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Keywords: a case history, therapy, ischemic disease of heart, an ischemic disease, an ischemia, a hypertonia, an atherosclerosis, an infarct, a myocardial infarction, an idiopathic hypertensia, a case history on therapy
the CASE HISTORY
the Clinical diagnosis: an ischemic disease, a myocardial infarction of a forward wall of a left ventricle (26.09), the subacute period. A coronary atherosclerosis. Complete blockade of the right leg of a ventriculonector. An idiopathic hypertensia III, group of risk IV. Chronic IIÀ, 3 functional class. A chronic discirculate encephalopathy. A chronic genyantritis in a stage of an exacerbation. Disease Parkinsona.
the PASSPORT PART
1. A surname, a name, a patronymic: *********** **** ********
2. Age: 81 year
3. A sex: female
4. A nationality: Russian
5. Formation: average special
6. A place of work, a trade: the pensioner
7. A home address: Domostroitelej 19 - 15
8. Date of entering in clinic: 2.10.02
9. The diagnosis of the directed establishment: has addressed itself
COMPLAINTS of the PATIENT AT ENTERING
Strong pressing, compressive retrosternal pains, feeling of fever and sharp inconvenience in a chest, feeling of shortage of air. Unpleasant sensations last from 30 till 50 minutes, then for 15-20 minutes intensity of a pain on a background of method of a plenty of Nitroglycerinum is a little reduced (but does not stop!), then the expressed thermalgias renew. The pain irradiates in the left brachium, in the right half of chest, a mandible, is accompanied by feeling of an incorporation, a numbness of the left half of chest. Sharply expressed delicacy: the patient spends huge forces to make some steps. Blunt pressing, but rather intensive headache, especially strong in temporal and occipital areas. An illegibility of vision, a hymenium, a fog, sensation " navigation »ONn?NO«o" before eyes.
Nausea, desires on a vomiting.
the HISTORY of the PRESENT DISEASE
Counts itself the patient during approximately 20 flying (the patient then was " 61 year) when for the first time has felt a strong headache, has measured a blood pressure and has found out his increased: 160 and 90. Normal pressure in dormancy was 100 and 70. Attacks of rising of a blood pressure repeated all over again seldom: 1 time in 3-4 months, more often after an emotional overstrain, through 4-5 flying have become frequent up to 1 time in 2-3 weeks.
Pressure in dormancy has raised up to 140 and 90. Still approximately in 1-2 years the patient has noticed infringements on the part of a cardiovascular system: pressing, compressive retrosternal pains duration 3-5 minutes stoped independently or after method valokardina or Corvalolum have appeared. Gradually duration of a pain attack has increased till 10-12 minutes, for his cupping the patient accepted Nitroglycerinum. Pains arise after appreciable physical or (is (more often) than emotional loads. Some times during the last 10-12 flying pressure raised up to 220 and 110. In such cases the patient felt the sharp pulsating headache, the expressed delicacy, a nausea, desires on a vomiting. Accepted Adelphanum, caused first aid.
About 7-10 flying has become back to appear palpitation, sensation " jumping out from a breast ?NOnµa", which passed independently within several minutes after the beginning of an attack. If palpitation proceeded more than 10 minutes, the patient accepted Verapamilum which well helped it. In a polyclinic and a hospital addressed seldom as itself all life worked as the nurse. The present deterioration has come 2 months ago (11.08) when on rate at son in Moscow suburbs where the patient has arrived to stay for a while, the expressed pain attack has developed. General duration of a pain was about 3-3,5 hours, with the periods of weakening and repeated intensifying. After the termination of an attack the patient was disturbed almost constantly with pressing, compressive sensations in the field of heart. Has been compelled to limit considerably physical activity as even smaller, than usually, loads were accompanied by unpleasant sensations in the field of heart. The patient accepted Nitroglycerinum, laid 5-6 days then has become to feel like much better and could return to Voronezh. Similar, only longer, the attack has repeated 26.09.02, after an appreciable exercise stress (changed linoleum). Burning retrosternal pains were accompanied by sharp delicacy, a giddiness, hum in a head and in the ears, a pulsating headache, a nausea, a fever. The patient has addressed in a polyclinic, has been written down by an electrocardiogram where the expressed focal changes are found out as ischemic in peredneperegorodochnoj areas. The patient is delivered in a reception of ÁÑÌÏ, is entered: Analginum, a papaverine, Dibazolum (from words of the patient), in hospitalization it refused (the patient did not insist on hospitalization). Within 3-4 days it was treated at home: accepted Nitroglycerinum, a saw abirritating collectings, laid. The condition was not improved, pains began to appear even after several steps (the patient could not reach without stoppings kitchen).
Intensity of pains estimates as stronger, than usually. 2.10. the nausea, sharp delicacy, a giddiness, a pulsating headache, a fever, a hymenium, a fog have joined strong retrosternal pains before eyes that has induced the patient to address in ÁÑÌÏ.
the HISTORY of LIFE of the PATIENT
Was born in the Orenburg area, during the present moment lives in Voronezh. Long time worked as the nurse and the senior nurse in tubercular hospital. Harmful habits (smoking, the use of alcohol and narcotics) are not present. The transferred diseases: a grippe, a chronic genyantritis, a chronic interstitial pneumonia, a chronic gastritis, a chronic pancreatitis, a chronic colitis, an appendectomia concerning an acute cholecystitis, fracture of a surgical neck of the left brachium, a wide-spread osteochondrosis, disease Parkinsona. An intolerance of Dimedrolum (cramp), Streptomycinum (sharp delicacy, block, headaches). An idiopathic hypertensia suffers " from 61-62 the flying, a sugar diabetes denies. Whether parents of a sick idiopathic hypertensia, an ischemic disease were sick, a sugar diabetes, oncologic diseases, an obesity the patient does not know. In detail on a state of health of the son also it is not informed (the son - the military man, lives with family in the other city).
the PRESENT CONDITION of the PATIENT
the General inspection of the patient.
the General average condition, consciousness clear, a position of the patient active, mood quiet, equal. Well, in detail and correctly replies.
Body build normosthenic, the patient of a normal feed. Features enlarged (large labiums, a nose). The patient does not know the body height and weight, in hospital these gaugings were not carried out.
Integumentsacyanotic, normal humidity, on the bottom extremities a skin dry; the moderate cyanosis of labiums, mild - stop is marked. On a skin of a chest and a back - individual spherical crimson specks in diameter of 1-2 mm. The turgor of a skin is reduced, a superfluous skin, is especial on forearms and brushes. The patient marks, that for the last 5-7 flying has appreciablly grown thin. Binds it that has become to watch itself and to limit in high-caloric products, it is especial in fried and fat.
Edemas are not present. Submandibular lymph nodes in the size of 5-6 mm, painless, are easily displaced.
the Muscle systemis normally advanced, the tonus of muscles is increased, the expressed static tremor of the top extremities, a muscle tension, at an extension of an arm - a sign " gear ¬«?N?a" (disease Parkinsona). The osteal system, joints without deformations, at a palpation are painless. A body temperature - 36,8 - 36,9 °.
System of organs of respiration
the Nose of a regular form, is present a reddening in the field of genyantrums, morbidity at pressing, a mild beating. From a nasal cavity - a plentiful rich discharge.
Chest of a normal form, excursion from both sides identical, respiration deep, in a correct rhythm, ×ÄÄ=16 in one minute. At a percussion - a box sound.
Active mobility mild on a middle-axillary line on the right - 5 sm, at the left - 4 see. At an auscultation - rigid respiration, the individual whistling dry rhonchuses more expressed on the right are auscultated. In 1999 year at a roentgenoscopy of organs of a chest it is revealed: mild emfizematozny, pulmoskleroz, a fibrosis of roots mild; augmentation of a left ventricle, expansion of a diameter of heart, an aorta it is developed, sklerozirovana.
System of organs of a circulation.
the Apical jerk is localized in 5-th intercostal space on 1,5 sm to the left from a mammilar line. Borders of heart: right - on 1 sm to the right of a right edge of a breast bone, top - 3 intercostal space, left - on 2,5-3 sm to the left from a mammilar line. Cardiac sounds rhythmical, muffled, a heart rate=from 58 up to 64 in one minute (predilection to a bradycardia). On an apex - the expressed systolic hum well conducted in a point of Botkin-Ýðáà. Pulse - from 58 up to 64 a minute of good filling and a strain, equal, rhythmical. Deficiency of pulse is not present (DP=0). A blood pressure at the moment of a curatio 120 and 70.
System of organs of digestion.
the Smell from a mouth is not present, labiums dry, cyanochroic. A mucosa of an oral cavity at the moment of a curatio of light pink colour, tongue of the usual size, wet, is impose with a quaggy white raid. Tooths are, a little plug-in. Colour of fauces - light pink.
the Belly of the usual form, slightly enlarged in volume due to a hypodermic tissue, a skin without a pigmentation, veins of a forward abdominal wall it is not visible. At a palpation soft, painless, unpleasant sensations are marked in the field of the right hypochondrium.
Liquids in an abdominal cavity it is not revealed. The sizes of a liver on Kurlovu: 6-8-11 (this size precisely to define it was not possible because of well advanced mammary gland).
At a palpation a liver painless. On edge of a rib arch, is closer to axillary area acts from under him on 1-1,5 see. Edge its equal, smooth, an elastic consistence. The lien is not palpated. Signs of a cholecystitis, a pancreatitis, a peritonitis it was revealed not.
Genitourinary system.
Kidneys are not palpated, sign Pasternatskogo negative. An emiction painless, infrequent (4-5 times day).
Mammary glands are well advanced, cicatrixes, tumours are not present.
Endocrine system.
the Isthmus of a thyroid gland is well palpated, his size " 0,6-0,7 mm, shares are palpated: mobile, elastic, are easily displaced. Secondary sexual attributes are well expressed.
Nervous system.
the Consciousness is kept, speech correct, cohesive, figurative. Thinking consecutive, logical, memory on the current and last events is kept, but slightly reduced.
Mood quiet, equal.
Gait: the patient goes fine short steps, at movement - kachatelnye movements of arms. Tea cannot drink, sitting on a bed as he spills. Is compelled to clasp an irrigator both arms, to put it on umbochku near to a bed and to reach for it.
Vision is reduced because of a cataract (both eyes, the last 7 flying). The width of pupils identical, their reaction to light is well expressed. The ear is reduced. 24.04.01 it has been examined in a polyclinic on a residence by the oculist. In a lens initial opacifications, an eyeground of light pink colour, border precise are found out. Vessels izvity, narrow arterias, veins of non-uniform calibre. The diagnosis of an initial age cataract, angiopatii retinas is put.
Pain sensitivity is in regular intervals expressed on all body.
the PRELIMINARY DIAGNOSIS
an ischemic disease, Construction Department. A coronary atherosclerosis. Blockade of the right leg of a ventriculonector. A hypertonic disease III, risk IV. Chronic cardiac nedostatochnot IIÀ, the functional class II-III. A chronic discirculate encephalopathy. Disease Parkinsona.
Suspicion on a myocardial infarction.
the Plan of inspection of the patient:
the General analysis of a blood, urine, a biochemical blood analysis, an electrocardiogram in dynamics, rentgenografija organs of a chest, ultrasonic of heart, a blood analysis on level TTG. Consultation of the oculist, the neurologist.
the Treatment planning of the patient:
1. A cupping of a pain attack: Sodium nitritums (Nitroglycerinum for a cupping on 0,4-0,6 mg of perorally each 5 minutes, Nitrosorbidum for the further treatment).
If Nitroglycerinum cannot stop a pain, enter Morphinum (v/v on 2 mg each 15 minutes up to a cupping of an attack, but no more than 25-30 mg totally).
2. Antihypertensive therapy: inhibitors APF (Captoprilum 0,0125 g 3 times day 2 hours prior to meal).
3. Antiagregantnaja therapy: Aspirinum in a dose of 150 mg (a tablet all over again to chew).
4. A polarizing admixture.
5. Riboxinum (on 0,2 g 3 times day). Results of additional methods of inspection of the patient.
the General analysis of a blood.
3.10.02.4.10.02.9.10.02
Hb 118 g/l 122 g/l 120 g/l
eritr. 3,8*1012/ë 4,06*1012/ë 4,0*1012/ë
lejk. 6,4*109/ë 5,0*109/ë 4,2*109/ë
SOE 655 the General analysis of urine.
3.10.02.9.10.02
Otn. Density 1005 g/l 1011 g/l< Acidic acidic
Fiber: is not present is not present
the Epithelium: flat, poorly flat, it is uniform. In p/zr.
Leucocytes: it is uniform. In p/zr. 1-2 the Analysis of urine on Nechiporenko:
leucocytes 0,5*106/ë the Biochemical analysis of a blood.
2.10.02. nuclear heating plants=66,7 nmol/l, ALT=75,1 nmol/l
3.10.02. glucose=4,6 mmol/l (3,3 - 5,5), a urea=4,1 mmol/l (2,5 - 8,3), an amylase=6,0 mg (2,2 - 7,0), ALT=55 nmol/l (27,8 - 189), nuclear heating plant=31 nmol/l (27,8 - 125), b-lipoproteins=4,6 g/l (3,50 - 5,50), a thrombinogen=100 % (80 - 100), Fibrinogenum=2,6 g/l (2,0 - 5,0), a hematocrit=48 % (36 - 48), trombinovoe time=16 sek (15 - 18), ACHTV=57ñåê (40 - 55), a bilirubin free=8 mkmol (5,0 - 20,50), etanolovyj the test=sl. +, UMRS=otr., a protamine - sulf. The test=otr.
At entering a blood pressure 170 and 100
the electrocardiogramfrom 26.09.02, 2.10, 7.10 are applied.
the DIAGNOSIS
an ischemic disease, a myocardial infarction of a forward wall of a left ventricle (26.09), the subacute period, a coronary atherosclerosis. Blockade of the right leg of a ventriculonector. A hypertonic disease III, group of risk IV. N IIÀ, 3ÔÊ. Hr. A discirculate encephalopathy. Hr. A genyantritis in a stage of an exacerbation. Disease Parkinsona.
the SUBSTANTIATION of the DIAGNOSIS
On the basis of the data of an epidemiology (the myocardial infarction arises more often at men after 55 and women after 65 flying, it is localized in 70-80 % of cases in a wall of a left ventricle), taking into account age sick (81 year), complaints to appreciable deterioration of state of health last 2 months, resulted in appreciable restriction of physical activity, long gripping pains not stoped by Nitroglycerinum behind a breast bone, irradiating in the left brachium and a mandible, sharply expressed delicacy, a short wind, periodically arising strong headache, attacks of palpitation, rise of a blood pressure (170 and 100), infringements of vision, a fever, a long anamnesis on an ischemic disease and a hypertonic disease (more than 15 flying), on the basis of the data of objective inspection (paleness, delicacy, a Crocq's disease, predilection to a bradycardia, is percussion determined expansion of borders of heart to the left, auskultativno determined developments of stagnation in the bottom shares mild, a systolic apex murmur, Testifying to a circulatory unefficiency); the given tool and laboratory methods of inspection: on an electrocardiogram: the expressed changes of apical - lateral area (from 26.09), peregorodochnoj and apexes (2.10), probably, on ischemic type, complete blockade of the right leg of a ventriculonector, EKG-ATTRIBUTES of a hypertrophy of a left ventricle, mild normohromnoj an anemia from 3.10, low specific weight of urine (1005 and 1011), taking into account expressed positive dynamics of a condition of the patient (weakening of a short wind, the termination of pains, a fever, a nausea, normalization of a blood pressure, positive EKG-DYNAMICS) after the lead course of treatment, is possible to diagnose an ischemic disease, a myocardial infarction peredne-peregorodochnoj walls of a left ventricle (26.09.02), the subacute period. A coronary atherosclerosis.
Blockade of the right leg of a ventriculonector. A hypertonic disease III, group of risk IV. HSN IIÀ, 3ÔÊ. A chronic discirculate encephalopathy.
On the basis of complaints of the patient to difficulty of nasal respiration in connection with an incorporation of a nose, objective inspection (morbidity at a palpation and a mild percussion in the field of genyantrums, presence plentiful rich separated of nasal ways), presence in an anamnesis of a chronic genyantritis, is possible to diagnose a chronic genyantritis in a stage of an exacerbation. On the basis of complaints of the patient to a constant tremor of arms with which it cannot consult, the data of an anamnesis (the tremor has appeared 5-7 flying back), the data of objective inspection: the static tremor, the expressed slouch, uncertain gait fine steps, a muscle tension, a sign " gear ¬«?N?a", it is possible to diagnose disease Parkinsona. DIFFERENTIAL DIAGNOSIS
Is carried out with a hypertonic crisis. For: Presence of a hypertonic disease and hypertonic crisises in an anamnesis, complaints at entering on a strong headache, deterioration of vision, a hymenium before eyes, a fever, a nausea; pressure in a reception, occurrence of an attack of the increased pressure 8.10.02 on a background of treatment by Sodium nitritums, a magnesia (170 and 100) with complaints to a strong headache, a nausea and a vomiting. Against: a blood pressure in reception at entering 170 and 100 (before a blood pressure raised and up to 220 and 120, thus the patient felt like better. It allows to assume, that vegetative infringements are caused more likely by a strong cardiac pain, instead of the increased blood pressure). Definition of MV-fraction KFK, troponina I.
Is carried out also with an alternative stenocardia. For: long pain attacks, presence of AV-blockade. Against: attacks of an alternative stenocardia are stoped by Nitroglycerinum, and at the patient was not stoped. Means, at the patient not an alternative stenocardia.
It Is carried out with an astable stenocardia. For: Augmentation of amount, expressiveness and prodolzhitelnsti attacks of a stenocardia of a strain (a stenocardia " ¬ONUN?n«") for last 2 months (a progressing stenocardia). A characteristic EKG-PICTURE: depression of segment SÒ, inversion zubtsa T, absence pathological zubtsa Q.
Weakening and subsequently absence of effect from Nitroglycerinum which stoped attacks earlier. Fermental diagnosis (MV-fraction KFK, troponin I and Ò) is necessary. At an astable stenocardia as against a myocardial infarction rising of a level of enzymes more than 40 % from an initial level do not happen. On troponinu it is possible to define, whether there is a damage of cardiomyocytes, that is whether there is a myocardial infarction. Really to lead holterovskoe a monitoring: to reveal changes, characteristic for an astable stenocardia.
Ultrasonic of heart: it is possible to distinguish zones and and hypokinesias, focal changes of a wall of heart. Taking into account senile age of the patient, a long anamnesis on an ischemic disease and a hypertonic disease, an expressiveness and duration of pain attacks (till several o'clock) probability the myocardial infarction is much higher, than an astable stenocardia.
For differential diagnosis of cardiac pains from pains in a chest, accompanying other diseases, it is necessary:
· to lead a X-ray inspection of organs of a chest to exclude: a pneumonia with involving a pleura, disease of a pleura, damage of ribs, diseases of organs of a mediastinum.
· radiological and endoskopicheskoe research of organs of a gastrointestinal tract for exception of a spastic stricture, a breakage of an esophagus, an esophagus reflux, a peptic ulcer of a stomach.
For the further specification of the diagnosis, an evaluation of a condition of the patient it is necessary to carry out the following laboratory researches: The general analysis of a blood, urine, research of biochemical parameters of a blood. EKG-DYNAMICS.
Disease Parkinsona (arises more often after 50 flying) is differentiated from an essential tremor which is observed in pullet age more often, from a tremor at a thyrotoxicosis (there are no other clinical displays: rise in temperature, a sweating, a tachycardia, the increased shine of eyes, irritability, a short wind). Taking into account, that besides occurrence of the expressed tremor of arms in the patient in the last a little bit flying bearing (an appreciable slouch), gait (moves fine short steps) has strongly changed, there is a sign of a cogwheel, it is possible to exclude a senile tremor and to diagnose disease Parkinsona.
the Leaf of medical purposes:a table ¹ 10.
1. Sol. Glucosae 5 % - 200 ml + Actropidi 2 ED + Sol. Kalii chloridi 4 % - 20 ml - v/v once a day daily.
2. Sol. Magnesii sulfatis 25 % - 10 ml - v/v once a day, daily.
3. Tab. Aspirini 0,5 - once a day
4. Tab. Nitrosorbidi 10 mg, 20 mg - 4 times day
5. Tab/Corvitoli 100 mg - 2 times day
6. Sol. Riboxini 2 % - 10 ml - â\â once a day.
the Diary of the patient.
10.10.02 Complaints to bad dream, the delicacy, unpleasant sensations in the field of a nape.
Has informed, that yesterday after a dropper with a magnesia the desire on a vomiting was. Pulse=a heart rate=58. frequencies of respiratory movements=17 in one minute. A blood pressure=120 and 70. In mild individual dry rhonchuses are auscultated. Cardiac sounds are muffled, systolic hum on an apex. The stool was, an emiction without features. The general condition of the average patient, on a background of therapy is marked by a magnesia some deterioration of state of health: delicacy, the paleness, the expressed vegetative reactions. A preparation is solved to cancel.
the Note: 8.10.02.1415. Complaints to a headache, a unitary vomiting after which there has come appreciable simplification. A blood pressure=170 and 100, a heart rate 75, tones rhythmical.
Temperature 37,7 °.
1910. It is entered Sol. Analgini 50 % - 2,0 ml - v/m,
Tab. Aspirini 0,5,
it is measured by a blood pressure - 130 and 70, pulse - 70 impacts in one minute.
11.10.02. Complaints to a rhinitis, a pain in the field of genyantrums, a rich discharge from a nose, an incorporation in ears. On the part of a cardiovascular system marks improvement, well slept at night. Pulse=a heart rate=56. frequencies of respiratory movements=16. blood pressures=110 and 70. In mild - individual dry rhonchuses. The stool was, an emiction - small amount, as a saw sick few.
Edemas are not present. The general condition of the patient is still kept average.
Paleness, delicacy, incorporation of a nose, reddening of his wings, areas of a projection of genyantrums, change of a timbre of a voice are marked. Consultation otorinolaringologa is recommended.
12.10.02. Complaints to a rhinitis, an incorporation of a nose. On the part of a cardiovascular system of complaints does not show.
The retrosternal pains, unpleasant sensations in the field of heart, did not disturb a head.
In the evening has fallen asleep quickly, slept strong and quietly, since morning feels like had a rest, vigorous. Pulse=a heart rate=62. frequencies of respiratory movements=14. A voice hoarse. Cardiac sounds are muffled, systolic hum on an apex. In mild at an auscultation - rigid respiration, rhonchuses are not present. A stool was not, an emiction usual. The general condition of the average patient, is observed the tendency to improvement: the smaller expressiveness of delicacy and paleness, the patient is more active, is mobile, marks improvement of mood.
the EPICRISIS
*********** **** ********, 81 years, the pensioner. Has acted in hospital ¹ 92.10.02 with complaints to the burning retrosternal pains which for the first time have arisen 26.09.02 after appreciable exercise stress. Pains all over again were stoped by Nitroglycerinum in 30-40 minutes after occurrence, repeating some times in day. 2.10.02 pain has become especially strong, proceeded more than 3 hours, was not stoped by Nitroglycerinum, irradiated in the left arm, a brachium and in a mandible, was accompanied by strong delicacy.
strong headaches, a giddiness, a hymenium, a fog before eyes, sensation of a pulsation of vessels in occipital and temporal areas, a nausea and desires on a vomiting Have joined. All this has compelled the patient to address in hospital. The hypertonic disease about 20 flying, an ischemic disease - about 15 flying suffers. 5-7 flying attacks of a Bouveret's disease which were stoped independently or after method of Verapamilum back began to appear.
In an anamnesis - some hypertonic crisises for the last 10 flying (a blood pressure maximal - 220 and 120). At entering the patient acyanotic, slightly delayed, a blood pressure 170 and 100 (at home before hospitalization, according to the patient, has accepted Adelphanum), a heart rate 75. At the moment of the first curatio - the paleness, the expressed cyanosis of labiums and stop, sharp expansion of borders of heart to the left, systolic hum on an apex, conducted in Botkin - Erba point. On an electrocardiogram from 26.09 and 2.10.02 deviation EOS to the left, predilection to a bradycardia, focal changes in peredne-peregorodochnoj areas, attributes of a hypertrophy of a left ventricle, complete blockade of the right leg of a ventriculonector.
the General analysis of a blood.
3.10.02.4.10.02.9.10.02
Hb 118 g/l 122 g/l 120 g/l
eritr. 3,8*1012/ë 4,06*1012/ë 4,0*1012/ë
lejk. 6,4*109/ë 5,0*109/ë 4,2*109/ë
SOE 655
the General analysis of urine.
3.10.02.9.10.02
Otn. Density 1005 g/l 1011 g/l
Reaction: acidic acidic
Fiber: is not present is not present
the Epithelium: flat, poorly flat, it is uniform. In p/zr.
Leucocytes: it is uniform. In p/zr. 1-2
the Analysis of urine on Nechiporenko:leucocytes 0,5*106/ë
the Biochemical analysis of a blood.
2.10.02. nuclear heating plants=66,7 nmol/l, ALT=75,1 nmol/l
3.10.02. Glucose=4,6 mmol/l (3,3 - 5,5), a urea=4,1 mmol/l (2,5 - 8,3), an amylase=6,0 mg (2,2 - 7,0), ALT=55 nmol/l (27,8 - 189), nuclear heating plant=31 nmol/l (27,8 - 125), b-lipoproteins=4,6 g/l (3,50 - 5,50), a thrombinogen=100 % (80 - 100), Fibrinogenum=2,6 g/l (2,0 - 5,0), a hematocrit=48 % (36 - 48), trombinovoe time=16 sek (15 - 18), ACHTV=57ñåê (40 - 55), a bilirubin free=8 mkmol (5,0 - 20,50), etanolovyj the test=sl. +, UMRS=otr., a protamine - sulf. The test=otr.
On the basis of the mentioned above complaints, an anamnesis of the patient, the data of objective inspection, additional methods of inspection the diagnosis is put: an ischemic disease, a myocardial infarction of a forward wall of a left ventricle (26.09), the subacute period, a coronary atherosclerosis. Blockade of the right leg of a ventriculonector. A hypertonic disease III, group of risk IV. Chronic heart failure IIÀ, 3 functional class. A chronic discirculate encephalopathy. A chronic genyantritis in a stage of an exacerbation. Disease Parkinsona.
According to complaints of the patient, clinical displays of disease, the data of objective inspection, additional researches, switching and laboratory, the transferred hypertonic crisis is not excluded.
Taking into account a fast cupping of a pain in a hospital, downstroke of a blood pressure, appreciable improvement of state of health of the patient for 8-th day of stay in hospital, nerezko the expressed circulatory unefficiency (N IIÀ), a balanced diet of the patient and diligence of a message (and before hospitalization) a correct way of life, considering age sick - 81 year-, impossibility of complete restriction of exercise stresses (the patient lives one), predilection to long emotional experience of all events, the nearest forecast, under condition of keeping the regimen promoting convalescence, rather favorable. About the remote forecast speech of a message while it is difficult.
treatment Spent by the patient included a cupping of a pain attack, downstroke of a blood pressure, and then
1. Sol. Glucosae 5 % - 200 ml + Actropidi 2 ED + Sol. Kalii chloridi 4 % - 20 ml - v/v once a day daily.
2. Sol. Magnesii sulfatis 25 % - 10 ml - v/v once a day, daily.
3. Tab. Aspirini 0,5 - once a day
4. Tab. Nitrosorbidi 10 mg, 20 mg - 4 times day
5. Tab/Corvitoli 100 mg - 2 times day
6. Sol. Riboxini 2 % - 10 ml - â\â once a day. A feed - a table ¹ 10.
During a presence in hospital is marked expressed positive dynamics: the termination of the retrosternal pains, unpleasant sensations in the field of heart, downstroke of the blood pressure, appreciable decrease of delicacy: the patient well moves on chamber, corridors of hospital. The aggravation of symptoms of the patient was observed for 7-th day of treatment (8.10.02) when has again raised a blood pressure up to 170 and 100, pulse 75, the headache, a nausea and a vomiting after which the patient has felt appreciable simplification has appeared. In the evening of a blood pressure 130 and 70, pulse 70, in 1910 is intramuscularly entered r-r Analginum, the tablet of Aspirinum is given. The patient has lead night restlessly, but felt like much better in the morning. The next days - positive dynamics on the part of a cardiovascular system, but has become aggravated (probably, because of bad heating in chamber) hr. A genyantritis.
the Patient is recommended after an extract from a hospital the greatest possible restriction of physical and emotional loads, moderate restriction of fibers, Adepses and carbohydrates in conditions of a regimen with circumscribed mobility. Restriction of method of a common salt up to 4-5 g (at norm for a healthy organism 12-15ã), liquids up to 1-1,2ë, and at îò¸êàõ-0,8ë. Advisable dishes: bread grey a grinding, crackers. Soups groat, milk, vegetarian, borshches, a low-fat beef broth once a week.
Low-fat grades of meat, fish and bird in the boiled and baked kind. Oat and buckwheat porridges, puddings, baked puddings. An albuminous omelette. Vegetable russian salads and salads (except for a sorrel and funguses). Fruits, berries, juices. Adepses in day up to 50ã, from them of 50 % vegetative.
Sahara up to 40 g in day. Rather weak tea. Limit: strong tea, coffee, cocoa, a radish, a radish, a garlic, a common onion, pod-bearing plants. Are forbidden: fat dishes from meat, fishes, fancy pastry, brains, kidneys, a liver, a liverwurst, salty snack, canned food, alcohol, calf. Regular method of antihypertensive agents (gr is recommended. Inhibitors APF, for example, enalapril on 0,01 g once a day), antianginalnyh (Sodium nitritums, for example, Isosorbidum monoSodium nitritum on 20 mg 3 times day, Nitroglycerinum under tongue at a pain attack), antiagreganty (Aspirinum daily on 150 mg is better for chewing). Taking into account advanced age of the patient, presence of complete blockade of the right leg of the ventriculonector, the course of treatment lead by a hospital by b-blockers, houses to accept b-blockers, and also blockers of slow calcium canals are not recommended.
Considering, that sick 81 year, it is necessary to use cautiously (if to use) preparations, capable to cause an orthostatic hypotension (Methyldopum, Prazozinum, labetalol), and also preparations of the central action (Clonidinum, Methyldopum, Reserpinum), treatment with which can result in such complications as depression or a pseudodementia. Taking into account an emotional lability of the patient, it is possible to recommend method of mild sedatives (for example, Valeriana, Tinctura Araliae of Leonurus). the List of the literature:
1. Internal diseases 1 that under A.I.Martynova, N.A.Mukhin, V.S.Moiseyev's edition.
Moscow, 2001.
2. Vidal 2001 (Manual VIDAL of PRACTICES).
3. A disc " the Big medical encyclopedia 2000".
DATE the SIGNATURE of the CURATOR ____________
To discuss a material at a forum of a site Keywords: a case history, therapy, ischemic disease of heart, an ischemic disease, an ischemia, a hypertonia, an atherosclerosis, an infarct, a myocardial infarction, an idiopathic hypertensia, a case history on therapy
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