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CASE HISTORY
Student:
Mathew Joseph
Group :
478
2010
PASSPORT PART
Age : 77 yrs
Sex : Female
Profession : Pensioner
COMPLAINTS
A. Cardiovascular system
B. Respiratory system
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
E. Nervous system
ANAEMNESIS VITAE
2. Occupational history
4. Past illnesses
No childhood infections.
Previous medical and surgical treatment: 30 years back had
2/3rd gastrtectomy.
Sustained trauma: None
5. Hereditary
6. Habits
7. Allergic history
8. Epidemic history
General examination
Cardiovascular system
Inspection
-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
Vascular bundle:
Conclusion:
Auscultation
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:
Conclusion:
Comparative Percussion:
No pathological findings.
Auscultation
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
Percussion
Urinary system
Nervous system
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.
PLAN OF INVESTIGATION
Blood analysis:
Hemoglobin 144 120-
140g/l
Color 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 89.4
H+ 4.7%
Neutrophil(seg) 63 47-72%
Biochemical Test:
Urine analysis:
Glucose Negative
Protein Negative.
Bilrubin Negative.
Urobilin Normal.
KET Negative.
BLD Negative.
NIT Negative.
LEU Negative.
PH 6.5
SG 1.025
Color Yellow.
Consistency Transparent.
Echocardiography
Left heart border changing ,left ventricle hypertrophy .
Aorta is not enlarged.
General contractile ability of heart is normal.
right chambers without changes
general 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
DIFFERENTIAL DIAGNOSIS
1.Thyrotoxicosis:
Common features:
1.Dyspnoea
2.Weakness
3.Palpitation
Distinguishing Features:
1. Exophthalmus
2. Some neurological symptoms
3. Increase body temperature
4. Weight loss
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
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
Epicrysis:
Main complaints: