Apical impulse:
1) position - 5 m / rib 1 cm medially from the SCL;
2) limited;
3) high;
4) strong;
5) resistant.
· There is no tremor of the chest.
· No pathological pulsations.
· No pericardial friction.
Percussion:
Borders of relative cardiac dullness:
right - 1 cm outward from the right edge of the sternum at 4 m / rib;
left - 1 cm medially from the left SCL at 5 m / rib;
upper - 1 cm outward from the left sternal line at the level of the upper edge of the III rib;
waist of the heart - along the parasternal line at 3 m / rib;
borders of the vascular bundle - 2 m / rib along the edges of the sternum.
Boundaries of absolute cardiac dullness:
right-left edge of the sternum at 4 m / rib;
left - 1 cm medially from the left border of relative cardiac dullness at 5 m / rib;
upper - at the level of the IV rib along a line located 1 cm laterally from the left sternal line.
Auscultation:
· Tones are clear, rhythmic, heart rate = 20 / min, the ratio of tones at all points: weakening of the I tone at the apex, the accent of the II tone above the aorta, the rhythm is two-term.
· No pathological murmurs.
Preliminary diagnosis:
Essential hypertension II stage of decompensation, encephalopathy of II stage.
Syndromes:
1. Arterial hypertension syndrome (leading):
Under the influence of a stressful situation, the excitability of the cerebral cortex and hypothalamic autonomic centers increases. This leads to a spasm of the arterioles of internal organs, especially the kidneys, which in turn causes the production of renin JHA of the kidneys, in the presence of which the inactive form of plasma angiotensin turns into an active form with a pronounced pressor effect. As a result of this, the blood pressure rises. With a further increase in blood pressure, it becomes more constant, because the influence of pressor mechanisms increases.
Symptoms:
Increase in blood pressure more than 160/100
The pulse is symmetrical, hard (due to the compaction of the vascular wall), high and fast (due to a decrease in the elasticity of the aorta)
Percussion - expansion of the borders of the vascular bundle,
· Auscultatory-weakening of the I tone at the apex, the accent of the II tone over the aorta.
2) Syndrome of myocardial damage:
Cardialgia syndrome
Pressing pains, dull. During an attack, stitching, long, diffuse.
Cardiomegaly syndrome
Aortic configuration of the heart
ECG: Rv5.6> Rv4, el. Axis deflected to the left, shift of the transition zone to the right, kV1.2, increase in the time of internal deflection in V5.6> 0.05 ", displacement of the ST segment and negative T in V56, I, aVL.
3) Syndrome of vascular encephalopathy:
Dizziness, tinnitus, flashing of flies before the eyes.
4) Syndrome of coronary insufficiency:
The cause of an attack of angina pectoris is angiosposm, which is associated with a violation of the mechanisms of neurohumoral regulation of the heart. As a result, myocardial oxygen demand increases and hypoxia develops, which leads to metabolic disorders, the release of biologically active substances from the cells that irritate myocardial interoreceptors and vascular adherence.
Coronary pain syndrome:
Pressing pains, arising in standard conditions, prolonged;
ECG: during an attack - depression of the ST segment, the appearance of negative T.
5) Clinical anamnestic syndrome.
Patient's additional research plan:
2.B / chemical analysis of blood.
4.Analysis of urine according to Nechiporenko.
5.Analysis of urine according to Zimnitsky.
Tell us about us!
Clinical diagnosis:
1) The main disease is ischemic heart disease, stable exertional angina, III functional class; atrial fibrillation; chronic heart failure stage IIB, IV functional class.
2) Complication of the underlying disease - ischemic stroke (1989); chronic discirculatory encephalopathy
3) Background diseases - hypertension stage III, risk group 4; inactive rheumatism, combined mitral defect with a predominance of insufficiency.
4) Concomitant diseases - bronchial asthma, cholelithiasis, urolithiasis, COPD, diffuse nodular goiter.
PASSPORT DATA
- Full Name - ******** ********* ********.
- Age - 74 years old (born 1928).
- Female gender.
- Russian nationality.
- Education - secondary.
- Place of work, profession - retired from 55 years old, previously worked as a technologist.
- Home address: st. *********** d. 136, apt. 142.
- Date of admission to the clinic: October 4, 2002.
- The diagnosis on admission was rheumatism, inactive phase. Associated mitral valve disease. Cardiosclerosis. Paroxysmal atrial fibrillation. Hypertension stage III, risk group 4. Heart failure IIA of the left ventricular type. Chronic discirculatory encephalopathy.
COMPLAINTS ON ADMISSION
The patient complains of shortness of breath, especially in a horizontal position, severe weakness, diffuse headache, discomfort in the heart, interruptions in the work of the heart, periodic, paroxysmal, non-intense stitching pains in the heart, arising in a calm state, radiating to the left shoulder. Dyspnea is relieved by sitting. When walking, shortness of breath increases, pain in the heart area occurs more often.
HISTORY OF THE PRESENT DISEASE
Considers herself ill since 1946, when she was 18 years old. After angina, rheumatism developed, which manifested itself in intense pain in large joints, swelling, and a sharp difficulty in movement. She was treated in the 3rd city hospital, received salicylic acid. In 1946 he was diagnosed with mitral valve insufficiency of the 1st degree. In 1950, at the age of 22, there was a repeated rheumatic attack after suffering a sore throat. A rheumatic attack was accompanied by severe joint pain, dysfunction of the joints, swelling of the affected joints (elbow, hip). In 1954 she underwent tonsillectomy. Since 1972 (age 44), the patient has noted regular increases in blood pressure (BP) up to 180/100 mm Hg, sometimes up to 210/120 mm Hg. In 1989 - a stroke. She took antihypertensive drugs, including in 1989-2000. clonidine. Since 1973 he has been suffering from chronic pneumonia; since 1988 - bronchial asthma; developed an allergy to odors. Since 1992, she was diagnosed with gallstone disease, and she refused the operation. In the last 3 years, complaints of shortness of breath. Shortness of breath increased 4 days before hospitalization.
LIFE STORY OF THE PATIENT
She was born in the Voronezh region in a family of collective farmers. Living conditions in childhood were difficult. She grew and developed in accordance with her age. She worked first as a primary school teacher, then as a technologist, first in the city of Bobrov, then in the Khabarovsk Territory, then in Voronezh. The work was related to ammonia. The psychological atmosphere in the team was friendly, conflicts rarely arose.
Does not smoke, alcohol consumption is moderate, drug use denies. For 11 years (1989-2000) regularly took clonidine in connection with hypertension.
As a child, she often suffered from colds and sore throats. At the age of 18 - rheumatism with damage to the mitral valve of the heart. Since 1972 (age 44) - hypertension, since 1973 - chronic pneumonia, since 1978 - bronchial asthma, since 1988 - allergy to odors. 1989 - suffered a stroke. From 1953 to 1990, she noted stabbing pains in the region of the heart. 1992 - gallstone disease. Since 1994 - a disabled person of the II group. 1996 - atrial fibrillation. In the past two years, she has noted a decrease in body weight by 10 kg. In 1997, she was diagnosed with urolithiasis, cysts in the kidneys, noted pain in both kidneys, radiating to both legs. In 2000, a nodular goiter was discovered. Took mercazolil, potassium iodide, L-thyroxine. She stopped treatment, as she noted worsening from the therapy.
He denies tuberculosis, Botkin's disease, venereal diseases in himself and his relatives. Allergy to antibiotics. The mother died at the age of 51 (according to the patient, probably a stroke), the father died at 73, suffered from hypertension.
She has been married since the age of 22. Menstruation began at age 15, regular. Pregnancies - 7, childbirth - 2, induced abortions - 5. The pregnancies proceeded calmly, there was no threat of termination of pregnancy. Menopause from 48 years old. Notes an increase in the frequency and degree of rise in blood pressure after menopause.
PRESENT CONDITION OF THE PATIENT
General inspection.
The patient's condition is moderate. Consciousness is clear. The patient's position is active, but she notes that dyspnea increases in the horizontal position and when walking, so she spends most of the time in the "sitting" position. Facial expression is calm, however, there is "mitral" cyanosis of the lips. The body type is normosthenic, a patient of moderate nutrition, however, she notes that over the past two years she has lost 10 kg. In youth and adulthood, she was overweight. Height - 168 cm, weight - 62 kg. Body mass index - 22.
The color of the skin is pale, with a yellowish tinge. Skin turgor is reduced, there is excess skin, which indicates a decrease in body weight. The skin is wrinkled, especially on the hands. The hairline is moderately developed, the growth of hair on the upper lip is enhanced.
There are mild edema of the legs, constant, decrease after taking furosemide. There is a poorly healing wound on the right leg resulting from a household injury.
Submandibular lymph nodes are palpated, moderately dense, painless, pea-sized, mobile, not soldered to each other and to the surrounding tissues. The skin above them is not changed. Other peripheral lymph nodes are not palpable.
The muscular system is developed in accordance with age, there is general muscle wasting, muscle strength and tone are reduced. Soreness and tremors of the muscles were not detected. The head and limbs are of normal shape, the spine is deformed, asymmetry of the clavicles is noticeable. The joints are mobile, painless on palpation, the skin in the area of the joints is not changed.
Body temperature - 36.5 ° C.
CIRCULATORY SYSTEM
The chest in the region of the heart is protruding ("heart hump"). The apical impulse is palpated in the fifth intercostal space along the left nipple line, diastolic tremor is determined. The impulse is not palpable. Musset's symptom is negative.
Percussion of the heart: the boundaries of the relative dullness of the heart - right - along the right edge of the sternum, upper - in the third intercostal space, left - along the midclavicular line. The width of the vascular bundle is 5 cm in the second intercostal space. The length of the heart is 14 cm, the diameter of the heart is 13 cm.
Auscultation of the heart. Heart sounds are weakened, I tone is sharply weakened. The accent of the II tone above the aorta is determined. A systolic murmur is heard at all points of auscultation. The systolic murmur is best heard at the apex. Heart rate (HR) - 82 beats / min. Pulse rate (Ps) - 76 beats / min. Pulse deficiency (pulsus defficiens) - 6. Pulse irregular, full, satisfactory filling. BP = 150/85 mm Hg on the right arm, BP = 140/80 on the left arm.
RESPIRATORY SYSTEM
The nose is of the correct shape, palpation of the paranasal sinuses is painless. The larynx is painless on palpation. The shape of the chest is normal, symmetrical, there is a slight protrusion in the region of the heart. The type of breathing is chest. Respiratory rate (RR) - 24 per minute. Breathing is rhythmic, shallow. Severe dyspnea, aggravated in horizontal position and when walking. The rib cage is resistant, the integrity of the ribs is not broken. There is no pain on palpation. The intercostal spaces are not widened. Voice tremor is enhanced.
With percussion, the dullness of the percussion sound in the lower parts of the lungs is determined: along the scapular line at the level of the IX rib on the left and at the level of the VII rib on the right. In the rest of the lungs there is a clear pulmonary sound. Topographic percussion data: the lower border of the right lung along the midclavicular line - 6 rib, along the mid axillary line - 8 rib, along the scapular line - 10 rib; the lower border of the left lung along the midclavicular line - the 6th intercostal space, along the middle axillary line - 8 rib, along the scapular line - 10 rib (dullness). The width of Kroenig's fields is 5 cm.
During auscultation, bronchovesicular breathing is heard, fine bubbling rales are heard, breathing is weakened in the lower parts of the right lung.
Digestive system
The mucous membrane of the mouth and pharynx is pink and clean. The tongue is moist with a light coating, the taste buds are well pronounced. The dentition is not preserved, many teeth are missing. The lips are cyanotic, the corners of the lips are without cracks. The anterior abdominal wall is symmetrical and participates in the act of breathing. Abdomen shape: "frog" belly, which indicates the presence of free fluid in the abdominal cavity. With percussion of the lateral parts of the abdomen, a slight dullness of the percussion sound is revealed. Visible intestinal peristalsis, hernial protrusions and enlargement of the saphenous veins of the abdomen are not detected. On palpation, there is no muscle tension and soreness, the abdominal press is moderately developed, there is no divergence of the rectus abdominis muscles, the umbilical ring is not enlarged, there is no fluctuation symptom. Symptom Shchetkin-Blumberg negative.
The lower edge of the liver is painless, protrudes 4 cm from under the costal arch. The size of the liver according to Kurlov is 13 cm, 11 cm, 9 cm. The spleen is not palpable. Soreness at the point of projection of the gallbladder is a positive symptom of Zakharyin. Symptoms of Georgievsky-Mussey, Ortner-Grekov, Murphy are negative.
URINE SYSTEM
On examination of the lumbar region, no swelling or bulging was found. The kidneys are not palpable. Pasternatsky's symptom is negative on both sides. The reproductive system is normal.
ENDOCRINE SYSTEM
The thyroid gland is not visualized. An isthmus of 5-7 mm is palpated and an increase in both lobes of the gland is noted. In the left lobe of the thyroid gland, nodes are palpated. The shape of the eye slits is normal, there is no bulging. The presence of increased hair growth on the upper lip.
Consciousness is clear. The memory for real events is reduced. Shallow sleep, often waking up at night due to increased dyspnea in a horizontal position. No speech disorders. The coordination of movements is normal, the gait is free. Reflexes were preserved, convulsions and paralysis were not found. Vision - left eye: cataract, no vision; right eye: moderate myopia, reduced vision. Hearing is impaired. Dermographism is white, rapidly disappearing.
Ischemic heart disease, arrhythmic variant. Atrial fibrillation. Exertional angina pectoris II FC, chronic heart failure IIB stage, IV functional class. Hypertensive disease of the III degree, 4 risk group, inactive rheumatism, stenosis and mitral valve insufficiency.
General blood test, biochemical blood test, general urine analysis, ECG, Echo-KG, urine analysis according to Nechiporenko, phonocardiography, Holter monitoring, TSH blood test, examination by an ophthalmologist.
General blood analysis (7.10.02):
Hemoglobin (Hb) - 116 g / l (N = 120-150)
Erythrocytes - 3.6 * 10 12 / l (N = 3.7-4.7)
Leukocytes - 6.2 * 10 9 / l (N = 5-8):
eosinophils - 3% (N = 0.5-5)
stab neutrophils - 5% (N = 1-6)
segmented neutrophils - 66% (N = 47-72)
Medical history - ischemic heart disease - cardiology
Diagnosis of the underlying disease: Ischemic heart disease. Functional class III exertional angina. Atherosclerosis V / A, CABG in 2001. Atherosclerotic aortic disease. AK prosthetics in 2001 NK IIB Art. CHF IV à III. Hypertension stage III, risk 4. Concentric LV hypertrophy. Diastolic dysfunction. Dyslipidemia IIb. CKD stage III
I. Passport part
- Full Name: -
- Age: 79 years (date of birth: 11/28/1930)
- Female gender
- Profession: pensioner, disabled of the II group
- Place of permanent residence: Moscow
- Date of admission to the hospital: November 8, 2010
- Date of supervision: November 22, 2010
II. Complaints about:
- shortness of breath (when getting out of bed, a few steps along the corridor), subsiding at rest after 2-3 minutes;
- pain behind the sternum, pressing in nature, radiating to the left arm, arising with minimal physical exertion. Can be stopped with nitroglycerin;
- palpitations;
- weakness;
- rapid fatigue.
III. History of the present disease (Аnamnesis morbi)
Considers himself a patient since 2001, when chest pains, palpitations, a rise in blood pressure, weakness and fatigue appeared. She was sent to the Research Institute of Transplantology, where, on the basis of ECG, ultrasound of the heart, coronary angiography and probing of the cardiac cavities, the following diagnosis was made:
Atherosclerotic aortic heart disease with predominance of stenosis,
Calcification 3st,
Arterial hypertension of the 2nd degree (with maximum figures up to 170/100 mm Hg, adapted to 130/80 mm Hg);
Angina pectoris of exertion and rest, stenotic lesion of the coronary arteries
Accompanying illnesses:
Chronic gastritis (EGDS)
On November 22, 2001, the patient underwent surgery: aortic valve replacement and coronary artery bypass grafting of the anterior interventricular and right coronary artery. The postoperative period was complicated by cardiac and respiratory failure.
Appointed:
Sincumar ½ x 2p / d
Prestarium 1t / d
Atenolol 50mg - ½t x 2r / d
Digoxin 1 / 2t x 2r / d
Libeksin 2t x 2p / d
During treatment, the patient's condition improved. Sternum pain was much less common. The shortness of breath has diminished. Hemodynamic parameters stabilized at 130/80 mm Hg. Heart rate - 73 / min.
In January 2010. with complaints of frequent pain behind the sternum, she was admitted to the City Clinical Hospital No. 1, where I was diagnosed with coronary artery disease, unstable angina pectoris. Prescribed: monocinque (40mg-2r), thrombotic ACC (100mg-in the morning, 2.5mg-1r in the evening), concor (3mg-1r), nifecard (30mg-2r), sinhal (10mg-1r).
11/8/2010 felt pressing severe pain behind the breastbone, shortness of breath, turned to the city polyclinic No. 60, from where she was sent for inpatient treatment at City Clinical Hospital No. 64.
IV. Life story (Аnamnesis vitae)
She was born in 1930 in Moscow. She grew and developed normally. She did not lag behind her peers. Received a complete secondary education.
Family and sex history. menstruation from the age of 14, were established immediately, after 28 days, for 4 days, moderate, painless. Has been married since the age of 22. She had 2 pregnancies, which ended in two urgent births. Menopause at 55. The climacteric period was uneventful. She is currently married and has two children: a son of 40, a daughter of 36.
Work history. She began her career at the age of 22. After graduation and until retirement (at the age of 55) she worked as a biology teacher at school. Professional activity was associated with psycho-emotional stress.
Household history. The family consists of four people and currently occupies a comfortable three-room apartment with a total area of more than 70 m 2. Throughout her life she lived in Moscow, never been to environmental disaster zones.
Nutrition. high-calorie, varied. In recent years, he has been trying to comply with the diet.
Bad habits. does not smoke, alcohol, drugs.
Past illnesses. in early childhood she suffered from mumps, measles, complicated by otitis media. During her subsequent life, she suffered from "colds" diseases on average 1-2 times a year.
Epidemiological history. in contact with febrile and infectious patients, in endemic and epizootic foci was not. Blood transfusion. its components and blood substitutes were not carried out. Injections, operations, oral cavity sanitation, and other medical procedures that violate the integrity of the skin and mucous membranes have not been performed over the past 6-12 months.
Allergic history. not weighed down.
Heredity. father died at 68 from stomach cancer. The mother suffered from hypertension with high blood pressure, died at the age of 72 from a stroke. The sister died at the age of 55 from a breast tumor.
VI. Status praesens
The general condition of the patient: moderate.
Consciousness: clear.
Patient position: active.
Body type: normosthenic constitutional type, height 164 cm, body weight 75 kg, BMI 27.9 - overweight (pre-obesity). The posture is stooped, the gait is slow.
Body temperature: 36.6 ° C.
Facial expression: tired.
Skin, nails and visible mucous membranes. The skin is clean. Moderate acrocyanosis is observed. Scars in the chest area from coronary artery bypass grafting and aortic valve replacement. Visible tumors and trophic changes in the skin are not detected. Slight swelling of the legs at the level of the ankles and feet.
The skin is dry, its turgor is somewhat reduced. Hair type is female.
Nails: the shape is correct (there are no changes in the shape of the nails in the form of "watch glasses" or koilonychia). The color of the nails is cyanotic, there is no striation.
Visible mucous membranes cyanotic, wet; rashes on the mucous membranes (enanthema), ulcers, no erosion.
Subcutaneous fat. moderately and evenly developed. The thickness of the subcutaneous fat layer at the level of the navel is 2.5 cm. There is no edema or pastiness. Soreness and crepitus on palpation of the subcutaneous fat is absent.
Lymph nodes: not palpable.
Zev : pink color, moist, no puffiness and plaque. Tonsils do not protrude beyond the arches, pink, without swelling and plaque.
Muscles. developed satisfactorily. Muscle tone and strength are slightly reduced. There is no soreness and seals on palpation of the muscles.
Bones: The shape of the bones of the skeleton is not changed. There is no soreness when beating bones.
Joints: the configuration of the joints is not changed. There is no swelling and soreness of the joints when feeling them, as well as hyperemia, there is no change in the temperature of the skin over the joints. Active and passive movements in the joints in full.
RESPIRATORY SYSTEM
Complaints: shortness of breath that occurs with minimal exertion, not worsening when lying down.
Nose: the shape of the nose is not changed, breathing through the nose is somewhat difficult. There are no discharge from the nose.
Larynx: no deformities or swelling in the larynx region. The voice is low, hoarse.
Rib cage. the shape of the chest is normosthenic. The supraclavicular and subclavian fossa are pronounced. The width of the intercostal spaces is moderate. The epigastric angle is straight. The shoulder blades and collarbones protrude distinctly. The rib cage is symmetrical. The circumference of the chest is 86 cm with calm breathing, while inhaling - 89, while exhaling - 83. The excursion of the chest is 6 cm.
Breathing: Breathing movements are symmetrical, type of breathing is mixed. The auxiliary muscles are not involved in breathing. The number of respiratory movements is 16 per minute. Breathing is rhythmic.
Pain on palpation is not detected. The elasticity of the chest is not reduced. Voice tremor in symmetrical areas of the chest is the same.
Lung percussion:
With comparative percussion, a clear pulmonary sound is determined over symmetrical areas of the lungs.
Topographic percussion.
1. Full name: _ _____________________ ____
2. Patient's age: _ 64 (20. 01. 1940) ______________________________________
3. Patient gender: _ f ____
4. Permanent residence: _ Novoshakhtinsk, st. ___________________ ______
5. Place of work, profession or position: _ retiree _______________________
COMPLAINTS OF THE PATIENT
Paroxysmal baking pains in the heart with irridation to the left shoulder blade, shoulder, epigastric region, spine and lower back lasting 10-15 minutes, without a clear dependence on physical activity, which are stopped by taking nitroglycerin or erinit. As well as complaints of shortness of breath and increased sweating that occur with little physical exertion, a feeling of shortness of breath.
ANAMNESIS OF DISEASE
Considers himself ill since 2004, when pain in the heart area first appeared, __
shortness of breath after exercise. She was observed and treated in a polyclinic in Novoshakhtinsk with short-term improvement. The last exacerbation was two months ago; was treated in a polyclinic at the place of residence. The treatment had no effect; she was sent to the OKB for examination, clarification of the diagnosis and selection of therapy. Takes etlon, erinit, sustak, sedative burs .__
1. Condition of the patient: _ moderate _____________________________
2. Position: _ active ___________________________________________
3. Consciousness: _ clear _______________________________________________
4.Body type: _ normosthenic _________________________________
5. Growth: _162 cm ___________________________________________________
6. Body weight: ________ 76 kg _________________________________________________
7. Body temperature: _ 36.7 o C _______________________________________
8. Leather: _ pale pink color, warm, without hemorrhage, scarring _ and_______
rashes. Turgor saved .______________________________________ _________
9. Visible mucous membranes: _ clean, pale pink, moderately _______
wet ._____________________________________________________________
10. Subcutaneous fat: _ expressed moderately, no seals ________
observed ._____________ ___________________________________________
11. Lymph nodes: _ palpation is available, not enlarged, ______________
painless, not adhered to surrounding tissues and skin._ ______________
12. Muscles: _ well developed, tone is preserved, tenderness on palpation_
absent. ____________________________________________________________
13. Bones: _ normal shape, without deformations, pain when feeling and tapping .__________________________________________________________
14. Joints : _ normal configuration, mobility is fully preserved, painless on palpation ._______
15. Glands: thyroid gland of normal size, soft consistency_
Respiratory system
1. Examination of the chest:
· the form_ normosthenic, no deformities, symmetrical ______________
Participation of both halves of the chest in the act of breathing: _ both halves__
participate in the act of breathing to the same extent .________________________
Breathing type: _ breast __________________________________________
Breaths per minute: _ 21 ____________________________________
The depth and rhythm of respiratory movements: _ breathing is even, deep, rhythm_ correct ________________________________________________
Shortness of breath: _ No _________________________________________________
2. Palpation of the chest:
Elasticity of the chest: _ good ____________________________
Soreness: _ absent __________________________________
3. Comparative chest percussion: _ clear pulmonary sound all over ______________________________ __________________________
4. Topographic percussion:
- standing height of the tops
front left 4 cm above the collarbone on right 3 cm above the collarbone
back left stop fr. Vii shane call on right stop fr. Vii shane call
- width of Kroenig fields
left_ 5 cm __________ on right__ 5.5cm _____________
Lower boundaries of the lungs
1. Passport part.
Age 54 years (02/14/1956)
Place of residence
Profession and work performed:
Date of receipt: 31.01.2011
Date of supervision: 4.02.2011-10.02.2011
2. Complaints
at the time of admission: aching, mildly intense pain behind the sternum, in its upper part, turning into intense pressing and squeezing, burning; non-radiating; wavy character; accompanied by palpitations; arising after emotional stress; weakness.
at the time of supervision: pressing pains behind the breastbone of mild intensity, non-radiating, arising without previous loads; shortness of breath of an inspiratory nature with little physical exertion ( when passing ~ 320m); weakness.
3. Anamnesismorbi.
He considers himself to be sick during the year, when, for the first time after moderate physical activity (work at the summer cottage), pressing pain appeared in the region of the heart, of medium intensity, non-radiating. The pain was relieved on its own after rest. He did not seek medical help, did not receive treatment.
Then the patient began to notice an increase in the occurrence of pains of a pressing nature in the region of the heart, non-radiating. The intensity of the pain began to intensify. The patient began to take 1 table. Nitroglycerin under the tongue when pain occurs - the pain was stopped. He did not seek medical help.
Over time, according to the patient, the intensity of the compressive pain in the region of the heart increased, for relief, the patient began to take 2 tables. Nitroglycerin under the tongue. The incidence of pain increased (up to 1 time per day). The pain occurred after minor physical exertion and emotional stress. The attack of pain was accompanied by palpitations. Inspiratory dyspnea, which occurs after walking ~ 430m, was added. The patient began to notice rapid fatigue. He turned to the local therapist for medical help, treatment was prescribed (it is difficult to name the drugs). But he used medicines irregularly.
In December 2010, after returning from work, there were severe pains behind the sternum of a pressing character, without irradiation, accompanied by palpitations, weakness, sweating, taking 2 tabl. Nitroglycerin was not stopped. The patient called the ambulance team. Was hospitalized in the 2nd Department of Emergency Cardiology, the condition was regarded as myocardial infarction. The treatment was carried out (it is difficult to name the drugs), a positive trend was observed: the pains were stopped. The patient was discharged, treatment was prescribed (it is difficult to name the drugs). He took the prescribed drugs regularly.
During January 2011, periodically noted the emergence of compressive pain in the heart area of medium intensity after emotional stress, pain became very frequent (more than 6 times a day), the duration of an anginal attack increased, was stopped by taking 4 tabl. Nitroglycerin. Inspiratory dyspnea began to appear after walking ~ 350m.
The attack of pain was accompanied by palpitations.
A real deterioration occurred in the evening of January 30, when there were aching, mildly intense pains behind the sternum, in its upper part, turning into intense pressing and squeezing, burning (maximum pain intensity at 4:00 on January 31); non-radiating; emerged after emotional stress. Taking nitroglycerin did not stop the attack. The patient called the ambulance team. He was admitted to the cardiology department of the KBSMP for further examination and treatment.
Within 10 years, he noted an increase in blood pressure (maximum up to 190/110 mm Hg) after emotional stress.
4. Life history.
Grew and developed according to age and gender. According to the patient, the father suffered from arterial hypertension. He is married and has two children. Family members are healthy.
Smokes from 20 years to 20 cigarettes per day. Smoking experience 34 years. From the age of 20, he rarely drinks small amounts of alcoholic beverages.
Past illnesses.
According to the patient, he annually suffers from acute respiratory infections, angina, lasting no more than 2 weeks.
He does not suffer from typhoid fever and dysentery. There are no indications of tuberculosis in the anamnesis, he denies venereal diseases. Infection with HIV and hepatitis viruses has not been established.
Allergic history is not burdened.
Sanitary and epidemiological history.
He lives in an area that is relatively safe in terms of environmental, radiation, epidemiological aspects, in a safe apartment. Uses tap water. Follows the rules of personal hygiene. I have not traveled to other areas lately. I have not been in contact with infectious patients. In the past six months, vaccinations against infectious diseases and parenteral interventions have not been carried out.
Professional history.
Has been working as a driver for 30 years.
The work is associated with an increased prof. harmfulness: constant emotional stress, forced sitting position, frequent hypothermia.
5. Statuspraesens
General research.
Height 179 cm.Body weight 80kg (BMI = 24.97 ).
Consciousness is clear.
The eyeballs, conjunctiva, sclera, pupils, eyelids and periorbital tissue are unchanged.
The skin is flesh-colored, moderately moist. Turgor of tissues and elasticity are normal. Pronounced cyanosis, icterus is not observed. The hairline is developed according to age. Male pattern hair growth. No edema was detected.
Palpable tonsillar, submandibular, cervical, axillary lymph nodes are single, mobile, painless, soft-elastic consistency.
Muscles are moderately developed, painless; their strength and tone are reduced. Joints of normal configuration, active and passive movements in them in full. The constitutional body type is normal.
Respiratory system.
Nasal breathing is preserved, free through both halves of the nose.
The ribcage is in the form of a truncated cone, symmetrical, both halves of it participate in the act of breathing.
The type of breathing is abdominal. Breathing is rhythmic. Respiratory rate 18 per minute.
The muscles of the anterior abdominal wall take part in the act of breathing.
Palpation: the chest is painless, rigid, vocal tremor is weakened over the entire surface of the lungs.
Percussion: comparative: over the projection of the lungs - pulmonary sound.
Topographic: the mobility of the lower edges of the lungs is normal.
| Line | on right | left |
| l. parasternalis | 5 rib | — |
| l.medioclavicularis | 6 rib | — |
| l.axillaris anterior | 7 rib | 7 rib |
| l.axillaris media | 8 rib | 9 rib |
| l.axillaris posterior | 9 rib | 9 rib |
| l.scapularis | 10 intercostal space | 10 intercostal space |
| l / paravertebralis | At the level of the spinous process of the 11th thoracic vertebra |
Lung auscultation: breathing is vesicular, weakened in the lower parts. Solitary dry wheezing, predominantly over the lower fields.
The cardiovascular system.
The region of the heart is not changed. The impulse is not visible. Apical impulse in the 5th intercostal space of the mid-clavicular line.
Palpation: pulse 60 / min, synchronous, the same on both hands, rhythmic, soft, small, not accelerated, uniform, there is no pulse deficit, the vascular wall is dense, tortuous.
Percussion: the limits of relative dullness:
Percussion boundaries of absolute cardiac dullness:
Auscultation: the rhythm of the heart contractions is correct. Heart sounds are muffled, rhythmic.
Blood pressure: systolic - 130 mm Hg. Art.
diastolic - 90 mm Hg. Art.
Digestive system.
The mucous membrane of the oral cavity, palatine arches, posterior pharyngeal wall is pink. Tongue moist with a whitish coating.
The abdomen is normal and symmetrical. The abdominal wall is involved in the act of breathing.
At superficial palpation the abdominal wall is painless, relaxed. Symptom Shchetkin-Blumberg negative. There is no divergence of the rectus abdominis muscles.
Above the entire surface - tympanic sound, soreness, tension of the abdominal wall, fluctuations are absent.
Deep sliding palpation according to Obraztsov-Strazhesko... The cylinder-shaped sigmoid colon is tight-elastic, smooth, painless. The cecum is soft-elastic, painless. The terminal ileum is not palpable. The ascending, hepatic bend, the transverse colon of a soft-elastic consistency, painless, with limited mobility.
Stomach: large curvature 3 cm above the navel, in the form of an even tightly elastic cylinder. The gatekeeper is not palpable.
Auscultation: moderate peristalsis, murmur, peritoneal friction and vascular murmurs are not audible.
Liver. On examination, the liver is not enlarged. With percussion: the borders of the liver: upper - 7 intercostal space along the midclavicular line, lower - 0.5 cm below the costal arch.
There are no soreness when percussion and tapping.
Determination of the borders of the liver according to Kurlov: 10 * 9 * 8cm
On palpation, the edge of the liver is sharp, painless, soft-elastic, the surface is even, smooth.
The gallbladder is not palpable. The gallbladder point is painless. Symptom Ortner, Obraztsov-Murphy were not identified.
The pancreas is not palpable. There is no pain on the projection of the pancreas, at the Mayo-Robson point and in the Shoffard zone.
Spleen. There is no visible increase. The spleen is not palpable. With percussion of the spleen according to Sali, the percussion dimensions of the spleen are determined: diameter 4 cm, length 6 cm.
Urinary system.
The lumbar region is not changed, the skin and soft tissues are normal, the kidneys and bladder are not palpable.
The ureteral points are painless. Pasternatsky's symptom is not detected on both sides. Urination is regular, painless.
Endocrine system.
There are no disturbances in the growth and proportionality of body parts. The thyroid gland is not enlarged. Secondary sexual characteristics correspond to sex and age.
Nervous system.
The patient is sociable, emotionally labile, pupils are normal, they react vividly to light. There are no obvious signs of damage to the nervous system. Tactile, pain sensitivity and coordination of movements are preserved.
Preliminary diagnosis:
Main: Ischemic heart disease (unstable angina pectoris, in dynamics to exclude repeated myocardial infarction; atherosclerotic and postinfarction (myocardial infarction 2010) cardiosclerosis.)
Background: AH stage III, risk IV.
Donor .: CHS II A FC II
Sop .: COPD, without exacerbation.
Survey plan:
1. Complete blood count (platelets, reticulocytes)
2. General analysis of urine.
3. Biochemical blood test (o. protein, ALT, AST, alkaline phosphatase, cholesterol, creatinine, GGT, LDH, glucose, CPK, potassium, magnesium, sodium, LDL, HDL, urea, total bilirubin, direct bilirubin)
Determination of the Wasserman reaction.
4. Troponin test.
5. Coagulogram.
6. ECG in dynamics.
7. Radiography of the OGK.
8.Echocardiography
9. Holter monitoring.
10. Ultrasound of the abdominal cavity, kidneys, Doppler ultrasound of the renal arteries.
11. Consultation with a neurologist.
12. Consultation with an ophthalmologist.
13. Blood for antibodies to HIV, HbS-Ag.
14. Ultrasound of the adrenal glands.
15.HP profile
You can download the full version of the medical history for therapy.
Department of Internal Medicine №1.
Head of the department, prof. Shabrov V.A.
Teacher ass. Won L.S.
Clinical history of the disease
sick Teterin Viktor Fedorovich, 46 years old.
Diagnosis: main: Ischemic heart disease, exertional angina, functional class 3-4. Postinfarction cardiosclerosis (myocardial infarction from 12.12.94). Hypertonic disease II .
Complications: -
Accompanying illnesses: -
Curator: student of group 533 of the medical faculty,
Krasnozhon D.A.
The time of supervision is from 24.10.96 to 2.11.96.
Passport part.
Age 46 years old
Secondary education
Place of work -
Date of admission to the clinic: 10/14/96.
Complaints at the time of supervision : for pain behind the sternum and in the region of the heart of a compressive nature, and radiating to the right shoulder, arm, right shoulder blade (with numbness), arising after physical exertion (lifting no more than 2 floors), and sometimes at night, accompanied by dizziness, sweating, difficulty breathing mainly on inspiration. Headache (in the temples, heaviness in the back of the head). Pain is relieved by taking nitroglycerin under the tongue.
Complaints at the time of admission: on pain behind the sternum, and in the area of the heart of a compressive nature, and radiating to the right shoulder and arm, right scapula, arising after physical exertion (climbing to the second floor, long walking), and recently (3-4 months) at night; for interruptions in the work of the heart, episodes of palpitations occurring simultaneously with pain in the chest or preceding them. The attacks of pain are sometimes accompanied by increased sweating, dizziness (in August 1996, loss of consciousness while working in the garden, which was preceded by such a condition). Pain in the heart area disappeared after taking nitroglycerin, but the last time after taking nitroglycerin, the pain decreased but did not go away completely, numbness of the right hand persisted (up to the wrist, mostly on the outer surface).
He also complained of headache (heaviness in the back of the head, temples), high blood pressure (maximum 180/100, working 130 / 100-90).
During his stay in the clinic, the patient notes a slight decrease in pain attacks, which he associates with the treatment being carried out and a decrease in physical activity, headaches, dizziness are not currently disturbing. Sternum pain is quickly relieved by nitroglycerin.
ANAMNESIS OF DISEASE ... Considers himself ill since December 1994, when, while in the district hospital in Tosno due to pneumonia, in the evening after a strong psycho-emotional stress, intense pains behind the sternum, of a compressive nature, radiating to the right arm, right shoulder blade, accompanied by pouring sweat, appeared, headache, weakness and anxiety. The patient took a sustak-forte tablet, but the pain did not go away. The patient did not sleep, because of these pains, in the morning, during a round, he turned to the attending physician with these complaints, an ECG was taken, and with a diagnosis of myocardial infarction, the patient was transferred to the cardiology department, where the treatment was carried out (which he does not remember exactly). At the end of January 1995, he was discharged from the hospital with a recommendation to change his job (he worked as a foundry worker). I did not notice such attacks anymore, however, after I went to work at my previous place of work, I began to notice attacks of compressive pains behind the sternum, in the heart region, radiating to the right scapula, the arm, arising after physical exertion, as well as when climbing to the floor, walking, lifting weights ... In case of seizures, he took nitroglycerin under the tongue, then began to take nitrosorbide 2-4 tablets a day. Although the patient was often bothered by pain, he turned to the doctor after about six months. He was sent to VTEK where he was given the second group of disability, the local cardiologist prescribed treatment: nitrosorbide 2 tablets 4 times a day, asparks 1 tablet 2 times a day. From the end of 1995 to August 1996, he noted regular attacks of constricting pains in the chest and in the region of the heart, radiating to the right arm, scapula. Before an attack of pain, sometimes he noted the appearance of sweat, impaired consciousness, and dizziness. The patient tried to limit physical activity, and such attacks practically did not bother him, but in April 1996, while working in the garden, he felt pain behind the sternum, dizziness after which he lost consciousness, when he woke up, he found that he was lying unconscious for about 10 minutes. I did not go to the doctor about this. At the onset of such attacks, the patient always sat down and rested. In August 1995, he underwent VTEK, for consultation he was sent to the regional cardiologist. At the same time, he noted an attack of pain behind the sternum, of a constrictive nature, radiating to the shoulder (the shoulder and arm were “numb”). After taking nitroglycerin, they slightly decreased, but the patient noted numbness of the hand. These pains lasted for about 2 days, coinciding with the examination of the regional cardiologist, who sent the patient to the regional cardiological dispensary for hospitalization. She is currently receiving therapy with nitrates, potassium preparations (asparkam), antiaggregants (aspirin), antiarrhythmics (anaprilin). She notes an improvement in her condition, which is manifested in a decrease in seizures, which the patient associates with the treatment being carried out and a decrease in physical activity, he does not bother with headaches, dizziness and disturbances of consciousness simultaneously with bouts of pain are not noted.
An increase in blood pressure is noted (before that it was measured only during preventive medical examinations at the plant, according to the patient's blood pressure was 120/80 mm Hg) from about January 1995, which manifested itself as a headache, which occurred mainly after emotional stress, wore the nature of the heaviness in the back of the head, temples, passed by itself after a few hours. Often the headache was accompanied by pain in the heart, the maximum pressure that the patient noted was 180/120 mm Hg. For these headaches he took baralgin or analgin, after which the pain subsided a little.
ANAMNESIS OF LIFE .
Born in 1950 in the city of Leningrad, the only child in the family. I went to school at the age of 7, in mental and physical development I did not lag behind peers, after finishing 8 classes of secondary school I worked at a factory as a loader. From 1970 to 1972 he served in the Soviet Army. From 1972 to 1983 he worked as a loader in a store, then worked as a caster at the Leningrad carburetor plant in a hot shop.
Family history: married since 1973, with a 22-year-old son. Divorced since 1992.
Heredity: Father and mother died of a stroke (suffered from hypertension).
Professional history: he began his career at the age of 15. The working day has always been rationed, work has always been associated with heavy physical exertion. At the last place of work, he worked in a hot shop (temperature 70-80 degrees). Holidays were granted annually, usually during the summer.
Household history: lives in a separate apartment with all conveniences, financially provided relatively satisfactorily. Eats 3 times a day with hot food in sufficient quantities at home.
Epidemiological history: infectious hepatitis, typhoid and typhus, intestinal infections, the disease denies. There were no intramuscular, intravenous, subcutaneous injections. I have not traveled outside the Leningrad Region for the last 6 months. He denies tuberculosis, syphilis, and sexually transmitted diseases.
Habitual intoxication: from the age of 15 he smokes one pack of cigarettes a day, after the onset of the disease he limits himself to smoking (one pack for 2-3 days), does not abuse alcohol.
Allergic history: no intolerance to drugs, household substances and food.
Insurance history: disability group 2 since January 1995.
OBJECTIVE RESEARCH. The patient's condition is satisfactory. Active position. The physique is correct, there are no skeletal deformities. Height 175 cm, weight 69.5 kg. The subcutaneous fat is moderately expressed (the thickness of the skin-subcutaneous fat fold above the navel is 2 cm). The skin is of normal color, clean. Skin turgor is preserved, the skin is dry, elasticity is not reduced. Visible mucous membranes are pale pink.
Musculoskeletal system... The general development of the muscular system is good, there is no soreness when feeling the muscles. There are no deformities of the bones, no pain when feeling the joints. The joints are of normal configuration. Active and passive joint mobility in full. The shape of the skull is mesocephalic. The shape of the chest is correct.
The mammary glands are not enlarged, the nipple is normal. The pectoralis major muscle is palpated.
Lymph nodes: occipital, anterior and posterior cervical, submandibular, axillary, elbow, inguinal, popliteal, not palpable.
Thyroid not increased, softly elastic consistency. There are no symptoms of thyrotoxicosis.
The cardiovascular system... Pulse 80 beats per minute, rhythmic, relaxed, satisfactory filling. Identical on the right and left hand.
Palpation of the vessels of the extremities and neck: the pulse on the main arteries of the upper and lower extremities (on the brachial, femoral, popliteal, dorsal arteries of the foot, as well as on the neck (external carotid artery) and head (temporal artery) is not weakened. BP 130/100 mm. RT. Art.
Palpation of the region of the heart: the apical impulse to the right by 3 cm deviating from the midclavicular line in the fifth intercostal space, diffuse, increased in length (about 3.5 cm).
Percussion of the heart: the boundaries of relative cardiac dullness
Percussion boundaries of absolute cardiac dullness
Auscultation of the heart: heart sounds are muffled, the ratio of sounds is preserved at all points of auscultation. Weakened at the apex, rhythmic. The systolic murmur is well audible at the apex and Botkin's point. It is not performed on the vessels of the neck and in the axillary region.
Auscultation of large arteries revealed no murmurs. The pulse is palpated on the large arteries of the upper and lower extremities, as well as in the projections of the temporal and carotid arteries.
Respiratory system... The shape of the chest is correct, both halves are evenly involved in breathing. Breathing is rhythmic. Respiratory rate 18 per minute.
Palpation of the chest: the chest is painless, inelastic, vocal tremor is weakened over the entire surface of the lungs.
Percussion of the lungs: with comparative percussion of the lungs over the entire surface of the pulmonary fields, a clear pulmonary sound is determined, in the lower parts with a slight boxy shade.
Topographic lung percussion:
| line | on right | left |
| l.parasternalis | 5 rib | - |
| l.medioclavicularis | 6 rib | - |
| l.axillaris anterior | 7 rib | 7 rib |
| l.axillaris media | 8 rib | 9 rib |
| l.axillaris posterior | 9 rib | 9 rib |
| l. scapulars | 10 intercostal space | 10 intercostal space |
| l.paravertebralis | at the level of the spinous process 11 thoracic vertebra |
at the level of the spinous process 11 thoracic vertebra |
Height of standing of the tops of the lungs:
Mobility of the pulmonary edges
right 7 cm
left 7 cm
Auscultation of the lungs: breathing is hard, weakened in the lower parts of the lungs.
With bronchophonia, a weakening of the voice conduction in the lower parts of the pulmonary fields was revealed.
Digestive system .
Examination of the oral cavity: the lips are dry, the red border of the lips is pale, the dry transition to the mucous part of the lip is pronounced, the tongue is moist, coated with a grayish coating. Gums pink, no bleeding, no inflammation. The tonsils do not protrude beyond the palatine arches. The mucous membrane of the pharynx is moist, pink, clean.
STOMACH. Examination of the abdomen: the abdomen is symmetrical on both sides, the abdominal wall is not involved in the act of breathing. On superficial palpation, the abdominal wall is soft, painless, relaxed.
With deep palpation in the left iliac region, a painless, smooth, densely elastic consistency of the sigmoid colon is determined. The blind and transverse colon are not palpable. With approximate percussion, free gas and liquid in the abdominal cavity are not detected. Auscultation: normal intestinal motility.
Stomach: borders are not defined, there is no splashing noise of visible peristalsis. Intestines. Feeling along the colon is painless, the splash noise is not detected.
Liver and gallbladder. The lower edge of the liver does not come out from under the costal arch. The boundaries of the liver according to Kurlov are 9,8,7. The gallbladder is not palpable. Symptoms of Mussey, Murphy, Ortner are negative. Frenicus has a negative symptom. The pancreas cannot be felt.
The spleen is not palpable, the percussion borders of the spleen: upper at 9 and lower at 11 intercostal space along the mid-axillary line.
Genitourinary system... The kidneys and the area of the projection of the ureters are not palpable, the tingling along the lumbar region is painless. The external genital organs are developed correctly, the testicles of a dense elastic consistency are palpable in the scrotum.
Neuropsychic status... Consciousness is clear, speech is intelligible. The patient is oriented in place, space and time. Sleep and memory are saved. No pathology was revealed on the part of the motor and sensory spheres. Gait without peculiarities. Tendon reflexes without pathology. The membranous symptoms are negative. The pupils are dilated, react vividly to light.
Preliminary diagnosis ... Cardiac ischemia. Angina pectoris 3-4 functional class. Postinfarction cardiosclerosis (acute myocardial infarction of December 12, 1994). Hypertension II.
Based on the patient's complaints: pain behind the sternum and in the region of the heart of a compressive nature and radiating to the right shoulder, arm, right scapula, arising after physical exertion (ascent to the second floor, long walking), and recently (3-9 months. ) at night, for interruptions in the work of the heart, episodes of palpitations occurring simultaneously with pain in the chest or preceding them. The attacks of pain are sometimes accompanied by increased sweating, dizziness (in August 1996, loss of consciousness while working in the garden, which was preceded by such a condition). Pain in the heart area disappeared after taking nitroglycerin, but the last time after taking nitroglycerin, the pain decreased but did not go away completely, numbness of the right hand persisted (up to the wrist, mostly on the outer surface); based on the history of the disease: attacks of pain behind the sternum and in the region of the heart, of a compressive nature, radiating to the right arm, right scapula, arising after physical exertion (ascending to the second floor), and recently arising at night, interruptions in the work of the heart, episodes of palpitations arising simultaneously with pain in the heart; light-headedness (and in August 1996, loss of consciousness while working in the garden). Heart pains disappeared after taking nitroglycerin sublingually; on the basis of objective research data: expansion of the percussion borders of the heart to the left, muffled heart sounds, systolic murmur that is not carried out on the vessels of the neck and in the axillary region, it is possible to diagnose ischemic heart disease, exertional angina, functional class 3-4.
Based on the history of the disease: acute myocardial infarction from 12.12.94; on the basis of objective research data: muffled tone, expansion of the boundaries of the heart to the left. Postinfarction cardiosclerosis can be diagnosed.
Based on the patient's complaints of headaches (heaviness in the back of the head, temples), which appears more often in the morning and passes from taking analgesics and antispasmodics (analgin, baralgin); on the basis of objective research data: expansion of the left border of the heart, emphasis of the first tone over the aorta. HELL 130/100 mm Hg Pulse of satisfactory filling, relaxed, symmetrical, based on data from the medical history: increased blood pressure since January 1995, up to 130/100, up to a maximum of 180/120 mm Hg. hypertension can be diagnosed 2.
Patient examination plan .
1.Clinical blood test
2.Clinical analysis of urine
3.Analysis of feces for worm eggs
4.blood test F-50 and RW
5. biochemical analysis of urine: ALT, AST, CPK, LDH5, cholesterol, lipoproteins, creatinine, bilirubin, sodium, chlorine, potassium.
6.Electrocardiography
7.echocardiography
8. chest x-ray in two projections (frontal and lateral)
9.Ultrasound of the abdominal organs (carefully kidneys, liver)
10. Consultation with an ophthalmologist.
Laboratory data :
Clinical blood test from 19.10.96.
hemoglobin 146 g / l
color index 0.96
eosinophils 1
segmented 56
lymphocytes 35
monocytes 4
ESR 7 mm \ h
Clinical blood test from 10/22/96
hemoglobin 146 g / l
erythrocytes 4.7 x 10 to 12 degrees per liter
color index 0.96
the number of leukocytes 3 x 10 to 9 degrees per liter
eosinophils 1
segmented 56
lymphocytes 35
monocytes 4
ESR 7 mm \ h
Urine analysis 10/19/96.
color light yellow
acid reaction
specific gravity 1012
protein 0.033 g / l
leukocytes 1-2 in the field of view
Urine analysis 10/16/96.
color light yellow
acid reaction
specific gravity 1015
protein 0.033 g / l
leukocytes 1-2 in the field of view
erythrocytes fresh 0-2 in the field of view
epithelium flat 0-1 in the field of view
Urine analysis 10/23/96.
color light yellow
acid reaction
specific gravity 1010
protein 0.033 g / l
leukocytes 0-1 in the field of view
erythrocytes fresh 0-2 in the field of view
epithelium flat 1-3 in the field of view
Blood chemistry:
urea 6.4 - norm
creatinine 0.07 - normal
cholesterol 8.3 norm
bilirubin 10.88 - normal
ALT - 0.4 - normal
Electrocardiography from 10/16/96. RR = 0.80, PQ = 0.16, HR 0.34 QT 0.33, QRS 0.064
Conclusion: sinus rhythm with a frequency of 75 per minute. Indirect signs of initial left ventricular hypertrophy. Deterioration of the coronary blood supply in the posterior wall.
Electrocardiography dated 10.22.96. Sinus rhythm 72 beats per minute, compared to ECG with ECG improved coronary blood supply in the posterior wall region.
Echocardiography dated 10/16/96. Conclusion: the dimensions of the heart cavities, the thickness of the myocardium and its contractile ability are within normal limits. Consolidation of the walls of the aortic root. The opening of all valves is sufficient. There are no local myocardial contractility disorders. Doppler ultrasonography: valvular mitral regurgitation.
Ultrasound from 15.10.96. The kidneys are of normal shape, the calyx-pelvic system is not dilated. The adrenal glands are the norm.
Chest X-ray: on the chest X-ray in two projections (overview and left lateral X-ray), fresh focal and infiltrative changes in the lungs are not detected. The walls of the medium-caliber bronchi are thickened. The roots of the lungs are structured, not expanded, with petrification. Pleural layers in the anterior sinus. The heart is not enlarged. The aorta is not changed.
Oculist consultation 10/23/96. There are no complaints about the eyes. The anterior segments of the eyes are not changed, the optical media are transparent. The fundus of the eye: the optic disc is pink, the contours are clear, the arteries are moderately narrowed.
Taking into account the analysis of urine (protein, leukocytes, erythrocytes at the border of the norm), it is necessary to conduct a detailed study of renal function (urine analysis according to Zimnitsky, Nechiporenko), if necessary, a radioisotope study of the kidneys.
Final diagnosis and its rationale .
Cardiac ischemia. Angina pectoris 3-4 functional class. Postinfarction cardiosclerosis (acute myocardial infarction of December 12, 1994). Hypertension II.
Based on the patient's complaints: pain behind the sternum and in the region of the heart of a compressive nature and radiating to the right shoulder, arm, right scapula, arising after physical exertion (ascent to the second floor, long walking), and recently (3-9 months. ) at night, for interruptions in the work of the heart, episodes of palpitations occurring simultaneously with pain in the chest or preceding them. The attacks of pain are sometimes accompanied by increased sweating, dizziness (in August 1996, loss of consciousness while working in the garden, which was preceded by such a condition). Pain in the heart area disappeared after taking nitroglycerin, but the last time after taking nitroglycerin, the pain decreased but did not go away completely, numbness of the right hand persisted (up to the wrist, mostly on the outer surface); based on the history of the disease: attacks of pain behind the sternum and in the region of the heart, of a compressive nature, radiating to the right arm, right scapula, arising after physical exertion (ascending to the second floor), and recently arising at night, interruptions in the work of the heart, episodes of palpitations arising simultaneously with pain in the heart; light-headedness (and in August 1996, loss of consciousness while working in the garden). Heart pains disappeared after taking nitroglycerin sublingually; on the basis of objective research data: expansion of the percussion borders of the heart to the left, muffled heart sounds (only increased tones at the apex), systolic murmur that is not carried out on the vessels of the neck and in the axillary region;
on the basis of laboratory research: in a biochemical blood test: an increase in cholesterol levels, normal numbers of indicator enzymes of the heart; ECG: conclusion (from 10/16/96): sinus rhythm with a frequency of 75 per minute. Indirect signs of initial left ventricular hypertrophy. Deterioration of the coronary blood supply in the posterior wall; echocardiographic data (10.16.96): conclusion: the size of the heart cavities, the thickness of the myocardium and its contractile ability within normal limits. Consolidation of the walls of the aortic root. The opening of all valves is sufficient. There are no local myocardial contractility disorders. Doppler sonography: valvular mitral regurgitation; can be diagnosed with coronary heart disease, angina pectoris 3-4 functional class.
Based on the history of the disease: acute myocardial infarction from 12.12.94; on the basis of objective research data: muffled tone, expansion of the boundaries of the heart to the left; based on ECG data: sinus rhythm with a frequency of 75 per minute. Indirect signs of initial left ventricular hypertrophy. Deterioration of the coronary blood supply in the posterior wall region; postinfarction cardiosclerosis can be diagnosed.
Based on the patient's complaints of headaches (heaviness in the back of the head, temples), which appears more often in the morning and passes from taking analgesics and antispasmodics (analgin, baralgin); on the basis of objective research data: expansion of the left border of the heart, emphasis of the first tone over the aorta. HELL 130/100 mm Hg pulse of satisfactory filling, relaxed, symmetrical, based on data from the medical history: increased blood pressure since January 1995, up to 130/100, up to a maximum of 180/120 mm Hg; on the basis of instrumental studies excluding symptomatic hypertension: ultrasound of the kidneys: no pathology; hypertension can be diagnosed 2.
Treatment of the underlying disease .
The effectiveness of drug treatment of angina pectoris depends on how much it is possible to change in a favorable direction the balance between myocardial oxygen demand and its delivery. This can be achieved by increasing the ability of the coronary system to deliver blood and ischemic areas; or by reducing myocardial oxygen demand. Antianginal drugs include three main groups of drugs: nitro-containing drugs, beta-adrenergic receptor blockers and calcium antagonists.
Antianginal drugs are groups of drugs with different mechanisms of action that affect angina pectoris syndrome by changing the hemodynamic conditions of the heart or improving coronary blood flow.
The positive effect of nitrates:
Decrease in the volume of the left ventricle
Decrease in blood pressure
Reduction of emission
This leads to a decrease in myocardial oxygen demand.
Decrease in diastolic pressure in the left ventricle
· Increased blood flow in collaterals leads to improved perfusion in the ischemic area.
· Vasodilation of the endocardial coronary arteries neutralizes spasm in the periphery.
Negative effect of nitrates:
Insignificant increase in heart rate
Increased contractility
Decreased diastolic perfusion due to tachycardia
All this leads to an increase in myocardial oxygen demand, a decrease in myocardial perfusion. With prolonged use, addiction is possible, which can lead to a decrease in the effect.
Preparations: nitroglycerin, nitrosorbide, trinitrolong, sustak forte and sustak mit, nitrong ,.
Nitrosorbide differs from nitroglycerin in its pharmacological properties. When taken orally, the effect of the drug begins after 50-60 minutes. Duration of action is 4-6 hours. Nitrosorbide is rapidly metabolized in the liver. The elimination half-life is about 30 minutes when taken orally, while for its active metabolites it is 4-5 hours. When chewing a tablet, the effect of nitrosorbide occurs earlier - after 5 minutes and is more pronounced and more pronounced 9 this also applies to the collaptoid reaction), which allows the use of sublingual drug administration to relieve angina attacks. Nitrosorbide and its metabolites are excreted by the kidneys.
Side effects of the use of nitro drugs: headache, continuation of treatment usually leads to the development of tolerance to this side effect. Reducing the dose, changing the route of administration of the drug or the use of analgesics reduce the severity of the headache. Postural hypotension is manifested by dizziness, weakness, and even short-term loss of consciousness. This effect is enhanced by alcohol consumption. Methemoglobinemia, as well as severe nitrate poisoning, occurs mainly in young children.
Contraindications: individual intolerance (tachycardia, hypotension, headache), acute myocardial infarction with hypotension, cerebral hemorrhage, increased intracranial pressure, obstructive cardiomyopathy.
Rp .: Nitrosorbidi 0.01
D.t.d. # 50 in tab.
Rp .: Sustac-forte 6.4
S. Take 1 tablet 2 times a day.
Rp.:Nitroglycerini 0.0005
S. Take for pain in the heart. Sublingually.
Rp.:Trinitrolong 0.001
Beta-adrenergic blockers and drugs affecting the adrenergic system: beta blockers reduce myocardial oxygen demand by suppressing sympathetic activity. The combination of nitrates and a beta-blocker can neutralize the effect on heart rate. The negative effect of beta-blockers: increased bronchial obstruction (can not be used in patients with pulmonary pathology), affect myocardial contractility (be careful with heart failure). The main indications for the appointment of these drugs are angina pectoris, arterial hypertension and arrhythmias. Distinguish between cardio-nonselective beta-blockers, blocking beta-1 and beta-2 receptors, which include timolol, propranolol, sotalol, nadolol, oxprenolol, alprenolol, pindolol, etc. and cardioselective with predominantly beta -1 inhibitory activity (metoprolol, atenolol , acebutolol, praktolol). Some of these drugs have sympathomimetic activity (oxprenolol, alprenolol, pindolol, acebutolol), which allows, although slightly to expand the scope of beta-blockers, for example, in heart failure, bradycardia, bronchial asthma. Cardioselective drugs should be preferred in the treatment of angina pectoris in patients with chronic obstructive respiratory diseases, peripheral arterial lesions, diabetes mellitus. Some beta-blockers have intrinsic sympathomimetic activity, which means the ability of a drug to affect the same beta receptors that agonists do. Drugs with this property reduce the heart rate at rest to a lesser extent, causing a negative chronotropic effect mainly at the height of physical activity, which is important for patients with angina pectoris with a tendency to bradycardia.
Side effects of beta-blockers: during treatment with beta-blockers, bradycardia, arterial hypotension, increased left ventricular failure, exacerbation of bronchial asthma, atrioventricular block of varying degrees, exacerbation of chronic gastrointestinal disorders, increased Raynaud's syndrome and intermittent blood flow (changes in peripheral blood flow) may occur. in rare cases - sexual dysfunction.
Contraindications to the use of beta-blockers. These drugs should not be used in severe bradycardia, hypotension, bronchial asthma, asthmoid bronchitis, sick sinus syndrome, atrioventricular conduction disorders, gastric ulcer and duodenal ulcer, diabetes mellitus in the stage of decompensation, impaired peripheral circulation, beta-blockers in combination with diuretics and cardiac glycosides), pregnancy (relative contraindication).
Rp.:Propranololi 0.08
D.t.d. # 10 in tab.
S. Take 1 tablet 3 times a day.
Rp.:Trasicor 0.08
D.t.d. # 20 in tab.
S. Take 1 tablet 3 times a day.
Rp.:Talinololi 0.1
D.t.d. # 20 in tab.
S. Take 1 tablet 3 times a day.
Rp.:Pindololi 0.005
D.t.d. # 50 in tab.
S. Take 1 tablet 4 times a day.
Calcium antagonists. The antianginal effect is associated with their direct effect on the myocardium and coronary vessels, and with the effect on peripheral hemodynamics. Calcium antagonists block the entry of calcium ions into the cell, thus reducing its ability to develop mechanical stress, and, consequently, reducing myocardial contractility. The effect of these funds on the wall of coronary vessels leads to their expansion (antispastic effect) and an increase in coronary blood flow, and the effect on the peripheral arteries leads to systemic arterial dilation, a decrease in peripheral resistance and systolic blood pressure. Thanks to this, an increase in the supply of oxygen to the myocardium is achieved while the need for it decreases. Calcium antagonists also have antiarrhythmic properties. Drugs: verapamil, nifedipine, diltiazem.
Verapamil (isoptin, finoptin), in addition to vasodilating, has a pronounced negative inotropic effect. Heart rate and blood pressure under the influence of the drug are slightly reduced. Conduction along the atrioventricular junction and the automatism of the sinus node are significantly suppressed, which makes it possible to use the drug for the treatment of supraventricular rhythm disturbances. Verapamil is the drug of choice for the treatment of angina pectoris of vasospastic genesis. It is highly effective in the treatment of exertional angina, as well as in combination with angina pectoris with supraventricular arrhythmias and cardiac contractions.
Side effects are observed only in 2-4% of patients. The most common are headaches, dizziness, fatigue, redness of the skin, minor swelling of the lower extremities. Gastrointestinal symptoms and bradycardia are also described.
Contraindications: Corinfar should not be prescribed for initial hypotension, sick sinus syndrome, pregnancy. Verapamil is contraindicated in atrioventricular conduction disorders, sick sinus syndrome, severe heart failure and in various hypotensive conditions.
Rp.:Cardizemi 0.09
D.t.d. # 50in caps.
S. Take 1 capsule 2 times a day
Rp.:Verapamili 0.04
D.t.d. # 50 in tab.
S. Take 1 tablet 4 times a day.
Rp.:Adalati 0.01
D.t.d. # 50 in tab.
Drugs that improve myocardial metabolism.
Riboxin. Riboxin is a purine derivative (nucleoside). It can be seen as a precursor to ATP. There is evidence of the drug's ability to increase the activity of a number of enzymes of the Krebs cycle, stimulate nucleotide synthesis, have a positive effect on metabolic processes in the myocardium and improve coronary circulation. By the type of action, it belongs to anabolic substances. As a nucleoside, inosine can penetrate cells and increase the energy balance of the myocardium. Riboxin is used for ischemic heart disease (with chronic coronary insufficiency and with myocardial infarction), with myocardial dystrophy, with rhythm disturbances associated with the use of cardiac glycosides. Assign inside before meals in a daily dose of 0.6 to 2.4 g. The course of treatment is from 4 weeks to 3 months.
Rp.:Riboxini 0.2
D.t.d. # 50 in tab.
S. Take 1 tablet 3 times a day.
Retabolil. It has a strong and long-lasting anabolic effect. After the injection, the effect occurs in the first 3 days, reaches a maximum by the 7th day and lasts for at least 3 weeks. It has no pronounced androgenic (and virilizing) effect than phenobolin. The main indications for use in therapeutic practice: chronic coronary insufficiency, myocardial infarction, myocarditis, rheumatic heart disease).
Apply 1 ml of oil solution intramuscularly 1 time per month.
Rp.:Retabolili 5% 1 ml
D.t.d. # 50 in amp.
S. Administer intramuscularly 1 time per month, 1 ml.
Cocarboxylase. In terms of biological action, it is close to vitamins and enzymes. It is a prosthetic group (coenzyme) of enzymes involved in the processes of carbohydrate metabolism. In conjunction with protein and magnesium ions, it is part of the carboxylase enzyme, which catalyzes the carboxylation and decarboxylation of alpha-keto acids. Thiamine introduced into the body to participate in the above biochemical processes must first be phosphorylated and converted into cocarboxylase. The latter, therefore, is a ready-made form of coenzyme formed from thiamine during its conversion in the body. It is used as a component of complex therapy for acidosis of any origin, coronary insufficiency, peripheral neuritis, various pathological processes requiring an improvement in carbohydrate metabolism, 0.05-0.1 g is injected intramuscularly once a day, the course of treatment is 15-30 days.
Rp.:Sol.Cocarboxylasi 5 ml
D.t.d. # 5 in amp.
S. inject intramuscularly 1 time per day, 5 ml.
Cytochrome C. It is an enzyme that takes part in the processes of tissue respiration. The iron contained in the prosthetic group of cytochrome C reversibly passes from the oxidized form to the reduced one, and therefore the use of the drug will accelerate the course of oxidative processes. Cytochrome is used to improve tissue respiration in asthmatic conditions, chronic pneumonia, heart failure, infectious hepatitis, and senile retinal degeneration. Usually 4-8 ml is injected into the muscles 1-2 times a day. The course of treatment is 10-14 days.
Rp.:Cytochromi C pro inectionibus 4 ml
D.t.d. # 10 in amp.
S. Introduce intramuscularly 4 ml 2 times a day.
Drugs that lower cholesterol and blood lipoproteins:
Clofibrate. Lowers the content of the level of VLDL and beta-lipoproteins. The mechanism of action consists in reducing the biosynthesis of triglycerides in the liver and inhibition of cholesterol synthesis (at the stage of formation of mevalonic acid). Increases the activity of lipoprotein lipase. The drug simultaneously has a hypocoagulant effect, enhances the fibrinolytic activity of the blood, and reduces platelet aggregation. It is used for atherosclerosis with high levels of cholesterol and triglycerides in the blood, for sclerosis of the coronary, cerebral and peripheral vessels, for diabetic angiopathy and retinopathy, various diseases accompanied by an increase in blood lipoproteins.
Side effects: nausea, vomiting, headache, muscle pain, skin rash. Contraindicated in violations of liver and kidney function, during pregnancy, it should not be prescribed to children.
Cetamifene. The mechanism of the cholesterol-lowering action of cetamifen: it binds part of coenzyme A to form phenylethyl coenzyme A, and thus acting as a “false metabolite”, prevents the formation of oxymethyl-gluctaryl-coenzyme A and the further course of endogenous cholesterol formation.
Side effect: increased thyrotropic function of the pituitary gland, bile excretory function of the liver.
The indications are atherosclerosis, all other diseases accompanied by hypercholesterolemia.
Rp.:Cetamipheni 0.25
D.t.d. # 20 in tab.
S. take 2 tablets 4 times a day.
Nitro drugs: nitrosorbide 0.01, 2 tablets 4 times a day.
It was prescribed because the patient, after trial therapy with sustak and erinitis, had side effects - headache, dizziness.
Calcium antagonists: verapamil 0.04 1 tablet 3 times a day. Prescribed as an antianginal agent, antihypertensive agent.
Antiplatelet agents: aspirin 0.5 a quarter of a tablet 1 time per day (in the morning after meals). It is prescribed to improve the rheological properties of blood, as the prevention of atherosclerosis.
Means that improve trophism and myocardial metabolism: Riboxin 0.2, 1 tablet 3 times a day.
FORECAST .
The prognosis for life is relatively favorable, subject to the recommendations and constant maintenance therapy with nitro drugs, calcium antagonists and antiplatelet agents.
The prognosis for recovery is unfavorable. So at the heart of the patient's disease is atherosclerosis of the vessels of the heart, which is an irreversible pathological process, and which can only be prevented or suspended.
PREVENTION... Prophylaxis in the patient consists in the constant intake of nitro drugs, calcium antagonists and antiplatelet agents, limiting physical activity, as well as taking drugs that lower cholesterol and blood lipoproteins (Lipostabil, 1 tablet 1 time a day, 2-3 courses for one year, 2-3 weeks).
Epicrisis .
Patient x 46 years old is in the department of the regional cardiac dispensary cx 14.10.96. Was admitted as planned with complaints: pain behind the sternum, and in the area of the heart of a compressive nature, and radiating to the right shoulder and arm, right scapula, arising after physical exertion (climbing to the second floor, long walking), and recently (3 -4 months) at night; for interruptions in the work of the heart, episodes of palpitations occurring simultaneously with pain in the chest or preceding them. The attacks of pain are sometimes accompanied by increased sweating, dizziness (in August 1996, loss of consciousness while working in the garden, which was preceded by such a condition). Pain in the heart area disappeared after taking nitroglycerin, but the last time after taking nitroglycerin, the pain decreased but did not go away completely, numbness of the right hand persisted (up to the wrist, mostly on the outer surface). Also complaints of headache (heaviness in the back of the head, temples), increased blood pressure (maximum 180/100, working 130 / 100-90).
From the anamnesis it is known that in December 1994 he suffered an acute myocardial infarction, since January 1995 he has noted regular attacks of pain behind the sternum and in the region of the heart of a compressive nature, radiating to the right arm and shoulder, scapula, arising after a little physical exertion (rising to the 2nd floor) , sometimes accompanied by the appearance of shortness of breath and palpitations, light-headedness (in August 1996, he lost consciousness while working in the garden). Examination revealed ischemic heart disease, postinfarction cardiosclerosis (myocardial infarction from 12.12.94), exertional angina pectoris, functional class 3-4. Hypertension 2, which was confirmed by laboratory and instrumental research methods. She was treated with nitro drugs, calcium antagonists and antiplatelet therapy. During the course of supervision, the patient's condition slightly improved - attacks of pain in the heart are less bothersome, headaches occur only in the morning, and quickly disappear. The patient was recommended to continue treatment in a hospital setting.
Clinical diagnosis : ischemic heart disease, exertional angina pectoris 3-4 functional class, postinfarction cardiosclerosis (myocardial infarction from 12.12.94). Hypertension II.
List of used literature :
1. Lecture on internal medicine “Non-penetrating myocardial infarction” (Makhnov).
2. Lecture on internal medicine “Symptomatic hypertension” (Shulutko).
3. Lecture on internal medicine “Tachyarrhythmias” and “Bradyarrhythmias”.
4. Mashkovsky M.D. Medicines part 1 and 2. Moscow, "Medicine", 1987.
5. Handbook of a practical doctor, 1 and 2 volumes, edited by A.I. Vorobyov. , Moscow, Medicine, 1992.
6. Clinical pharmacology with international drug nomenclature. V.K. Lepekhin, Yu.B. Belousov, V.S. Moiseev. Moscow, Medicine, 1988.
7. Almazov V.A. Chireikin L.V. Difficulties and errors in the diagnosis of diseases of the cardiovascular system. L. Medicine, 1985
8. Minkin R.B., Pavlov Yu.D. Electrocardiography and phonocardiography. M. Medicine, 1984.
9. Vinogradov A.V. Differential diagnosis of internal diseases, M. Medicine, 1980
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