You are on page 1of 10



2. Etiology

3. Passport data Full name: Titova Valentina Igorevna Age: 1950 Gender: Female Education: Completed High School Place of work: Pensioneeer Home address: Pronski region Date of admission: 31/08/2011
4. Present Complaints;

Patient felt a pressing squeezing pain on the left side of her chest,radiating to the left hand and lasting 4-5 minutes. Reaction with nitroglycerin was unclear. Pain was accompanied by relatively moderate breathlessness and headache.

5. Anamnesis Morbi;

Patient has a history of hypertension , highest recorded being 180/120mmHg. She has stable angina and constantly takes enalapril and aspirin since 2006. USS of heart showed stenosis of atrioventricular valve.

2 months ago patient was at a funeral and had a fainting spell, over the next month pains became more regular during exertion and patient took nitroglycerin to alleviate them and when ECG was done it showed AV Block and patient was hospitalised and advised to implant a pacemaker.

6. Anamnesis Vitae Patient was born in Pronski region of Ryazan. She had a normal childhood and has had all normal childhood illnesses. She is educated to highschool level. Patient has a long history of her family there is no prior history of cardiovascular disease. In 2010 patient had cholecystectomy. Patient is married with 2 sons and 1 daughter. She has no known allergies and does not smoke although by her own admission she used to be a heavy consumer of vodka.

7. Physical Examination Current condition General condition General condition: satisfactory Position of patient: active Condition of consciousness: clear Face: symmetrical Constitution: height 154cm weight 82 Gait is normal. Construction: normosthenic Body temperature:36.7 Skin Normal colour of skin, moisture is normal, elasticity is normal. No blisters, erosions, rashes, no scratches etc. she has post-operative scar on the right hypogastriuml. No tumours projecting on the skin. she has normal hair distribution. Nails have normal colour, not brittle and no clubbing. Visible Mucosa (of mouth nose and eyes) Colour: pink No rashes, erosions or haemorrhages present. Mucosa is moist. Tongue has a grey-pink coating Eyes are moist and there are no signs of jaundice Subcutaneous fat Development: moderate with evident fat deposits on abdomen. degrees Celsius

Oedema: no oedema or evidences of oedema on palpation. Lymphatic system Lymph nodes are not palpable No pain on palpation. Skin above lymph nodes is of normal colour and elasticity. Muscles Uniformly developed, muscle tone is preserved and strength is good Bones No observable abnormalities in skull, spine and limbs. No pain in bones is present and there are no fractures present Joints All joints are normal with free movement and no pain Mobility of joints: All joints are movable

I. Respiratory Nose: The patients breathing is free and without painful sensation or sensation of dryness. There is no discharge from the nose and no pain is felt in the paranasal sinuses. Larynx Voice is clear and patient speaks and swallows with no pain. Lungs There is no pain in the chest and breathing is normal. Dyspnoea No dyspnoea and no asthma noted. Cough No cough noted. Sputum No discharge of sputum and no haemoptysis. Patient experiences no general temperature rise, sweating or cold shivers.

Examination of Chest The patients chest is normosthenic, Supra and sub-clavicular regions are symmetrical, there is no retraction or bulging of half of the chest. Patients ribs are normal, intercostal spaces are not bulged. Scapulae are tight fitting. Patients breathing is abdominal and there is symmetry in breathing movements. Rate: Depth and rhythm of breathing is normal. Maximum respiratory excursion: 7cm No dyspnoea. Palpation of Chest There is no pain during palpation Resistance of chest is normal Percussion Auscultation of lungs Vesicular breathing Added sounds Bronchophony
II. Circulatory

No pain syndrome, no palpitations & no unusual sensations in heart. No oedema on the lower limbs or varicose veins Arteries appear normal. Arterial pulse is Palpation of arteries is smooth. Examination of neck veins: reveals that there is no swelling and pulse is not expressed. Blood pressure

Palpation Apex beat is felt to the left of the mid-clavicular line in the 5th intercostal space. There is no evidence of cats purrs. Abdominal aorta is not felt below the sternum. Heart beat is felt on the parasternal line. Auscultation Initially a slight arrhythmia was heard over apex but within 3 days was no longer auscultated Percussion

III. Digestive Appetite is preserved. No dryness of mouth and unpleasant taste in mouth. No drooling salivary discharge. Amount of liquid drunk in day: General examination Mouth No fissures, bruises or other abnormalities. Gums are normally coloured with no visible signs of bleeding. Teeth No bleeding, some teeth are not present. Tongue Tongue has a grey-pink coating and moist. Not furry and no teeth prints. No ulcers, no swelling. Throat Usual colour Tonsils are normally sized and shaped. Pharyngeal mucosa is pink, absence of granulation on back surface of pharyngeal wall. Odour from mouth is non offensive.

Anus Prolapse of rectal mucosa: pink colour No pain and no growth Condyloma, fissures, ulcers and fistulas are absent. Abdomen Moderately developed musculature and there is no palpable pathology of abdominal organs. Pain and hyperesthesia are absent. Muscles are not tense on superficial palpation and on deep palpation there are pathological processes like cysts detected. Intestines are smooth on palpation and painless. Liver: There is no visible enlargement of the liver or any signs of pulsation. The upper boarder along the right midclavicular line = 9cm, along the anterior midline = 8cm and along the left costal margin = 7cm. Palpation by Obraztsov showed that the edge is soft, painless and regular. The surface is smooth IV. Urinary

V. Nervous Memory is accurate. Sleep is not disturbed Conscience is clear General examination Pupil reflex to light is normal. Hearing is normal, speech is normal and adequate. Movement is coordinated VI. Endocrine

8. Preliminary Diagnosis

9. Plan of investigation Blood Analysis RBCs: 4.8 x 1012 Haemoglobin: 155g/l WBCs: Neutrophils: Lymphocytes- 28% (norm 24-30) Monocytes: 3% (norm 6-8) ESR: 15mm/hr Glucose: 6.3 mmol/l Bilirubin: general- 20.35 Direct- 16.6 Indirect- 4.18 Free nitrogen: Amylase: General protein: Creatinine: 84umol Coagulation Urine Analysis Average amount of urine excreted per day = Colour: Transparency: In the field of view: RBCs = WBCs = Epithelial cells Specific gravity = Cylinders ketone bodies Glucose Protein =

10.Instrumental Investigation 11. Final Diagnosis


13.Plan of Treatment

14.Recipes of Medications

15. Diary (3 days) 2/09/11 : Patient was in good spirits,measured blood pressure

16.Prognosis; (for life, for work, for relative)