FIRST MOSCOW STATE MEDICAL UNIVERSITY

Medical Faculty
Division for Foreign Students with Instruction Conducted in English
Department of Therapy
Students: Tong Kah Yee
Patient: Mamysheva
(Turner before)

Group: 85
Age

: 59

Date: 26/02/2015
Occupation: Retired

Sex: Female Weight: 83 Height: 163 BMI: 31.2(obese)

Chief Complain:
Patient was admitted to the ward due to
1.
2.
3.
4.
5.

Chest Pain
Shortness of breath
Fatigue & weakness
Swelling on feet
Pain in knees

History of present illness:

(When did the disease start provoking factors, its exacerbation and cause, treatment)

Patient suffered from Diabetes Mellitus since 1988 and hypertension (150/90) .The following
drugs are used for the course of the diseases : Insulin on 2001 with 3 times per day,
Indapamide (Diuretics). On the date of admission, patient experience chest pain which :

Onset : from year of 2005

Duration : 1-5minutes
Nature : Crushing
Site & Radiation : Retrosternal and radiate to the back
Aggravating Factors : Moderate Exertion
Relieving Factors : Nitroglycerin
Associated symptoms : dyspnea

Besides, she also has shortness of breath during fast walk or walking on stairs. She has
frequent fatigue and weakness. Moreover patient has blurred vision and glaucoma for
years. She has no history of acute Myocardial Infarction (AMI), Stroke and dysrhythmia.

Past medical history:

1. Appendicitis in 1983 and performed Appendectomy.

Family Medical history:

1. Mother had Diabetes Mellitus and arterial hypertension before, died on the age of
59, Cause of death: Myocardial Infarction
2. Father had heart problem also (insufficiency of information)
3. Only child in the family, husband and a son and a daughter (no other disease)

Allergies:
1. Allergic to Animal Insulins

Gynecological history:
1. Postmenopausal for 13 years

Social history:
1.
2.
3.
4.

Non-drinkers or smokers
Average intake 2 cups of sugar free coffee per day
Hypoglycemic diet
1-2 times of swimming per week

Physical exam: Results (only abnormal findings)

Cardiovascular system

Complaint: Retrosternal pain , ankles swelling

General Inspection of precordial areas and vessels
Size/ Any deformities
: None
Apex best
: Not visible
Pulsation of pulmonary trunk
: Not visible
Pulsation of aorta
: Not visible
Pulsation of subclavian arteries (sub- and suprascapular areas): Not visible
Carotid pulse
: Not visible
Jugular pulse
: Not visible
Epigastric pulsation
: Not visible
Other pulsation on extremities and lower trunk : Not visible
Palpation on heart and vessels
Apex beat
: Palpable
Capillary pulsation
: Not palpable
Pulsation of pulmonary trunk and aorta
: Not palpable
Pulsation of cardiac beat
: Not palpable
Pulsation of epigastric
: Not palpable

Palpation on radial arteries on both hands

1. Synchronous pulsation on both hands
2. Same amplitude of pulsation on both hands
Auscultation of apex beat and counting radial pulse at the same time
Both Apex beat and radial pulse are the same (no pulsus deficit)
Palpation of radial pulse
Regularity : Regular
Rate: 83 beats/min
Amplitude: Normal
Tension: Normal
Velocity and shape: Normal
Percussion of heart
Relative Dullness

Absolute Dullness
(left edge of sternum)

Upper border
Width of vessel bundle

1 cm laterally of the right

edge of the sternum
1.0 cm medially of left
midclavicular line
3rd intercoastal space
5-6cm

Shape of heart

Normal

Right border
Left border

Auscultation of heart
1st heart sound
2nd heart sound
3rd and 4th heart sound
Adventitious sounds
Area of auscultation
Apex beat
Aorta
Pulmonary artery
Tricuspid valve
Botkins Erb point

:
:
:
:

(1-2cm medially of border of

relative dullness)
(level of 4th rib)

Normal loudness and frequency

Normal loudness and frequency
Absent
Absent

Tone
Normal, rhythmical tone of both S1 and S2
Normal
Normal
Normal
Normal

Pericardial friction : Absent

Heart rhythm
: Rhythmic
Heart rate
: 80/min
Pulse
: 130/80 mmHg(s/d) on left hand
: 130/80 mmHg(s/d) on right hand

Pulmonary System
Complaint: Shortness of breath during exertion
Inspection

Symmetrical chest form

Synchronous breathing on both sides
Form

of chest
Normosthenic
Shape : Conical
Supraclavicular fossa : prominent
Louis angle : present
Epigastric angle : 90 degree
Ribs direction laterally: oblique
Scapula : closely fit to the chest

Respiratory movements
Breathing rate : 18/min
Type of breathing : thoracic breathing
Depth of breathing : superficial
Rhythm of breathing : Rhythmic
Accessory muscle usage : None
Ability of chest to dilate : yes
Ability of chest to expel air : yes
Chest circumference
Normal : 100cm
During forced inspiration : 104cm
During forced expiration : 98cm
Expansion :6cm
Palpation of chest
Area of painfulness : None
Elasticity : Normal
Tactile fremitus : Normal
Percussion
Comparative percussion : same intensity of clear lung sound/resonance was heard over
symmetrical areas of the chest
Part of the chest

Area

Anterior

Supraclavicular fossa
Clavicle
Subclavicular
1st intercostal space up to
liver dullness
Along midclavicular line
Suprascapular area
Interscapular area
Subscapular area

Lateral
Posterior
Topographic percussion

Sound intensity of left

and right lungs
Symmetrical

Symmetrical
Symmetrical

a) Upper border of lungs

Apex
Anterior (cm above
clavicle)
Posterior (cm from lateral
process of 7th vertebra)
Kroenigs area (width,cm)

Right Lung
4

Left Lung
3.8

5.5

5.5

Right Lung
5th intercostal space
6th rib
7th rib
8th rib
9th rib
10th rib
Spinous process of 11th
thoracic vertebra

Left Lung
7th rib
8th rib
9th rib
10th rib
Spinous process of 11th
thoracic vertebra

b) Lower border of lungs

Percussion point
Parasternal line
Midclavicular line
Anterior axillary line
Midaxillary line
Posterior axillary line
Scapular line
Parasternal line

Respiratory mobility of the lower lung borders (cm)

Topographic Right lung
Left Lung
line
Inspiration Expiration Total
Inspiration
Midclavicula
r line
Middle
axillary line
Scapular
line

Expiratio
n
-

Total

1.5

2.5

1.5

2.5

Nervous System
Complaints : Weakness ,Sleep disturbances
Sensory system :
Pin prick test shows hypersensivity on distal part of both sided hands and legs.

Endocrine System
No feel thirsty nor polyuria

Musculoskeletal System
Complaints : Joints: pain, swollen

Spontaneous of provoked pain at

locomotions
General degree of muscular system
development
Painfulness at palpation
Tension
Consolidation
Local hypertrophies, atrophies

Absent
Moderate
yes
Normal
No
Absent

Preliminary diagnosis:
From physical examination of cardiovascular system, there are absence of right & left
ventricular hypertrophy, absence of murmur sounds , so suggested exclusion of
aortic/mitral stenosis/regurgitation and cardiomyopathy. Patient has no reveal any
xanthelasma or xanthomas.
Based on patients
Complaints
Chest Pain and shortness of breath on walking or climbing stairs rapidly
Blurred vision
Swelling and pain of legs
Risk factors
obesity
family history of premature myocardial infarction (her mother had diabetes
mellitus and died of ACS on the age of 59)
Diabetes Mellitus
Suggest patient has Diabetes Mellitus type 2, coronary heart disease (stable angina
stage II), retinopathy, hypertension stage 2 and chronic heart failure stage I (reversible).
Edema of lower extremities also may be due to kidney disease therefore further lab and
instrumental investigation are needed to confirm the preliminary diagnosis.

Plan of investigation:
FBC
Biochemical test (include troponin test to rule out myocardial necrosis)
Urine test
Glycosylated haemoglobin (HbA1C) &fasting glucose
Lipid Profile
ECG
Chest Xray

Xray of lower extremities

Plan of treatment:
Non-pharmalogical: diet modification low-sodium diet ,low-spicy diet, hypoglycemic
diet.
Pharmacological:
Angina relief : Nitroglycerine
Indapamide (2,5mg) -1 Table-morning
Prestarium (10 mg) l table-morning, within 10 days ,:
Insulin injection
Aspirin(75mg)

Teacher :____________________
Grade

:____________________

Assessment :____________________