2010 Directed by: Emergency services Diagnosis by emergency services: Ischemic heart disease Diagnosis at time of admission: Progressive Angina pectoris Diagnosis at cardiology department: IHD: progressive angina pectoris. atherosclerosis. Severe weakness. At the moment of meeting(01.04. Pain and breathlessness started without any physical activity.09. . COMPLAINTS: At time of admission: Compressive pain in the region of heart and retrosternal area. Feeling of discomfort in the heart region and retrosternal area.GENERAL DATA: Name of the patient: Tamara Ivanovna Kravtsovic Sex: Female Date of birth: 28.1927 Profession: Cashier Date of admission: 31.08.2010): Weakness. compression of hands. Breathlessness.

Father also had an infarct. has maximum blood pressure of 200/120 mm Hg. Digoxin half tablet everyd ay. Has hypertension since 20 yrs. Patient s mother died at age of 70 yrs because of myocardial infarction. Patient has osteoarthritis of knees. No disability in the patient. ANAMNESIS VITAE: Patient born and brought up in Saint -Petersburg. and stable around 150/90 mm Hg. measles. Chilhood infections: Chicken pox. Veroshperone. Then she had breathlessness and felt compression in hands. Patient had first symptom of ischemic heart disease 25 yrs ago. Has had no insult. Patient had weakness since last 10-14 days. Patient worked as a cashier. Patient does not have diabetes. Stopped working since 1995. Patient is not allergic.ANAMNESIS MORBI: Patient started feeling pain in the heart region suddenly without any physical activity. . She takes Agilok. Patient had first infarct in 2007. Last hospitalisation was in june 2010 to ophthalmology department in another hospital for surgery but did not undergo surgery. Rinetec.

hypertension(3 rd stage). Systolic murmur in aorta. RESPIRATORY SYSTEM: Breathing rate: 20/min Auscultation: No pathological sounds . Arrythmic in both hands Percussion: Left heart border deviated to the left. osteoarthritis of knee joints. heart failure stage 2a 3 rd functional class.CONCOMITANT DISEASES: Post-infarctional cardiosclerosis with formation of aneurysm. Auscultation: Arrythmic tonus. chronic pyelonephritis. chronic pancreatitis. OBJECTIVE STATUS: Consciousness of patient: Clear Position of body: Active Constitution: Hypersthenic Skin and mucous membranes: Pale Peripheral lymph nodes: Not enlarged Musculo-skeletal system: Deformation of knees due to osteoarthritis Peripheral edema: Edema in the legs below the knee CARDIOVASCULAR SYSTEM: Palpitation of carotid vessels: Absent Pulse: 78/min. Accentuation of 2 nd heart tone in aortic point.

propanolol.DIGESTIVE SYSTEM: Tongue: Moist Formation of abdomen: Enlarged No palpation due to ascites. Eg. Veroshperone. Eg. Calcium channel blockers: To decrease heart rate. Eg. Verapamil. ACE inhibitors: To correct Heart failure and decrease overload on heart. Eg. Furosemide. Nifedipine. Also for antiarrythmic effect. PRIMARY DIAGNOSIS: Ischemic heart disease: Angina pectoris PRIMARY TREATMENT: Beta blockers: To decrease systolic blood pressure causing relaxation of myocardium and prevent angina. Statins: As prophylaxis. Sublingual nitroglycerine. Metaprolol. Nitrates: As a relaxant from pain. Symvostatin. Diuretics: To reduce edema in feet and reduce ascites. . Enalapril.

RESULTS FROM EXAMINATIONS: ECG: ST depression . Aspirin. Urine analysis. Creatine kinase) Routine blood test. Serum analysis: Check cardiac enzymes(AST. Scintigraphy: To check signs of ischemia. Stress echocardiography: To detect zone of hyperkinesia.Anticoagulant therapy: To prevent thromboembolic complications. Ticlodipine. RECOMMENDED EXAMINATIONS: ECG: To check for ST elevation or depression and changes in T wave. Eg. Treadmill test: With ECG monitoring to grade the limitivity of physic al activity.

low cholesterol. . Because of typical signs and history of patient. PLAN OF TREATMENT: Drugs: Metaprolol Digoxin Enalapril Aspirin Veroshperone Symvostatin Diet: Low salt.CLINICAL DIAGNOSIS: IHD: Unstable angina pectoris(Progressive angina).

Pulse rate: 74/min. Pulse rate: 74/min . Patient has no complaints other than weakness.09.09. Blood pressure: 130/80 mm Hg. 05.09. Not hurt.2010: No complaints. More active than yesterday. Has sleep disturbances due to constant urination.2010: Patient underwent magneto therapy for osteoarthritis. 06.2010: Patient fell down from bed not because of dizziness. Blood pressure:140/80 mm Hg. Blood pressure:130/80 mm Hg. Weight of patient -109 kg. Pulse rate:72/min. In medication patient is now being given Ibuprofen.09.2010: Pain in chest reduced from yesterday.2010: No complaints other than weakness. Pain in knees decreased. 04.09. Pulse rate: 71/min 03. Blood pressure: 140/80.DIARY: 02.

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