MATHEW ID SECOND SEM

SAINT PETERSBURG STATE MEDICAL ACADEMY NAMED AFTER

I. I. MECHINKOV

DEPARTMENT OF INTERNAL DISEASES

HEAD OF DEPARTMENT: DR.BOLIDEVA S.ATEACHER: DR.BELYEVA E.L

CASE HISTORY

Patient Name : Valentina Emelyanovna NatheesheenaAge :77 yearsDiagnosis :

PRIMARY ARTERIAL HYPERTENSIONSEVERE DEGREE 3RD STAGE - RISK 4

Student: Mathew Joseph

Group : 478

2010

PASSPORT PART

Surname and Name : Valentina Emelyanovna Natheesheena

Age : 77 yrs Sex : Female

Place of residence :Sofikelevskaya Street, SPB Profession : Pensioner

Date of hospitalization : 22 April 2010

Type of hospitalization : Emergency

STATUS PRAESENS SUBJECTIVUS

COMPLAINTS

At the time of examination the patient was sitting on the bed with a clear consciousness. She had a slight headache, weakness, dyspnoea when BP increases, edema in face. Edema in lower extremities during night time, pain in large joints and back due to osteochondrosis. The patient complains about bad and interrupted sleep.

At the time of hospitalization the patient had high blood pressure, headache, dyspnoea. Her hospitalization was emergency type.

SUBJECTIVE STATE OF ORGANS AND SYSTEMS

A. Cardiovascular system

Pain in the chest region of pressing and tearing character. Pain radiates to shoulder. Increased BP causes dyspnoea,weakness and headache. Palpitation occurs on a sudden. Edema in lower extremities during night time.

B. Respiratory system

Breathing difficulty during physical exertion and during increased BP. No other complaints of breathing difficulties, wheezing, cough or hemoptysis. Absence of cyanosis. Patient has clear voice.

C. Digestive system

Appetite is satisfactory and drinks approximately 1.5 liters of water daily. No complaints of heartburn, nausea, meteorism. Normal defecation pattern – once daily with normal colour and consistency. No complaints of abdominal pain, dysphasia, vomiting, eructation.

D. Urinary system

Normal micturition of a clear colour. No complaints of burning sensation or pain during micturition. Absence of pain in the loin area.

E. Nervous system

Bad and interrupted sleep. Absence of strokes, epilepsy or other neurological symptoms. Patient is well oriented to time, space and person.

F. Skeletal and Muscular system

Normal musculature. Pain in large joints and pain in vertebra due to osteochondrosis.

HISTORY OF PRESENT DISEASE (ANAEMNESIS MORBI)

The time of the onset of the disease: 15 years ago, in 1995

The first symptoms and progression of the disease: The first signs of the disease was a rise of blood pressure above 170/100mmHg. It was associated with weakness and headache. After that from 2005 onwards the patient is experiencing headache, pain in the heart area after an increase in BP. Pain occurs sudden and dyspnoea occurs during even small physical works. Edema was also present during night time. Patient was undergoing therapeutically treatment for the same. One year ago the patient had an ischemic attack of the brain. Her mother died due to hypertension. 30 years back 2/3 of her stomach was recessected. On 22nd April 2010 the patient had a sudden rise of BP along with weakness, headache and dyspnoea and was admitted to Hospital No. 122 at an emergency where she underwent blood, biochemical and urine analysis as well as ECG and , echocardiography.At the time of examination, on 29th April:

Blood Pressure : 150/100 mmHg Pulse : 78 beats per minuteTemperature : 36.6oC

ANAEMNESIS VITAE

1. General biographical information

Place of birth: St. PetersburgThe age at which patient began to walk and talk: Does not remember but earlyPhysical and mental development in childhood: Same as for a normal variant Condition of life in childhood: Quite hardThe age at which patient entered school: 5 yearsEducation level: Secondary education

2. Occupational history Profession: Gymnastics Trainer Condition of work: Satisfactory but sometimes had stressProfessional hazards: Stress, over physical activities

3. Material and social conditions

Condition of life: Patient usually sleeps for 8 hours. She is quite active.Condition of housing: Patient lives in a 1 room apartment on the 2nd floor. Her apartment is a middle class apartment, well illuminated and hygienic. She lived with her husband who died 1 week back.Peculiarities of nutrition: Eats 3 times daily.

4. Past illnesses

No childhood infections.Previous medical and surgical treatment: 30 years back had 2/3rd gastrtectomy.Sustained trauma: None

5. Hereditary Patient’s mother was diagnosed with arterial hypertension and died due to that.Patient’s father had hernia.

6. Habits Smoking : occasional smokerAlcohol : Doen’t use alcoholNarcotics : Doesn’t use narcotics.

7. Allergic history

No known allergic history to drugs, foods or chemicals.

8. Epidemic history

No tuberculosis, hepatitis, jaundice, venereal disease, malaria, diphtheria and HIV.Has never received blood transfusion. Has not been to another country for the last 10 years. Did not visit the dentist for the last 6 months.

She had a decreased immunity according to records.

9. Insurance

She has medical insurance and is on the invalidity list.

STATUS PRAESENS OBJECTIVUS

General examination

-General condition : Satisfactory.-Posture : Active (alert and orientated).-Consciousness : Clear.-Constitutional type : Hypersthenic . -Color of skin : Pale skin.-Temperature : 36.6oC.-Blood pressure : 150/100 mmH.g-Pulse : 78 beats per minute.-Sweating : Normal.-Gums and teeth : White teeth without gingival recession.

-Tongue : Moist and pink.-Eyes : No pathological findings but wears spectacles.-Edema : Slight edema on face and on extremities. -Skin : Elastic, Moist, slightly decreased turgor of skin, brown pigmentations present on the skin-Nail : Shiny and pink in color-Hair : Soft and non-brittle-Lymph nodes : Non palpable-Mucosa : Pink-Peripheral vessels : No pathological findings-Muscles : Muscular development is satisfactory, no local atrophy of muscles and no weakness of muscles-Bones and joints : No deformations of bones, joints are of normal shape, colour but painful during movements. -Thyroid gland : Palpable, soft and painless

STATUS OF OTHER ORGAN SYSTEMS

Cardiovascular systemInspection-No scars, deformity, visual pulsations. Cardiac hump is absent. Apex beat and cardiac beat are absent.

Palpation-Pulse is symmetrical, 78 per minute, rhythmical, moderate in volume and hard. Form and height of pulse is not changed and there is no pulse deficit between radial and apex beat. -Apex beat was not palpated .-Absence of systolic and diastolic Cat’s purr, cardiac beat and retrosternal pulsation.-Pulsation of carotid arteries is symmetrical and carotid shudder is not palpated.

Percussion

Relative cardiac dullness:

Right border -1.0 cm laterally from the sternal edge in the 4th right

Intercostal space.-3rd right intercostal space next to the right

edge of sternum.Upper border -On the 2nd rib between the left parasternal and sternal line.Left border -2.0 cm medially to the left anterior axillary

line in the 5th intercostal space.-2.0 cm medially to the left anterior axillary line in the 4th intercostal space.-On the left midclavicular line in the 3rd intercostal space.

Absolute cardiac dullness:

Right border -1 cm right to the edge of the sternum in the 4th intercostal space.Upper border -At the level of the 3rd rib margin in left parasternal line .Left Border -2 cm left to sternam in mid clavicular line.

Vascular bundle:

Along the edges of sternum left and right respectively with transverse diameter 5 cm.

Conclusion:

Hypertrophy of the left ventricle.

Auscultation

At 1st point of auscultation: S1 louder than S2 At 2nd point of auscultation: S2 louder than S1 (aortic valve)At 3rd point of auscultation: S2 louder than S1 (pulmonary valve)At 4th point of auscultation: S1 louder than S2 (tricuspid valve)At Botkin-Erb’s point: Absence of murmurs

-Accent of 2nd sound over aorta, no murmurs (systolic or diastolic).-Both sounds are decreased.

Respiratory system

Inspection-Chest has normal shape, without deformation.-Absence of participation in breathing of respiratory accessory muscles.-Both sides of the chest participate in breathing symmetrically.-Respiratory rate is 16/min.-Dyspnoea when increased BP.

Palpation-Tactile vocal fremitus is symmetrical and not increased.-Chest elasticity is decreased according to his age.-Absence of pain in palpation

Percussion

Topographic percussion:

Lower lung borders:RIGHT LEFT

Parasternal line 6th rib Not defined

Midclavicular line 6th rib Not defined

Anterior axillary line 7th rib 7th ribMiddle axillary line 8th rib 9th ribPosterior axillary line 9th rib 9th ribScapular line 10th rib 10th ribParaspinal line Spinous process of the 11th

thoracic vertebra

Upper lung borders:-Anterior apices:4 cm above the clavicles-Posterior apices: 7th spinous process of cervical vertebra-Kroenig’s area: 6 cm wide-Mobility: Normal

Conclusion:

Inspiratory dyspnoea when high BP.

Comparative Percussion:

No pathological findings.

Auscultation

-Patient has vesicular breathing without rales, crepitations and pleural rub.

Digestive system

Inspection

-Mucous membrane is pink and normal.-Tonsil is normal, pink.-Teeth: no pain, no caries, normal masticating surface.-Tongue is moist, no furring, rose colour, normal papilla.-Normal shape, size and symmetry of the abdomen.-No dilated subcutaneous veins, hernias, distensions or protrusions.-Abdomen participates in breathing regularly and symmetrically to the chest.

Palpation

-Left iliac, right iliac, left flank, right flank, left hypochondrium, right hypochondrium, epigastrium, umbilical, and suprapubic areas have normal mobility, no rigidity and no pain.-Sigmoid colon, caecum, transverse colon and greater curvature of stomach are painless, mobile, soft, cylindrical and no rumbling sound.-Liver’s margin was palpable – soft, painless and smooth.-Spleen was not palpable.

Percussion

-Liver size according to Kurlov was 9 x 8 x 7 cm-Spleen normal – 9th rib along midclavicular line.

Urinary system

-Kidneys are not palpable, pain free loin area. Nervous system

-Complaints of sleep disturbances.-Absence of loss of balance, speech disturbances, impairment of memory and intellect.-General reactions of the patient to questions are normal.

PRELIMINARY DIAGNOSIS

At the time of examination the patient had a slight headache, weakness, dyspnoea when BP increases, edema in face. Edema in lower extremities during night time. Had disturbed sleep.

Her anaemnesis morbi shows a history of fluctuating high blood pressure for the past 15 years which was under treatment and she had complaints associated with arterial hypertension. Her mother died of due to hypertension. Thus in her anaemnesis vitae there is genetic predisposition and diagnosed with arterial hypertension. She was a sports women and had vigorous physical exercices which also point to cause an increased hypertension. She was a occasional smoker and had stress due to occupation and family and was slightly obese. On percussion of his heart, the left border of the absolute cardiac dullness was increased concluding left ventricular hypertrophy. According to the patient’s complaints, anaemnesis morbi, anaemnesis vitae and physical examination the preliminary diagnosis is:

Primary Arterial Hypertension – Severe degree 3rd State withRisk 4.

PLAN OF INVESTIGATION

1. Blood analysis – to check any disorders of blood which could explain the increased blood pressure.

2. Biochemical analysis – to check the level of lipids, proteins, enzymes of the liver, electrolytes and urea.

3. Urine analysis – to check the function of the kidney.4. ECG – to check signs of hypertrophy, disorders of

rhythm and conduction.5. Echocardiography with Doppler – to check the position

and motion of the heart walls, internal structures of the heart. Doppler is done to check the flow blood to and from heart.

LABORATORY RESULTS AND INTERPRETATIONS

Blood analysis: Hemoglobin 144 120-140g/lColor index 0.93 0.85-1.05 Red blood cells 4.67 .10*12 /L 3.9-4.7.10*12 /L Thrombocytes 224.10*9per L 180-320.10*9per L White blood cell 6. 10*9/L 4-9.10*9/L Lymphocyte 32% 19-37%Monocyte 3% 3-11%Eosinophili 2% 0.5-5%ESR (mm/h) 8mm/hur 2-15mm/hr MCV 89.4H+ 4.7%Neutrophil(seg) 63 47-72%

Biochemical Test:

Bilirubin 12 µmol/L Normal. ALAT 34unite/L (3-35) Normal. ASAT 30unite/L (3-35) Normal.

Protein 76g/L (60-80) Normal. Sugar 4.3mmol/l Normal.Cholesterol 5.3mmol/L Normal.Alpha Amylase 25mmol/LBil1urubin Direct 9mmol/lPotassium 3.45(3.5-5) mmol/LCalcium 2.35(2.12-2.65) mmol/LUrea 6.5mmol/LCreatine 90mmol/L.

Urine analysis: Glucose NegativeProtein Negative.Bilrubin Negative.Urobilin Normal.KET Negative.BLD Negative.NIT Negative.LEU Negative. PH 6.5SG 1.025Color Yellow.Consistency Transparent.

Microalbuminuria 4.7 mg/l(N upto 20)

EchocardiographyLeft heart border changing ,left ventricle hypertrophy .Aorta is not enlarged.General contractile ability of heart is normal.right chambers without changesgeneral contractile activity normal

ECG Results:

P - 0.01, PQ -016,QRS- 0.06,R-R max – R-R min - 1.75- 0.94,R-R – 0.99,Frequent – 83. QT- 0.39. Sinus rhythm.Electrical axis shifts to right. Hypertrophy of left ventricle. Early repoleration of the ventricle.

FINAL DIAGNOSIS

At the time of examination the patient had a slight headache, weakness, dyspnoea when BP increases, edema in face. Edema in lower extremities during night time. Had disturbed sleep.

Her anamnesis morbi shows a history of fluctuating high blood pressure for the past 15 years which was under treatment and she had complaints associated with arterial hypertension. Her mother died of due to hypertension. Thus in her anamnesis vitae there is genetic predisposition and diagnosed with arterial hypertension. She was a sports women and had vigorous physical exercises which also point to cause an increased hypertension. She was a occasional smoker and had stress due to occupation and family and was slightly obese. On percussion of his heart, the left border of the absolute cardiac dullness was increased concluding left ventricular hypertrophy. The laboratory investigation of blood reveals no signs of infection or inflammation. Glucose is normal and as result no diabetes mellitus. Normal AST and ALT, so no signs of heart failure. Urine analysis reveals that kidney function is normal. Echocardiogram shows signs of left ventricular hypertrophy. ECG results also reveals left ventricular hypertrophy.

According to the patient’s complaints, anaemnesis morbi, anaemnesis vitae, physical examination and laboratory investigation the final diagnosis is:

PRIMARY ARTERIAL HYPERTENSION – SEVERE DEGREE 3RD STAGE - RISK 4

DIFFERENTIAL DIAGNOSIS

The main reasons of the arterial hypertension should be differentiated according to our patient’s signs and symptoms with the signs and symptoms of the following diseases:

1.Thyrotoxicosis:

Common features: 1.Dyspnoea 2.Weakness 3.Palpitation

Distinguishing Features:1. Exophthalmus2. Some neurological symptoms3. Increase body temperature4. Weight loss

Though few clinical symptoms are similar most of

the signs and symptoms of thyrotoxicosis and those of our patient differ and therefore a diagnosis of thyrotoxicosis for

our patient is not possible.

2. Cushing’s Syndrome:

A. The patient with Cushing’s syndrome will complain of increased weight over the flanks, increased appetite, weakness and feeling of thirst. Our patient did not have any of the above complaints. He was asymptomatic.

B. Arterial hypertension develops in Cushing’s syndrome due to increased secretion of glucocorticoids (cortisol). Our patient’s development of hypertension was due to genetic predisposition, stress and physical exertion.

C.Inspection of the patient with Cushing’s syndrome shows sign of moon face, truncal obesity, bruises on the skin and purple abdominal striae. Our patient did not have such signs during his examination.

D.Biochemical analysis of the patient with Cushing’s syndrome will show a high level of cortisol in the blood. Our patient was not tested for the level of cortisol in his blood.

The signs and symptoms of Cushing’s syndrome and those of our patient differ widely and therefore a diagnosis of Cushing’s syndrome for our patient is not possible.

TREATMENT1. Diet

2. Bed Rest

3. Oxygen therapy

4. B-Blockers Rp : Tab metaprololi 0.05 D.S. take 1 tab orally , 2 times a day

5. Ca-antagonist Rp : Tab amlodipini 0.005 D.S. take 1 tab orally , 1 times a day

6. Loop Diuretics Rp: Lasixi 0.60 IV DtdN 1 Inject twice daily

Prognosis:

Patient has a bad prognosis because she is old, has arteriolar hypertension 3rd stage 4 risk stages and already had stroke . Stress and smoking habit also is a negative mark for better prognosis.

PROPHYLAXIS

Primary Prophylaxis

-Lifestyle modification – dietary management with less cholesterol, less salt. Physical exercise regularly.-Stress relieving exercises – yoga, meditation.-Weight reduction to age specific BMI.-Stop smoking, stop alcohol consumption.

Secondary Prophylaxis

-Beta blockers-Diuretics-Angiotensin II receptor blockers-Calcium channel blockers-Statins-Control of blood pressure, blood sugar level, cholesterol levels especially LDL level.-Regular physical exercise, reduction of emotional stress.

DAIRY

April 29, 2010

-The patient did not have any active complaints.-The patient’s condition was satisfactory overall.

Cardiovascular system – edemas in lower extrimities, no palpitation, no intermissions and slight dyspnea.

Respiratory system – no cough, no pain during breathing, no expectoration of sputum. Auscultation revealed vesicular breathing.

Digestive system – appetite is satisfactory, no vomiting, no nausea, no heartburn, and no eructation. No pain in abdomen, no flatulence. Character of stool is normal, no constipation, no diarrhea. Palpation of the abdomen revealed no pain, no tenderness, absence of large formations, no rigidity and soft consistency.

Urinary system – no edemas, no pain in lumbar region, no disorders of urination. Urine color is normal.

Nervous system – Subjective condition is good, no epilepsy or other symptoms. Sleep was with disturbances.

Blood pressure – 170/100 mmHgPulse rate – 78 bpm

3 rd May, 2010


Cardiovascular system – no edemas, no palpitation, no intermissions and no dyspnea


Digestive system – appetite is good, no vomiting, no nausea, no heartburn, and no eructation. No pain in abdomen, no flatulence. Character of stool is normal, no constipation, no diarrhea. Palpation of the abdomen revealed no pain, no tenderness, absence of large formations, no rigidity and soft consistency.


Nervous system – Subjective condition is good, no epilepsy or other symptoms. Sleep was without disturbances.


4 th May, 2010


Cardiovascular system – no edemas, no palpitation, no intermissions and no dyspnea


Digestive system – appetite is good, no vomiting, no nausea, no heartburn, and no eructation. No pain in abdomen, no flatulence. Character of stool is normal, no constipation, no diarrhea. Palpation of the abdomen revealed no pain, no tenderness, absence of large formations, no rigidity and soft consistency.


Nervous system – Subjective condition is good, no epilepsy or other symptoms. Sleep was without disturbances.


BP has decreased slightly.

Epicrysis:

Patient: Valentina Emelyanovna NatheesheenaAge : 77 yrsDate of hospitalisation: 22nd April 2010.Type of hospitalisation: Emergency

Main complaints :

i) at the time of hospitalisation: She felt severe headache, weakness and dyspnoea

at a sudden increase of blood pressure.

ii) at the time of examination : Weakness, headache and odema in lower

extremities .

At the time of examination the patient had a slight headache, weakness, dyspnoea when BP increases, edema in face. Edema in lower extremities during night time. Had

disturbed sleep.

Her anamnesis morbi shows a history of fluctuating high blood pressure for the past 15 years which was under treatment and she had complaints associated with arterial hypertension. Her mother died of due to hypertension. Thus in her anamnesis vitae there is genetic predisposition and diagnosed with arterial hypertension. She was a sports women and had vigorous physical exercises which also point to cause an increased hypertension. She was a occasional smoker and had stress due to occupation and family and was slightly obese.

On percussion of his heart, the left border of the absolute cardiac dullness was increased concluding left ventricular hypertrophy.

The laboratory investigation of blood reveals no signs of infection or inflammation. Glucose is normal and as result no diabetes mellitus. Normal AST and ALT, so no signs of heart failure. Urine analysis reveals that kidney function is normal. Echocardiogram shows signs of left ventricular hypertrophy. ECG results also reveals left ventricular hypertrophy.

According to the patient’s complaints, anaemnesis morbi, anaemnesis vitae, physical examination and laboratory investigation the final diagnosis is:

PRIMARY ARTERIAL HYPERTENSION – SEVERE DEGREE 3RD STAGE - RISK 4

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MATHEW ID SECOND SEM