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442 DISTRICT MILITARY CLINICAL HOSPITAL
Discharge summary No.
1950, b. (56 years old), was on examination and treatment in 23 m / o 442 OVKG with a diagnosis of
coronary artery disease. Angina pectoris 2 f.cl. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and postinfarction (of unknown age) cardiosclerosis, complicated by a permanent form of atrial fibrillation, normosystolic variant. dilated cardiomyopathy. Aneurysm of the left ventricle. Hypertensive disease of the third stage (AH-2, Risk-4). NK-2b, KhSN-3 f.cl. Anasarka. Cardiac fibrosis of the liver. Varicose veins. Right-sided hypostatic pneumonia.
He was admitted to the clinic by ambulance with complaints of shortness of breath at rest, severe weakness, an enlarged abdomen, and swelling of the lower extremities.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
CP
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
21.11
136
4.49
6.7
0.92
17
222
28.9
5.6
2
63.5
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
21.11
clear
1020
yellow
5.0
0.025
no
no
no
no
no
1-2
no
3-5
no
_
_
_ rev.
Norm
21.11
Name
Unit. rev.
Norm
21.11
Creatinine
mmol/l
53-124
76
CS
mmol/l
3.7-7
3.92
Urea
mol/l
3-8.4
4
TG
mmol/l
0-2.37
Prothrombindex
%
70-120
72.6
β-LP
u
350-650
Fibrinogen
g/l
200-400
414
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
75
LDL
mmol/l
1.9-4
Albumin
%
50-70
CS /HDL
times
3-5
1
%
3-6
VLDL
mmol/l
0.6-1.2
2
%
9-15
coefficient atheros.
Unit
0-3
%
8-18
amylase
U/L
28-100
%
15-25
trypsin
u/l
0-0.35
globulins
g/l
17-35
ing. trypsin
u
18-36
a/g
1.1-2.5
Ig M
g/l
0.65-1.65
ALT
U/L
8.4-53.5
57
Ig G
g/l
7.5-15.5
AST
U/ L
7-39.7
33
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
163
CEC
u
6-66
LDH
U/L
100-220
Cl
mmol/l
95-108
97.3
GGTP
U/L
11-63
351
Na
mmol/l
130-150
131.1
Glucose
mmol /l
4.2-6.4
6.13
Ca
mmol/ l
2.0-2.7 Tot
. bilirubin
µmol/l
6.8-26
21.7
K
mmol/l.
4-6
4.28
Ex. bilirubin
mmol/l
0-7
Fe
mmol/l
10.5-25
Sial. to-you
g/l
1.9-2.5
TSH
mmol/l
0.27-4.2
Revm.
negative factor
T3
mmol/l
66-181
Urinary
acid fmol/l
150-420
T4
mmol/l
1.3-3.1
CPK
u/l
10-160
19
RW
quality
CPK-MB
u/l
0-12, 5
HBsAg quality
negative
form 50
AntiHCV
quality
negative
Results
of instrumental studies:
ECG from. 11/21/2006: Atrial fibrillation, HR=88 per minute, normosystole, EOS sharply deviated to the left. Blockade of the anterior branch of the left leg of the bundle of His. Cicatricial changes in the anterior septum X-
ray of the chest organs from 04.05.2006. Conclusion: the organs of the chest cavity without deviations from the norm.
DUCHG from 05/06/2006: V ex 40.9 ml, K about 32.7%, T abbreviated 65 min, V with 0.5% / min. Conclusion: violation of the contractile function of the gallbladder by hypomotor type.
Treatment was carried out: a regimen, a diet, a polarizing mixture with ascorbic acid, riboxin IV No. 8, platyfillin 0.2%–1 ml s / c 2-1 times a day, omeprazole 0.02 (1 tab 2 times a day ), Almagel (1 spoon 4 times a day), novocaine 0.5% - 10 ml NaCl 0.9% - 100 ml IV No. 5, Vit B6 IM 1 ml, Vit B12 IM 600 mcg, Creon 10000 IU (1 dr 3 times a day 30 minutes before meals), allochol (2 tablets 3 times a day).
Against the background of the therapy, the patient's condition improved, the abdominal pain syndrome decreased in intensity, frequency of occurrence and duration.
Recommended:
1. Observation of a therapist (gastroenterologist).
2. Omeprazole 0.02 (1 tab 2 times a day, morning and evening) - 1 week, then 1 tab at night - 2 weeks.
3. Almagel A or Maalox (1 spoon 4 times a day an hour after meals and at night) - 3 weeks
4. Pancitrate (creon) - 1 capsule 3 times a day, with meals - 1 week, then 1 capsule 2 times a day (morning and evening) - 2 weeks, then 1 capsule in the afternoon - 1 week.
5. Hymecromon (odeston) 200 mg (1 tab 3 times a day) - 30 minutes before meals - 3 weeks
6. Complete blood count - after 3 weeks
Does not need a sick leave. Discharged in a satisfactory condition.
DISTRICT MILITARY CLINICAL HOSPITAL IM. Z.P. SOLOVIEV
Discharge summary No.
1948, b. (58 years old), was examined and treated in the 23rd cardiological department of the 442th OVKG with a diagnosis of:
Ischemic heart disease, angina pectoris of the third functional class, atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis. Hypertensive disease of the second stage (arterial hypertension-2 Risk-4). Circulatory insufficiency stage IIa. Chronic heart failure of the third functional class. Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of diffuse neurological symptoms. Osteochondrosis of the thoracic, lumbar spine with a slight dysfunction. Chronic vertebrogenic sciatica with L5-S1 with radicular syndrome in remission. Chronic atrophic gastritis in remission. Angioectasia of the stomach. Prostate adenoma. Partial secondary adentia.
He was admitted to the clinic in a planned manner with complaints of dull pressing pain in the left half of the chest and behind the sternum with irradiation to the left hand when climbing to the 2nd floor or walking on a flat area for 100-150m, dull diffuse headache, dizziness, rise in blood pressure to 170/110 mm Hg, shortness of breath, palpitations, nausea.
Laboratory results:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
24.11
132
4.51
6.0
4
248
-
-
30.2
5.3
3
61.5
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
14.11
clear
1030
yellow
sour
no
no
urate
no
no
no
no
no
1-2
1-2
Biochemical blood test:
Name
Unit. rev.
Norm
24.11
CS
mmol/l
3.7-7
5.97
Total protein
g/l
63-87
69
ALT
U/L
8.4-53.5
14
AST
U/L
7-39.7
21
Cl
mmol/l
95-108
106
Na
mmol/ l
130-150
142
K
mmol/l.
4-6
4.8
GGTP
U/L
7-63
24
Glucose
mmol/l
4.2-6.4
5.3 Vol
. bilirubin
µmol/l
6.8-26
22.9
Fibrinogen
g/l
2.0-4.0
2.47
1.12.2006: APTT (1.12.06) =46 sec, INR (1.12.06)=0.88
Results of instrumental studies:
ECG dated 24.11.2006 .: Sinus rhythm with a frequency of 60 bpm, vertical EOS (α=800), increased potentials of the left ventricle.
ECHO-KG from 11/24/2006: MZHP-11.0mm, ZS-11.0mm, KDRLV-48mm, KSRLZh-33mm, EF-45%, E/A=0.6 Myocardium is symmetrically thickened. The cavities are free, not dilated, the valves are not changed, the leaflets of the mitral and aortic valves, the aorta is sealed. The pericardium is intact. The kinetics is not broken. Diastolic dysfunction of the left ventricle.
Ultrasound of the abdominal organs dated 11/15/2006: the liver is not enlarged, the contours are even, the vascular pattern is not clear, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein 13 mm, hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder is of the correct form, the contours are even, calculi and polyps are not visualized. The pancreas is located indistinctly, diffusely heterogeneous structure, the contours are clear, even, echogenicity is increased; Wirsung's duct is not dilated. Kidneys of normal size, normal location, with smooth contours, homogeneous parenchyma. The spleen is not enlarged. In the projection of the location of the adrenal glands, no pathological formations were found. The bladder is full, with a volume of 250 ml, the contours are even, the walls are not thickened (3-4 mm) The prostate gland V = cm3, the contours are fuzzy, the structure is heterogeneous due to compaction areas. Fibrosis in the right lobe. Smoothed interlobar furrow. The middle lobe protrudes slightly into the lumen of the bladder. The volume of residual urine is 30 ml.
Fibrogastroduodenoscopy No. 1156 dated December 8, 2006: in the study of the esophagus, stomach, duodenum, cardiac sphincter insufficiency, chronic gastritis with diffuse atrophy of the mucous membrane of the antrum of the stomach is determined. In the prepyloric and antral regions, two angioectasias are determined along the lesser curvature. The duodenal bulb and postbulbar section are not visually changed.
X-ray of the chest organs dated November 25, 2006: Conclusion: On the survey radiograph of the chest cavity organs in the lungs without fresh infiltrative changes. The roots are structural, the diaphragm is flattened, no free fluid was found in the pleural cavity. The heart is expanded in diameter to the left, the aorta is sealed.
On spondylograms of the thoracic spine in 2 projections from 26.11.06: increased physiological kyphosis due to a decrease in the height of the vertebral bodies in the anterior section Th5-6-7-8 small cartilaginous hernias on the upper and lower areas of the vertebral bodies. Deforming spondylosis Th4-11. X-ray picture of the consequences of osteochondropathy.
Treatment was carried out: regimen, diet, polarizing mixture, asparkam, atenolol, thrombolytic ACC, enalapril, sydnopharm, metabolic therapy.
On the background of the therapy, the patient's condition improved. Does not require sick leave.
Discharged in a satisfactory condition.
Recommended:
1. Outpatient monitoring by a cardiologist.
2. Exclude animal fats, fried, spicy foods from the diet.
3. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
4. Dispensary observation:
a. clinical blood test (with platelet count), urinalysis - 4-6 times a year;
b. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - at least 2 times a year;
c. Echocardiography - 2 times a year;
5. Continue taking:
a. Concor 5mg - 1 tab. in the morning - constantly
b. Sidnopharm - 1 tab. 3 times a day - constantly
c. Thrombo ACC 0.01 - 1 tab. In the morning
d. Ko-renitek - ¼ tab 2 times a day
MILITARY MEDICAL ACADEMY. HOSPITAL THERAPY CLINIC
Reference No.
(53 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy with a diagnosis of
Chronic gastroduodenitis in remission. Dolichocolon. Myopia of both eyes 1.25 D with visual acuity with a correction of 1.0 in both eyes.
The clinic was admitted in a planned manner with complaints of recurrent cutting pains in the epigastric region and along the colon, bloating, loosening of the stool; subfebrile body temperature during the last month, headaches, periodic nosebleeds that occur against the background of a rise in blood pressure to 150/90 mm. rt. Art.
Results of laboratory researches:
General analysis of blood, urine, feces dated 12/12/2006 was normal. Blood biochemical parameters (AST, urea, creatinine, glucose, creatinine phosphokinase, total protein, total bilirubin, K+, Na+, Cl-, lipase) dated 11/28/2006 were normal. Antibodies to HIV 1.2 from 11/30/2006 were not found. 04/09/2006 HbsAg, anti-HCV antibodies were not detected. 04/08/2006 CRP - 0. RW microreaction-precipitation with cardiolipin antigen from 11/28/2006 - negative. RSK with chlamydial antigen from 29.11.2006 was negative. RNHA with tuberculosis antigen, with dysentery antigens of Shigella (Zone, Flexner, Newcastle), with complex salmonella antigen, with pseudotuberculous antigen, yersiniosis antigen from 11/30/2006 - negative. ECG dated April 27, 2006, sinus rhythm, heart rate 50 beats per minute. Incomplete blockade of the right leg of the bundle of His. Initial manifestations of left ventricular hypertrophy. Rotation of the heart with the right ventricle forward. Ultrasound of the abdominal organs dated November 30, 2006: the liver is not enlarged, the right lobe is 13.5 cm, the left lobe is 7.5 cm, the contours are even, the structure is homogeneous, the vessels are not dilated, the portal and hepatic veins, intrahepatic bile ducts are without features. The gallbladder is not enlarged, the contours are even, the walls are thin, the contents are homogeneous, calculi and polyps are not visualized. Pancreas, spleen without features. The kidneys are not enlarged, mobile. The parenchyma is homogeneous, without signs of pathology. The cavity system is not expanded. No pathological formations were found in the projection of the adrenal glands. The spleen is not enlarged, the structure is homogeneous. X-ray examination of the chest organs from 02.10.2006: no pathological changes. FCC dated December 11, 2006: the device is inserted 20 cm from the anus. Further study was terminated due to the patient's inappropriate behavior and at his urgent request. In the examined area of the intestine, the mucosa is thinned, the vascular pattern is enhanced. In the lumen fluid with an admixture of feces. Ampoule of the rectum without features. RRS dated 12/15/2006: the tube of the proctoscope was inserted up to 15 cm. Due to the patient's inadequate behavior, the study was not completed. No organic pathology was found in the rectum. The mucosa is pink, shiny, a vascular pattern can be traced. The tone of the intestinal wall is normal. FGDS from 8.12.2006: The esophagus is passable, the socket of the cardia does not close completely. In the stomach, a significant amount of mucus, liquid (foamy with an admixture of bile). The folds are rough, edematous, tortuous. The mucosa is hyperemic. The gatekeeper gapes
Treatment was carried out: regimen, diet, omeprazole 0.02 (1 tab 2 times a day), Almagel (1 spoon 4 times a day), Creon 10,000 IU (1 dr 3 times a day 30 minutes before meals), allochol (2 tablets 3 times a day).
On the background of the therapy, the patient's condition improved. Certified by VVK. Recognized on the basis of the articles of column III of the Schedule of Diseases and TDT (annex to the Regulations on the military medical examination, approved by the Decree of the Government of the Russian Federation of 2003 No. 123) "A" - fit for military service.
Recommended:
1. Observation of a therapist (gastroenterologist).
2. Omeprazole 0.02 (1 tab 2 times a day, morning and evening) - 1 week, then 1 tab at night - 2 weeks.
3. Almagel A or Maalox (1 spoon 4 times a day an hour after meals and at night) - 3 weeks
Does not need a sick leave. Discharged in a satisfactory condition.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1937 (69 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy with a diagnosis
of duodenal ulcer in the acute phase. Multiple (ulcer of the duodenal bulb, ulcer of the back of the bulb) ulcers of the duodenum. Cholelithiasis. Asymptomatic stone carrying. Atherosclerotic cardiosclerosis. Solitary cyst of the right kidney.
He was admitted to the clinic with complaints of acute burning pain in the epigastric region, not associated with eating.
Laboratory results:
General clinical blood test:
Date
Hb, units.
Er., *1012/L
Leuk., *109/L
CP
Ht
%
ESR, mm/h
Thrombus
*109/L
E
%
B
% Lf
%
Pl.cl
%
M
%
Pia
%
Xia
%
20.12.
140
4.54
6.9
0.92
13
4
1
29
1
9
1
55
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
20.12
clear
1017
yellow
sour
no
no
no
1
no
no
0-2
no
0-2
no
Urinalysis according to Nechiporenko dated 12/14/06: Leu-0.75×109/l, Er.-0.25×109/l
Analysis feces: no features
Biochemical blood test:
Name
Unit. rev.
Norm
11.12
Name
Unit. rev.
Norm
11.12
Creatinine
mmol / l
53-124
CS
mmol / l
3.7-7
4.18
Urea
mol / l
3-8.4
TG
mmol / l
0-2.37
1.54
Prothrombin
%
70-120
90
LDL
units
350-650
500
Fibrinogen
g/l
2.0-4.0
3.5
Alpha 1
%
4.1
Total protein
g/l
63-87
67.8
Alpha 2
%
12.7
Albumin
%
50-70
56.1
Beta
%
12.8
a/g
1.1-2.5
1.28
gamma
%
14.4
ALT
U/L
8.4-53.5
Cl
mmol/l
95- 108
102.8
AST
U/L
7-39.7
16.1
Na
mmol/l
130-150
158.5
AP
U/L
36-92
56.4
K
mmol/l.
4-6
3.76
LDH
U/L
100-220
TSH
mmol/l
0.27-4.2
GGTP
U/L
7-63
ALP
Ukat/L
0.70-2.30
Glucose
mmol/l
4.2-6.4
4.5
form 50
quality
neg
. bilirubin
µmol/l
6.8-26
10.3
HBsAg
quality
neg
Sial
. k-ty
g/l
1.9-2.5
AntiHCV qual negative
Neg
Results
of
instrumental studies:
ECG dated 12/11/2006: Sinus rhythm with a frequency of 66 beats/min, EOS is not rejected (α=400), signs of hypertrophy of the left ventricle.
ECHO-KG No. 25 dated 12/10/2006: MZHP-10.0mm, ZS-11.3mm, KDRLV-52.4mm, KSRLZh-37.5mm, FV-54.5%, FU-28.4%, UO -72ml, LP-33.3mm, RV-24mm, E/A=0.7 Myocardium is not thickened. The cavities are free, not dilated, the valves are not changed. The pericardium is intact. The kinetics is not broken. The aortic valve annulus is sealed. Diastolic dysfunction of the left ventricle.
Ultrasound of the abdominal organs from 12/13/2006: the liver is not enlarged, the right lobe: 13cm; left 7.5 cm, smooth contours, homogeneous structure, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein and hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder has a regular shape, dimensions 7.1×3.4 cm, smooth contours, walls 2 mm, calculi N4-5 up to 9-11 mm. The pancreas is not located. Kidneys of normal size, normal location, with uneven contours, heterogeneous parenchyma 17 mm thick, cavitary systems are not expanded. There are no concretes. Spava cysts with a diameter of 30 and 32 mm. The spleen is not enlarged, 9.9×6.8×4.4 cm in size. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: Cholelithiasis (cholecystolithiasis). Cysts of the right kidney.
Fibrogastroduodenoscopy dated December 6, 2006: In the duodenal bulb on the posterior surface there is an ulcerative defect 0.7 * 0.7 cm under fibrin, the mucosa around is hyperemic, edematous with many acute erosions 0.1 cm under fibrin. In the postbulbar region there is a shallow ulcerative defect 2.0 * 2.0 cm under fibrin with areas of hemosiderin.
X-ray of the chest organs No. 71 dated 12/11/2006: Conclusion: On the survey radiograph of the chest cavity organs in the lungs without fresh infiltrative changes.
Treatment: regimen, diet, asparkam, omeprazole, amoxicillin, almagel, metronidazole, vikalin, motilium.
On the background of the therapy, the patient's condition improved. Does not require sick leave.
Discharged according to the report in a satisfactory condition.
Recommended:
6. Outpatient observation of a gastroenterologist.
7. Dispensary observation:
a. Frequency of observation by a doctor: - 4 times a year.
b. clinical blood test (with platelet count), urinalysis - 4 times a year;
c. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - 2 times a year;
8. Continue taking:
a. Omeprazole 0.02 (1 tab 2 times a day, morning and evening) - 1 week, then 1 tab at night - 2 weeks
b. 3. Almagel A or Maalox (1 spoon 4 times a day one hour after meals and at night) - 3 weeks
AND ABOUT. Deputy Head of the Department for Clinical Work M. Sarazov
Head of the 1st Department I. Pavlovich
Attending physician N. Gulyaev
December 23, 2006.
ENT /A.F. Sirotinin /
Complaints of periodic discomfort, a feeling of sore throat in the cold season, which have been bothering for 2 years.
Objectively: the maxillary lymph nodes are enlarged, painless on palpation. Pharyngoscopy: the mucous membrane in the area of the lateral ridges and palatine arches is hyperemic and edematous. Palatine tonsils of the 1st degree, loose, clear in the gaps. Swallowing is not difficult. Other ENT organs without features. Hearing acuity in the study of whispered speech - 6 m in both ears.
Diagnosis: Chronic compensated tonsillitis. Lateral pharyngitis.
Recommended:
a. Spray "Tantum Verde" 2 inhalations 3 times a day for 10 days,
b. Rinse with warm decoctions of sage, chamomile - 10 days
c. Suprastin - 10 days
d. Peach oil in the nose 1 drop in both nasal passages 3 times a day
e. Repeated examination in dynamics
OPHTHALMOLOGIST /A.Yan/
Complaints of discomfort when reading and writing
Vis.OD=0.6 with correction cyl. –1.0D = 1.0 (ax 1800→)
Vis.OS=0.6 with cyl correction. –1.0D = 1.0 (ax 1800→)
Intraocular pressure: OD=OS=21 mmHg
The eyelids are not changed, the usual form, the palpebral fissure is not narrowed. The position of the eyeballs is correct, the movements are full. Conjunctiva slightly hyperemic, superficial injection of blood vessels. The corneas are transparent, spherical, without pathological changes. The anterior chambers are of medium depth, moisture is transparent, does not opalize. Pupils are centered, regular round shape, photoreactions are alive, D=S. Deep optical media are transparent. The reflex from the fundus is pink. The discs are pale pink, in the plane of the retina, with clear boundaries, regular round shape. Vessels A:B=1:3, arteries are narrowed, veins are somewhat dilated, tortuous, a symptom of arteriovenous decussation of the first degree. No pathology was detected in the macular zone and on the periphery of the fundus.
Diagnosis: Simple myopic direct type astigmatism in 1.0 D, hypertensive angiopathy of the retina in both eyes.
SPH
CYL
AX
R
+0.50
-1.75
168
L
0.00
-1.25
19
PD=61, VD=12
Complaints of headaches, dizziness, unsteadiness when walking, numbness in the fingers of the upper extremities.
Neurological status: conscious, oriented. The pupils are D=S, the physiological reflexes of the pupils are reduced, the reaction of accommodation with convergence is reduced. There is no nystagmus. The face is symmetrical. Tongue in the midline. Swallowing, phonation are not disturbed. Reflexes of oral automatism are negative. Tendon reflexes D=S, functional areas are expanded. There are no pathological signs. Decreased sensitivity in the upper extremities of the radicular type (C5-C6, C6-C7). Performs coordination tests with a slight intention. He staggers in the Romberg pose. There are no meningeal signs.
Diagnosis: Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of cerebellar insufficiency. Widespread osteochondrosis of the spine.
REG from 18.09.03: the blood flow is slightly reduced in the basin of the carotid and vertebral arteries, symmetrical. The cerebrovascular tone is normal. The hyperventilation test is weakly positive. The elasticity of the vessels is moderately reduced. Venous outflow is difficult in the vertebrobasilar basin.
Makes no complaints.
The face is symmetrical. The mouth opens freely, in full. The mucosa is clean, moist. No foci of odontogenic infection were found. Dental formula:
km o pl o km km km o km o o o pl
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
km o o km pl km o o o km o
Diagnosis: partial secondary adentia.
Needs dentures.
ECHO-KG No. 631 dated 11/13/2006: MZHP-9.9mm, ZS-7.0mm, KDRLV-47mm, KSRLZh-24.1mm, FV-79%, FU-48.5%, UO-80.93ml , LP-33.3mm, RV-25.5mm, E/A=1.0 Myocardium is not thickened. The cavities are free, not dilated, the valves are not changed, on the mitral valve regurgitation I stage. The pericardium is intact. The kinetics is not broken. Diastolic dysfunction of the left ventricle.
MILITARY MEDICAL ACADEMY
Hospital Therapy Clinic
Discharge summary No.
born in 1964 (43 years old), was examined and treated at the hospital therapy clinic with a diagnosis of:
ischemic heart disease. Angina pectoris II f.k. Atherosclerosis of the aorta, coronary arteries. Atherosclerotic cardiosclerosis. Hypertension stage II. (AH grade 2, risk 4). NC I Art. Dyscirculatory encephalopathy of the second stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders. Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (27.02.02) due to a closed fracture of the surgical neck of the shoulder (15.02.02) and its repeated fracture (18.07.02) with moderate dysfunction of the left upper limb. A consolidating fracture of the neck of the right femur with a construction (09/25/2006) with a slight dysfunction of the right lower limb.
He was admitted to the clinic in a planned manner with complaints of compressive pain in the chest, shortness of breath during exercise, aching headaches with increased blood pressure, dizziness, general weakness, impaired concentration, memory loss, pain in the right shoulder and right thigh.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
CP
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
21.03
141
4.5
11.0
0.94
24
1
27
3
6
63 Rehberg's
test
Date
Blood
creatinine Urine creatinine
Diuresis in 1 min
Glomerular filtration
Tubular reabsorption
22.03
0.08
18.65
0.83
193.5
99.6
Biochemical blood test:
Name
Unit. rev.
Norm
22.03
Name
Unit. rev.
Norm
11.12
Creatinine
mmol/l
53-124
CS
mmol/l
3.7-7
2.87
Urea
mol/l
3-8.4
6.4
TG
mol/l
0-2.37
0.44
Prothrombindex
%
70-120
β-LP
U
350-650
450
Fibrinogen
g/l
200-400
HDL
mol/l
0.78-2.33
Total protein
g/l
63-87
65
LDL
Mole/l
1.9-4
Albumin
%
50-70 Cholesterol
/HDL
Times
3-5
1
%
3-6
VLDL
Mole/l
0.6-1.2
2
%
9-15
coef. atheros.
Unit
0-3
%
8-18
amylase
U/L
28-100
%
15-25
trypsin
u/l
0-0.35
a/g
1.1-2.5
Ig M
g/l
0.65-1.65
ALT
U/L
8.4-53.5
14.6
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
11.02
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
CEC
U
6-66
LDH
U/L
100-220
Cl
Mole /l
95-108
GGTP
U/L
11-63
11.8
Na
Mole/l
130-150
Glucose
mmol/l
4.2-6.4
4.5
Ca
Mole/L
2.0-2.7
1.85
Total bilirubin
µmol/l
6.8-26
5.6
K
mmol/l.
4-6
ALK pos
U/L
36-92
102.3
T3
Mol/l
66-181
Urinary
acid fmol/l
150-420
T4
Mol/l
1.3-3.1
CPK
u/l
10-160
RW
qual
Results of instrumental studies:
ECG from. 03/21/2007, Sinus rhythm with a heart rate of 58 beats, horizontal EOS. Left ventricular hypertrophy. Syndrome of early repolarization. Local violations of intraventricular conduction, violations of repolarization in the region of the lower wall.
Ultrasound examination from 30.03.2007. The liver is not enlarged, the right lobe is 13.8 cm, the left lobe is 6.4 cm. The contours are even, the structure is homogeneous, the echogenicity is medium, the vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape (curved, partially reduced). The pancreas is located indistinctly, it is not enlarged, the contours are fuzzy, even, the structure is homogeneous echogenicity is average, the Wirsung duct is not dilated. Kidneys: location and size are normal. Right - the contours are even, the parenchyma is homogeneous 16 mm, the cavity system is not expanded, there are no stones: the left one - the contours are not even, the parenchyma is homogeneous 18 mm, the cavity system is not expanded, there are no stones. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 8.8x3.6 cm, the structure is homogeneous. Flatulence.
EchoCG from 03/29/2007. Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed, calcifications in the AC. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no pericardial effusion.
The results of VEM and ECG Holter monitoring are on hand
X-ray of the chest organs dated 30.03.2007. In the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is slightly dilated to the left. The aorta is elongated.
X-ray of the skull from 30.03.2007. On survey craniograms in two projections, the Turkish saddle is normal. There is thinning of the bones of the cranial vault.
Radiography of the right hip joint dated April 2, 2007: on the radiograph of the right hip joint in two projections. Condition after metal osteosynthesis in the area of comminuted fracture of the upper third of the femur. The callus is expressed satisfactorily. The bolt of a metal structure protrudes into the soft tissue by 2.5 cm.
Specialist consultations
Optometrist: VIS OD 1.0; OS 1.0 IOP OD,OS - 18mm Hg
The auxiliary apparatus and the outer parts of the eyeballs are not changed, the optical media are transparent. The fundus of the eye: optic nerve disc of satisfactory nutrition, the contours are clear. The veins are moderately dilated, the arteries are sealed. Focal pathology is not defined.
Neurologist: Dyscirculatory encephalopathy of the 2nd stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders.
ENT: Endoscopic ENT organs without visible pathology. SR 6 m.
Traumatologist: Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (02/27/02) due to a closed fracture of the surgical neck of the shoulder (02/15/02) and its repeated fracture (07/18/02) with moderate dysfunction of the left upper limb . A consolidating fracture of the neck of the right femur with a construction (25.09.2006) with a slight dysfunction of the right lower limb.
Treatment was carried out: regimen, diet, olicard, ACC thrombosis, metoprolol, phenazepam.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
1. Observation of a therapist, neuropathologist, traumatologist of the TsKDP VMA.
2. Optimization of the regime of work, rest, nutrition.
2. Continue taking
• Olikard 0.04 1 caps. 1 r / d after breakfast
• Thrombo ACC 0.1 1 tab. 1 r / d after breakfast
• Metoprolol 0.05 ½ tablet 2 r / d (after breakfast and dinner)
• Asparkam 1 tablet 3 r / d the first 10 days of each month.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Reference No.
1918 (88 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy with a diagnosis of:
ischemic heart disease. Angina pectoris 3 f.cl. Atherosclerosis of the aorta, coronary and cerebral arteries, atherosclerotic and postinfarction (1996) cardiosclerosis. Hypertensive disease of the third stage (AH-3, Risk-4). NK-2a, KhSN-3 f.cl. Diabetes mellitus of the second type, mild. Dyscirculatory encephalopathy 2 tbsp. mixed (atherosclerotic, hypertensive) genesis. Chronic pyelonephritis in remission. HPN-0. Cataract in both eyes. Mild iron deficiency anemia.
The hospital was hospitalized in a planned manner with complaints of pain in the heart, shortness of breath with little physical exertion, weakness, swelling of the lower extremities, headache with an increase in blood pressure to 200/100 mm. Hg
Objectively: consciousness is clear, position is active, physique is normosthenic, satisfactory nutrition (BMI=23.8 kg/m2). The skin and visible mucous membranes are clean, of normal color. Skin turgor is somewhat reduced. Peripheral lymph nodes are not enlarged. The thyroid gland is not changed. There are no edema and pastosity. The pulse is rhythmic, the same on both hands, the frequency is 68 beats per minute, satisfactory filling, normal tension. Borders of the heart: right - along the right edge of the sternum, upper - III rib on the left, left - 1 cm outward from the left mid-clavicular line. Heart sounds are muffled, there are no noises, accent 2 tones over the aorta. Blood pressure - 140/80 mm Hg. Above the lungs percussion clear pulmonary sound. Breathing is vesicular, no wheezing. Respiration rate 16 per minute. The abdomen is soft and painless. The liver is not enlarged according to Kurlov 9×8×7 cm, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Neurological status: asthenic, not inhibited, pupils on the right and left are the same, photoreactions are alive, convergence and accommodation are somewhat weakened, the face is symmetrical. Tendon reflexes are evenly animated, flexor signs, abdominal reflexes are low and exhausted. There are no sensitive, coordinating disorders. Whispered speech six meters in both ears. There are no sensitive, coordinating disorders. Whispered speech six meters in both ears. There are no sensitive, coordinating disorders. Whispered speech six meters in both ears.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Retic.
‰
Leuc., *109/l
CP
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
10.05
96
3.2
7.6
0.90
21
-
5
2
22
10
61
16.05
80
3.0
6.8
0.8
22
-
1
1
17
8
3
70
17.05
85
3.05
13
6.8
0.83
23
161
1
1
31
7
2
58
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epithelium Profit center in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
10.05
clear
1016
yellow
sour
no
no
no
1
no
no
1-2
no
0-2
no
16.05
clear
1010
acidic
no
no
no
no
no
no
0-2
no
0-2
no
Biochemical blood test:
Name
Unit
. rev.
Norm
10.05
Name
Unit. rev.
Norm
10.05
Creatinine
mmol/l
53-124
CS
mmol/l
3.7-7
4.18
Urea
mol/l
3-8.4
8.1
TG
mmol/l
0-2.37
1.07
Prothrombindex
%
70-120
85
β-LP
u
350-650
Fibrinogen
g/l
200-400
3.72
HDL
mmol/l
0.78-2.33
Total protein
g/l
63 -87
69.1
LDL
mmol/l
1.9-4
Albumin
%
50-70
CS/HDL
times
3-5
ALT
U/L
8.4-53.5
11.2
Ig G
g/l
7.5-15.5
AST
U /L
7-39.7
9.73
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
66.4
CEC
u
6-66
LDH
U/L
100-220
Cl
mmol/l
95-108
GGTP
U/L
11-63
26.1
Na
mmol/l
130-150
140.7
Glucose
mmol/l
4 .2-6.4
6.6
Ca
mmol/l
2.0-2.7 Tot
. bilirubin
µmol/l
6.8-26
8.2
K
mmol/l.
4-6
5.01
Ex. bilirubin
mmol/l
0-7
Fe
mmol/l
10.5-25
4.06
Glucose (mmol / l, 16.05 / 18.05.07): 8.00 - 7.2 / 5.9; 11.00 - 9.6 / 8.5; 13.00 - 5.2 / 6.3
Results of instrumental studies:
ECG from. 8.05.07: sinus rhythm, HR=70 in 1 min. EOS is deflected to the left. Cicatricial changes in the anterior septal region. Left ventricular hypertrophy. Violation of repolarization of the apex-lateral region.
X-ray of the chest organs from 16.05.2007. Conclusion: the organs of the chest cavity are within the limits of age-related changes.
Ultrasound of the abdominal organs dated May 14, 2007: signs of nephrosclerosis.
ECHO-KG dated 9.05.07: Aorta - 32 mm, AK dilatation - 22 mm, RA - 46 mm, RV EDD - 24 mm, LA - 41 mm, LV ED - 36 mm, LV EDD - 47 mm, FU -25 %, EF 50%, IVS=ZS=14.5 mm, DLA – 24 mm Hg. Dilatation of the left chambers of the heart. The cavities are free. Pronounced symmetric hypertrophy of the myocardium of the left ventricle. A-dys-kinesia of the apical segments of the interventricular septum, lateral and anterior wall. Systolic dysfunction of the left ventricle. Consolidation and thickening of the aorta, aortic crescents, mitral valves. Calcification of the aortic and mitral rings. The pericardium is not changed. Mitral, tricuspid and pulmonary regurgitation.
The patient refused to undergo FEGDS and FCS.
Treatment: regimen, diet, efox-long, hypothiazide, enalapril, thrombo-ASS, asparkam, piracetam.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition. Does not require sick leave.
Recommended:
9. Outpatient monitoring by a cardiologist in a polyclinic.
10. Sanatorium treatment in the sanatoriums of the Leningrad region.
11. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
12. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
13. Dispensary observation:
a. clinical blood test (with counting of platelets and reticulocytes), urinalysis - every three months in the first year, then 1 time per year;
b. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - at least 2 times a year;
c. Echocardiography - 1 time per year;
14. Continue taking:
a. Efoks-long 50 mg - 1 tab in the morning.
b. Ko-renitek - ½ tab 2 times a day
c. Concor-Cor 2.5 mg - 1 tab. in the morning - constantly
d. Thrombo ACC 0.01 - 1 tab. in the morning
e. Phezam 0.8 - 1 tab in the morning and 1 tab. in the afternoon
MILITARY MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1963 (43 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis:
Main disease: Chronic bronchitis in the acute phase. Deviation of the nasal septum. Chronic right-sided sinusitis in the acute phase.
Concomitant diseases: hypertension of the second stage (AH 2st, Risk 3)
Complications: DN-0, NK-0
Hospitalized for urgent indications with complaints of chest pain when coughing, cough with a small amount of yellow discharge, dull headache , general weakness.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
CP
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pi
%
Xia
%
29.05
163
5.1
10.8
0.95
35
3
34
8
15
40
05.06
162
5.08
7.1
0.95
12
1
2
37
7
3
50
_
_
_
_
_
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MVP epithelium in pz
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
29.05
mud
1025
yellow
sour
0.09
no
no
2
no
no
1-2
0-1
0-6
20-30
05.06
clear
1014
yellow
sour
no
no
no
no
no
no
0-1
no
1-2
0-2
Nechiporenko test dated 06.06.07: leukocytes - 0.5 * 106 / l, erythrocytes - 0.25 * 106 / l
Biochemical blood test:
Name
Unit. rev.
Norm
29.05
Name
Unit. rev.
Norm
29.05
Creatinine
mmol/l
53-124
CS
mmol/l
3.7-7
5.63
Urea
mol/l
3-8.4
5.0
TG
mmol/l
0-2.37
Prothromb.index
%
70-120
106
β-LP
u
350-650
Fibrinogen
g/l
200-400
137
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
77.2
LDL
mmol/l
1.9-4
ALT
U/L
8.4-53.5
13.2
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
17.25
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
92.9
CEC
u
6-66
LDH
U/L
100-220
Cl
mmol/l
95- 108
GGTP
U/L
11-63
Na
mmol/l
130-150
Glucose
mmol/l
4.2-6.4
4.6
Ca
mmol/l
2.0-2.7
2.28
Total. bilirubin
µmol/l
6.8-26
7.7
K
mmol/l.
4-6
On the survey radiograph of the chest organs dated May 29, 2007. in direct and right lateral projections without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is slightly dilated to the left, the aorta is thickened.
On the radiograph of the paranasal sinuses dated May 29, 2007. total shading of the right maxillary sinus is noted.
ECHO-KG No. 394 dated 30.05.07. .: Aorta - 34 mm, AK opening - 19 mm, PP - 38 mm, RV EDD - 24.8 mm, LP - 33 mm, LV ECR - 25.6 mm, LV EDR - 48.8 mm, FU - 47, 5%, EF - 78.8%, IVS=12mm, AP=14mm, LA - 12 mm Hg. symmetrical hypertrophy of the left ventricular myocardium. The cavity is not expanded. The aorta, the rings of the aortic and mitral valves are sealed, the valves are intact, the blood flow on the valves is laminar, valvular regurgitation on the mitral and tricuspid valves. Diastolic dysfunction of the left ventricle. The pericardium is intact, there is no effusion.
ECG No. 1523 dated June 5, 2007: sinus rhythm with a frequency of 64 beats per minute, EOS is not rejected, hypertrophy of the left atrium and ventricle, impaired repolarization of the inferolateral region of the left ventricle.
Treatment: regimen, diet, ceazolin, amoxicillin, hypothiazide, enalapril, secretolytics, restorative therapy
Against the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
Disability certificate issued No. _________
Recommended:
15. Outpatient supervision of a polyclinic therapist.
16. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
17. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
18. X-ray examination of the paranasal sinuses after 1 month.
19. Continue taking:
a. Noliprel-forte - 1 tab in the morning constantly
b. Thrombo ACC 0.01 - 1 tab. in the morning constantly
MILITARY MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Discharge summary №
1960 b. (48 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy of the Year with a diagnosis of
systemic lupus erythematosus, a chronic progressive course with skin lesions ("butterfly", Raynaud's syndrome, ecchymosis), joints (arthralgia, osteoporosis of small joints of the hands), myocardium (myocardial dystrophy), lymphadenopathy, mild secondary hypochromic anemia, leukopenia; secondary Itsenko-Cushing's syndrome, active phase with a moderate (II) degree of activity, FNS-I, DN-0. Symptomatic arterial hypertension (AH-2 Risk-3).
Ischemic heart disease, angina pectoris of the first functional class, atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis with arrhythmias of the type of paroxysmal form of atrial fibrillation. Mitral valve insufficiency of the first degree. Circulatory failure of the first stage. Chronic heart failure of the second functional class.
Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of cerebellar insufficiency.
Osteochondrosis of the cervical, thoracic and lumbar spine with a slight dysfunction of the spine.
Chronic erosive gastritis in the acute phase. Sliding hernia of the esophageal part of the diaphragm of mixed type (axial and paraesophageal), secondary reflux esophagitis of the 2nd degree. Gastroptosis stage I Polyp of the gallbladder. Partial secondary adentia. Lateral pharyngitis. Chronic compensated tonsillitis.
Simple myopic astigmatism of the direct type in 1.0 D, hypertensive angiopathy of the retina in both eyes.
Subserous uterine myoma of small size, cicatricial deformity of the cervix, bilateral fibrocystic mastopathy.
She was admitted to the clinic for urgent indications with complaints of dull diffuse headache, dizziness, rise in blood pressure to 170/100 mm Hg, chest discomfort with irradiation to the left arm with little physical exertion, shortness of breath, palpitations; heartburn, belching sour, nausea, vomiting; soreness in the shoulder, knee, ankle, small joints of the hands and feet, itching of the skin of the face, hands, forearms, hyperemia of the back and wings of the nose, swelling of the face in the morning; weight gain, general weakness; internal discomfort and feeling of lack of air mainly at night; dull aching pain in the lumbar region.
Anamnesis morbi: She fell ill acutely in November 2005, when, against the background of relative well-being, severe morning stiffness, soreness, redness and swelling appeared in the area of small joints of both hands, shoulder, elbow and knee joints, fever up to 400C, sweating, severe general weakness, rapid fatigue. On November 14, she was examined by a general practitioner, and a course of anti-inflammatory therapy (diclofenac retard, prednisone 30 mg/day) was prescribed, which resulted in a significant improvement in her state of health. Due to the deterioration of her condition in January 2006, she was hospitalized at military unit 25515 with a diagnosis of rheumatoid arthritis, seropositive, articular form. She received cytostatic therapy with methotrexate, mini-pulse therapy with methylprednisolone, movalis, physiotherapy with a positive effect. Subsequently, against the background of outpatient cytostatic therapy (methotrexate 7.5 mg/week, prednisolone 10 mg/day), she felt satisfactory for the next three months. In May 2006, against the background of constant use of methotrexate, prednisolone and washing, pain, heaviness in the epigastric region and nausea after taking medications, in the left and right hypochondria, appeared, and therefore she independently refused to take medications. Against the background of refusal of treatment, the pain in the joints intensified, pains in the right elbow joint joined, subfibrile fever appeared. She resumed taking medications again without a positive effect. 26.06.06 for urgent indications, she was hospitalized in the rheumatology department of the NLMK Medical Unit, where she was diagnosed with systemic lupus erythematosus for the first time. Received treatment: methotrexate 10 mg/week, prednisolone 20 mg/day, movalis, chimes, pentoxifylline, physiotherapy with a positive effect. However, against the background of constant intake of these drugs, at the end of October 2006, pain in the joints increased again, there was hyperemia of the back of the nose and cheeks, itching of the skin of the face, hands, swelling on the face and hands, periodic pain behind the sternum and in the left half of the chest, palpitations, shortness of breath with little physical exertion, general weakness, pain in the mouth, nagging pain in the lumbar region after physical exertion and a decrease in the dose of prednisolone taken. Stationary held a course of plasmapheresis and plasmasorption, pulse therapy with methylprednisolone. After this course of therapy in the next 6 months, while taking 10 mg of prednisolone and 7.5 mg of methotrexate, she felt well. Exacerbations of the disease were noted in October-November 2007 and February-March 2007 and 2008, however, an increase in the dose of prednisolone to 80 mg/day for 3 weeks, followed by a gradual decrease in the dose to 15-40 mg/day, made it possible to stop exacerbations. Annually, she underwent planned inpatient treatment for the underlying disease, where the dose of medications taken was adjusted.
The last exacerbation of the disease was noted in September 2008. In the day hospital regimen, treatment was carried out: regimen, diet, intravenously: pulse therapy "Solu-medrol" 1000 mg (18.09.08 and 19.09.2008), asparkam, cardionate, cytoflavin and riboxin No. 5, neoton 4g No. 2, vitamins: C, B1, trental No. 3, cerebrolysin No. 1, piracetam No. 3, prednisolone 40 mg in the morning, methotrexate 10 mg / week. After the therapy, there was a short-term improvement in well-being, however, from mid-October, the condition progressively worsened in the form of discomfort behind the sternum with irradiation to the left arm and shortness of breath with little physical exertion (rise to the 1st floor), palpitations, heartburn, sour belching, nausea, pain in the chest. shoulder, knee, ankle, small joints of the hands, feet, swelling of the face in the morning, general weakness, internal discomfort and itching of the skin of the face, forearms, hands, as well as a feeling of lack of air mainly at night, hyperemia of the back and wings of the nose. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. brushes, as well as a feeling of lack of air mainly at night, hyperemia of the back and wings of the nose. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. brushes, as well as a feeling of lack of air mainly at night, hyperemia of the back and wings of the nose. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. as well as a feeling of lack of air mainly at night, hyperemia of the back and wings of the nose. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. as well as a feeling of lack of air mainly at night, hyperemia of the back and wings of the nose. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. pain in the epigastric region, heartburn, sour eructation, nausea, episodic vomiting after taking drugs, progressively increased general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. pain in the epigastric region, heartburn, sour eructation, nausea, episodic vomiting after taking drugs, progressively increased general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner.
Over the past two years, he has noted an increase in blood pressure up to 170/110 mmHg, accompanied by dizziness, nausea, and palpitations. He takes antihypertensive drugs regularly (noliprel 2 mg in the morning). For the first time, systolic murmur over the apex of the heart appeared in 2006, with time its intensity increased. Episodic pain in the epigastric region notes for ten years, was treated independently with a temporary positive effect. During the last two years, she notes unsteadiness when walking, numbness in the fingers of the upper limbs, she was not treated, she did not seek medical help.
Around 5:00 p.m. on November 17, 2008. I woke up with an unbearable headache and nausea. There was a single vomiting of food eaten the day before. Given the increase in blood pressure to 170/100 mm Hg. self-administered captopril 50 mg po, nifedipine 10 mg po without effect. Given the appearance of flies before the eyes, severe heaviness in the head, nausea, weakness caused an ambulance. She was taken to the VMA Hospital Therapy Clinic for further diagnosis and treatment.
The results of laboratory studies in dynamics:
General clinical analysis of blood:
Date
Hb, units.
Er., *1012/l
MCV
fl
Rt
‰ Leuc
., *109/l
Ht
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
22.09
92
3.83
78
6.2
29.8
5
306
1
46
4
3
46
5.11
100
3.1
CP=0.96
9
5.5
6
3
21
10
5
61
18.11
105
4.68
74
15.7
4.3
34.6
10
303
2
-
37
9
1
51
Anisopoikilocytosis-1, anisochromia (hypochromia)-2
03.12
93
4.17
75
25
8.2
31.3
6262
1
38
2
1
58
Anisopoikilocytosis
-
2, anisochromia (hypochromia
)
-2 rev.
Norm
22.09
18.11
3.08
Name
Unit. rev.
Norm
22.09
18.11
3.08
Creatinine
mmol/l
53-124
72.1
80.0
90
cholesterol
mmol/l
3.7-7
5.24
Urea
mol/l
3-8.4
7.2
7.4
6.6
TG
mmol/l
0-2.37
0.58
PTI
%
70-120
103
93
Ig M
g/l
0.65-1.65
7, 0
Fibrinogen
g/l
2.0-4.0
2.07
3.7
Ig G
g/l
7.5-15.5
8.5
Total protein
g/l
63-87
60.0
65.8
56.9
Ig A
g/l
1.25-2.5
0.8
Albumin
g/l
30.55
41.0
35.9
CEC
u
6-66
14
28
globulins
g/l
17-35
25.0
Cl
mmol/l
95-108
120.8
ALT
U/L
8.4-53.5
21.9
17.6
14.7
Na
mmol/l
130-150
139.9
56.9
AST
U/L
7-39.7
12.5
17.2
12.6
K
mmol/l.
4-6
4.39
4.5
ALP
U/L
36-92
56.6
42.4
37.0
Sa
mmol/l
2.1-2.55
2.09
2.04
GGTP
U/L
7-63
7 .3
5.2
Fe (serum)
mmol/l
10.5-25.0
3.53
3.12
Glucose
mmol/l
4.2-6.4
4.5
4.9
4.41
CPK-MB
U/l
0.0 -12.5
2.45
Rev. bilirubin
µmol/l
6.8-26
4.6
CPK
U/l
36-92
17.8
Sial. to-you
g / l
1.9-2.5
1.9
Rheumofactor
IU / ml
<30
Neg.
O-streptolysin
IU/ml
<200
<200
C-react. protein
mg/l
<6
<6
Safety factors [HBsAg, Anti-HCV (Core-n NS3-p NS4-n; Core-n NS4-p NS5-n), AT-HIV 1 and 2; Microreaction with cardiolipin antigen (RW)] from 11/19/2008. - negative.
Complete
urinalysis
date
_
PH
Protein
sugar
Ley in p / z
Er. in p/z
Epit.
Salts
Mucus
05.11.08
1018
turbid
sour
ref
2-3-4
no
flat a lot
of
oxalates
-
11.18.08
1025
clear
5.5
no
no
-
no
no
no
-
Reberg's test from 20.11.08. - a variant of the norm
Zimnitsky's test dated 11.21.08. – specific weight: 1005-1023; day diuresis - 1220 ml, night - 300 ml.
Nechiporenko test from 24.11.08. – leukocytes 0.5×106/l, erythrocytes were not detected
Antinuclear antibodies 03.06.08:
(serum dilution 1:100 screening)
• Antinuclear antibodies /+/ positive
• Fluorescence intensity: 2+ (moderate)
• Luminescence type: homogeneous nuclear fluorescence, chromosomal regions of dividing cells are stained at all stages of mitosis
• Probable types of autoantibodies: antibodies to DNA, DNP (deoxyribonucleoprotein), antibodies to histones, antibodies to other chromatin components.
• Recommended additional tests: determination of antibody titer, determination of antibodies to DNA, specific tests for rheumatoid factors, confirmatory and differentiating test with purified nuclear antigens by immunoblotting (ANA-profile)
• Antibodies to cytoplasmic components: /-/ negative
Dynamic immunological analysis of blood 2006 – 2008:
Indicator
norm
Result
11/15/2006
Result No. 10009 11/14/2008
before PF+PS
Result 12/3/2008
after PF+PS
Antinuclear factor on the HEp-2 cell line
<1:40
1:160 homogeneous type of luminescence
1:320 fine granular type of glow of the nucleus
<1:40
Antibodies to double-stranded DNA by ELISA
<25 U/ml - no antibodies to dsDNA detected
25-50 U/ml - low concentration
>50 U/ml - high concentration
79.73 U/ml
17.71 U/ml
1.9 U/ml
Antibodies to cardiolipin class IgG
<10 GPL-U/ml - no antibodies
10-30 GPL-U/ml - borderline concentration
>30 GPL-U/ml - high concentration
1.387 GPL-U/ml
-
8.11 U/ml
IgM anti-cardiolipin antibodies
<10 MPL-U/ml - no antibodies
10-20 MPL-U/ml - borderline concentration
>20 MPL-U/ml - high concentration
1.789 MPL-U/ml
-
2.2 MPL-U/ml
Antibodies to total extractable nuclear antigen (ENA screening)
Antibodies to the common extractable nuclear antigen were not detected Antibodies to the common extractable nuclear antigen were
detected -
Antibodies to the common extractable nuclear antigen were
detected
Antibodies to β2 glycoprotein of the IgG class by ELISA
Less than 12 U/ml - no antibodies were detected
5.79 U/ml
-
-
Antibodies to β2 glycoprotein of IgM class by ELISA method
Less than 12 U/ml - no antibodies detected
7.656 U/ml
-
-
Determination of the spectrum of antinuclear antibodies using immunoblot
Antibodies Sm, RNP/Sm, SS-A (60 kDa), SS-A (52 kDa) , SS-B, Scl-70, PM-Scl, PCNA, CENT-B, dsDNA/Histone/Nucleosome, Rib-P, AMA-M2, Jo-1 not detected
Detected antibodies to SS-A 60 kDa
-
-
Detection of cryoglobulins with RF activity
Cryocrit 0%
RF 37 deg - <1:20
RF 4 deg - <1:20
Cryocrit 0%
RF 37 deg - <1:20
RF 4 deg - < 1:20
-
-
Technical commentary on the study 11/15/2006:
Antibodies to the common extractable nuclear antigen of antibodies to the 60 kDa SS-A antigen have been found Antibodies to the 60 kDa Ro/SS-A antigen are relatively more frequently detected in patients with SLE than in those with Sjogren's syndrome and skin forms. Antibodies to the 60 kDa Ro/SS-A antigen are relatively more frequently detected in patients with SLE than in Sjogren's syndrome and cutaneous lesions, secondary dry syndrome, photosensitivity, and articular syndrome. A dangerous manifestation of SLE associated with antibodies against Ro / SS-A 60 kDa is the syndrome of congenital lupus, which develops in newborns from parturient women with SLE. This disease is based on the penetration of antibodies to Ro/SS-A into the blood of the newborn through the placenta. The main manifestation of congenital lupus is dermatosis and lesions of internal organs, including congenital transverse AV blockade, hepatitis, hemolytic anemia and thrombocytopenia. Antibodies to dsDNA are the main serological marker of SLE with kidney damage, since they are involved in the pathogenesis of lupus nephritis, in addition, they are included in the 10th criterion of SLE. Low titers of anti-DNA antibodies without concomitant ANF and antibodies to an extractable nuclear antigen can be observed against the background of viral and infectious diseases and, if isolated, are not a sign of SLE. There is a correlation between the increase in titers of antinuclear factor (ANF), antibodies to dsDNA and hypocomplementemia before the development of an exacerbation of SLE, which requires periodic determination of titers of antibodies to dsDNA and the level of complement factors C3 and C4 in all patients with SLE with a frequency of once every 3-6 months. Antibodies to dsDNA are the main serological marker of SLE with kidney damage, since they are involved in the pathogenesis of lupus nephritis, in addition, they are included in the 10th criterion of SLE. Low titers of anti-DNA antibodies without concomitant ANF and antibodies to an extractable nuclear antigen can be observed against the background of viral and infectious diseases and, if isolated, are not a sign of SLE. There is a correlation between the increase in titers of antinuclear factor (ANF), antibodies to dsDNA and hypocomplementemia before the development of an exacerbation of SLE, which requires periodic determination of titers of antibodies to dsDNA and the level of complement factors C3 and C4 in all patients with SLE with a frequency of once every 3-6 months. Antibodies to dsDNA are the main serological marker of SLE with kidney damage, since they are involved in the pathogenesis of lupus nephritis, in addition, they are included in the 10th criterion of SLE. Low titers of anti-DNA antibodies without concomitant ANF and antibodies to an extractable nuclear antigen can be observed against the background of viral and infectious diseases and, if isolated, are not a sign of SLE. There is a correlation between the increase in titers of antinuclear factor (ANF), antibodies to dsDNA and hypocomplementemia before the development of an exacerbation of SLE, which requires periodic determination of titers of antibodies to dsDNA and the level of complement factors C3 and C4 in all patients with SLE with a frequency of once every 3-6 months. Low titers of anti-DNA antibodies without concomitant ANF and antibodies to an extractable nuclear antigen can be observed against the background of viral and infectious diseases and, if isolated, are not a sign of SLE. There is a correlation between the increase in titers of antinuclear factor (ANF), antibodies to dsDNA and hypocomplementemia before the development of an exacerbation of SLE, which requires periodic determination of titers of antibodies to dsDNA and the level of complement factors C3 and C4 in all patients with SLE with a frequency of once every 3-6 months. Low titers of anti-DNA antibodies without concomitant ANF and antibodies to an extractable nuclear antigen can be observed against the background of viral and infectious diseases and, if isolated, are not a sign of SLE. There is a correlation between the increase in titers of antinuclear factor (ANF), antibodies to dsDNA and hypocomplementemia before the development of an exacerbation of SLE, which requires periodic determination of titers of antibodies to dsDNA and the level of complement factors C3 and C4 in all patients with SLE with a frequency of once every 3-6 months.
The results of instrumental studies in dynamics:
ECG from 11/17/2008: Sinus rhythm with a frequency of 66 bpm, normal EOS (α=400), local violation of intraventricular conduction in the posterior diaphragmatic region of the left ventricle. No dynamics from 2006 ECG.
ECHO-KG dated 11/22/2008: MZHP-8.0mm, ZS-8.0mm, KDRLZh-47.5mm, KSRLZh-27mm, FV-74%, FU-43%, UO-78ml, LP-33×34 ×46mm, RV-25.5mm, E/A=1.05 Myocardium is not thickened. The kinetics is not broken. The cavities are free, not dilated, the mitral leaflets and chords of the mitral valve are thickened, with an uneven surface, there are no vegetations, the rest of the valves are not changed, on the mitral valve regurgitation I-II st. Diastolic dysfunction of the left ventricle. The aorta is sealed. The pericardium is intact.
ECHO-KG from 04.12.2008: Aorta 28mm, aortic valve opening 20mm, MZHP-8.0mm, ZS-8.0mm, KDRLV-50mm, KSRLZh-33mm, FV-63%, FU-34%, UO-75ml , LP-37×30×45mm, RV-25mm, E/A=1.10 Myocardium is not thickened. The kinetics is not broken. The cavities are free, not dilated, the mitral leaflets and chords of the mitral valve are thickened, with an uneven surface, there are no vegetations, the other valves are not changed, on the mitral valve regurgitation I-II st. Diastolic dysfunction of the left ventricle. The aorta is sealed. The pericardium is intact. No significant dynamics.
Monitor observation of ECG and blood pressure according to Holter ID: IBK01 dated 11/20/2008: Duration of observation 21 hours 49 minutes. Leads A, I, D were recorded. The average heart rate during the day was 83 bpm (min.-57, max.-151), the average during night sleep was 96 bpm (min.-51, max.-186). In general, the dynamics of heart rate without features, the decrease at night is within the normal range. Against the background of sinus rhythm, which continued throughout the entire observation period, the following types of arrhythmias were registered: I. solitary supraventricular extrasystole with a pre-ectopic interval from 421 to 882 (average-570) msec; in total – 2, II. Paroxysm of atrial fibrillation-flutter (AF) with a heart rate of 121 beats/min., once a day at 23:04, subjectively manifested by a sharp attack of dizziness. Episodes of ST segment depression up to -1.8 mm, in leads characterizing the potentials of the anterior wall, lateral wall of the left ventricle, painless, occurring at the height of physical activity with different threshold heart rate >160 beats/min; stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. painless, occurring at the height of physical activity with different threshold heart rate >160 beats/min; stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. painless, occurring at the height of physical activity with different threshold heart rate >160 beats/min; stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. arising at the height of physical activity with different threshold heart rate >160 beats/min; stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. arising at the height of physical activity with different threshold heart rate >160 beats/min; stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning.
The function of external respiration 12/11/2006: a variant of the norm. VC = 3.36l (VC = 3.37l), FVC = 3.47l (107%), FEV1 = 2.92l (107%), RO inhalation = 0.77 l, RO inhalation = 1.83 l, FEV05 = 1.99 l , FEV1% VC=86.90 (107%), POS=4.7l/s (76%), MOS25=4.4l/s (79%), MOS50=3.99l/s (99%), MOS75 =1.73l/s (92%), SOS25-75=3.21l/s (98%), SOS0.2-1.2=4.22l/s, FEVOS=1.25l, FEVOS% FVC=36 .04, TPOS=0.32s, TFVC=1.54s, Aex=10.25l×l/s, IS BP=2.00c.u. DO=0.99l, BH=28
Ultrasound of the abdominal organs from 09/20/2008: the liver is not enlarged, the right lobe: 12.8 cm; left 7.7 cm, smooth contours, homogeneous structure, increased echogenicity; intrahepatic vessels are not dilated; portal vein 10 mm, hepatic veins of normal size (7-8 mm). Intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape, the contours are even, the walls are 2 mm, the calculi are not visualized, a polyp is located on the anterior wall with a diameter of 2.5-3.2 mm. The pancreas is located indistinctly, not enlarged, the contours are fuzzy, uneven, the structure is heterogeneous, echogenicity is increased; Wirsung's duct is not dilated. The kidneys are of normal size (right 10.8×3.8 cm, left 9.9×4.5 cm), normal location, with even contours, homogeneous parenchyma 14 mm thick, abdominal systems are not dilated. In the middle third of the right kidney, calicectasia up to 17.7 mm, in the left kidney in the middle and upper third of calicectasia up to 21.2 mm. The spleen is not enlarged, measuring 11×7.2×6.8 cm. In the projection of the location of the adrenal glands, no pathological formations were found. The bladder is filled, the contours are even, the walls are not thickened (3-4 mm). Uterus in anteflexio, to the left, enlarged up to 6 weeks, dimensions 80.4 × 54.8 × 68.3 mm, contours are uneven, deformed, the structure is heterogeneous, the formation of a heterogeneous structure with a diameter of 10 mm is visualized subserously along the anterior wall, the echostructure of the myomertium is cellular. The uterine cavity is not expanded, with a gap up to 3.8 mm with homogeneous contents, the endometrium is 6 mm wide. The ovaries are usually located, oval in shape, dimensions: left 45×28mm, enlarged along the uterine rib, anechoic D=21.6mm along the lateral contour; right 32×25mm, not enlarged contours are even, clear, cellular structure, along the lower contour, an anechoic formation D = 23.7 mm. On the anterior wall of the cervix, 2 endocervical cysts D=5 and 6 mm. Conclusion: gallbladder polyp, diffuse changes in the pancreas, calicectasia of both kidneys, subserous-interstitial uterine myoma of small sizes in combination with adenomyosis PE, cysts of both ovaries.
Ultrasound of the abdominal organs dated November 26, 2008: the liver is not enlarged, the right lobe: 14.1 cm; left 7.0 cm, smooth contours, homogeneous structure, increased echogenicity; intrahepatic vessels are not dilated; portal vein 10 mm, hepatic veins of normal size (7-8 mm). Intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape, the contours are even, the walls are 2 mm, stones are not visualized, a polyp is located on the anterior wall with a diameter of 4.5 mm. The pancreas is located indistinctly, not enlarged, the contours are fuzzy, uneven, the structure is heterogeneous, echogenicity is increased; Wirsung's duct is not dilated. The kidneys are of normal size (right 10.8×3.8 cm, left 9.9×4.5 cm), normal location, with even contours, homogeneous parenchyma 14 mm thick, abdominal systems are not dilated. The spleen is not enlarged, 12.7×8.7×6.0 cm in size. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: gallbladder polyp, diffuse changes in the pancreas.
Fibrogastroduodenoscopy No. 2124 dated 11.06.08: The esophagus is freely passable. The socket of the cardia closes incompletely. The mucous membrane of the esophagus is pink. The dentate line is higher than normal. The legs of the diaphragm close below the "toothed" line. STOMACH. The stomach contains foamy mucus. Peristalsis of the stomach can be traced throughout. The mucous membrane of the stomach is edematous, focally hyperemic. The mucosa of the antrum with focal atrophy. The gatekeeper is rounded, we pass. The mucosa of the duodenal bulb and the postbulbar section is pink. Biopsy of the gastric mucosa of different departments: chronic gastritis with restructuring of the glands according to the intestinal type. Conclusion: Hiatal hernia. Chronic atrophic antral gastritis.
Fibrogastroduodenoscopy dated 11/26/2008: the distal end of the apparatus was inserted into the esophagus, the latter was shortened. Z-line above the crura of the diaphragm, indistinct, barely visible, uneven (at the level of 32 cm from the upper incisors). At the same level, single erosions are determined, expanding distally to form, as it were, an additional cavity, there is a significant prolapse of the gastric mucosa into the esophagus. In the stomach, the folds are unexpressed, straighten out during insufflation, the mucosa is pale pink, in some places a vascular pattern is traced, petechial and hemorrhagic erosions are noted in the body and antrum. The gatekeeper does not close completely. In the bulb and postbulbar section, the mucosa is thinned, the circular folds are smoothed out. Conclusion: sliding hiatal hernia of mixed type: axial and paraesophageal. Erosive reflux esophagitis grade 2. Barrett's esophagus (?). Moderately pronounced atrophic gastroduodenitis, against which petechial and hemorrhagic erosions are noted in the stomach. Taken: from the esophagus and the antrum of the stomach, 2 pieces of biopsy.
Histological examination No. 10965-66 dated 05.12.08. (Material 26.11.08), biopsy No. 1 from the antrum of the stomach: moderate erosive gastritis of the outlet section of the 2nd (second) degree of activity with dysplasia of the 2nd (second) degree and foveolar hyperplasia of the integumentary epithelium. HP (-). / Time: Rumakin V.P. /
Histological examination No. 10963-64 dated 03.12.08. (Material 26.11.08) biopsy No. 2 from the esophagus: a section of stratified squamous non-keratinized epithelium with a submucosal base without an inflammatory component and a fragment of the muscular layer. There is no metaplasia of the gastric glands. /time: V. Yudaev/
X-ray of the stomach from 03.12.08: the esophagus and cardia are freely passable for barium suspension. The contours of the esophagus are even, longitudinal folds can be traced throughout. In a horizontal position, the patient's gastric mucosa prolapses into the esophagus, the fornix of the stomach falls into the posterior mediastinum. The stomach is hypokinetic, empty on an empty stomach. The contours of the stomach are even, the walls are elastic. Folds of mucous longitudinal are traced in all departments. Peristalsis is segmented, evacuation is not disturbed. Bulb with smooth contours. The loop of the duodenum is usually located. After 1.5 hours, a small amount of contrast medium in the stomach. The first portions of the barium suspension fill the blind and ascending colon. Conclusion: mixed hiatal hernia - esophageal with paraesophageal displacement of the upper stomach. gastroptosis. Hypermotor dyskinesia of the small intestine.
X-ray of the chest organs No. 2414 dated 11/21/2008: Conclusion: On the survey radiograph of the chest cavity organs in the lungs without fresh focal and infiltrative changes. The roots are structural, no free fluid was found in the pleural cavity. The heart is moderately expanded in diameter to the left, the aorta is sealed.
Spondylograms of the cervical spine in 2 projections No. 2414 dated November 21, 2008: osteochondrosis of the C4-5 motor segment with a decrease in disc height, subchondral sclerosis and marginal bone growths in the anterior sections at the same level, C4 displacement posteriorly by 0.4 cm.
On spondylograms of the thoracic spine in 2 projections No. 2414 dated November 21, 2008: physiological kyphosis is enhanced. Moderately reduced disc height Th7-8 Th8-9 end plates are compacted, small marginal bone growths in the anterior sections at the same levels are R-signs of osteochondrosis Th7-8 Th8-9 motor segments.
On spondylograms of the lumbar spine in 2 projections No. 2414 dated November 21, 2008: physiological lordosis is enhanced. The height of the disc L4-5 is moderately reduced - the phenomenon of chondrosis. L5-S1 - Schmorl's hernia.
Treatment: regimen, diet, polarizing mixture, lasix, asparkam, prednisolone 20 mg in the morning, methotrexate 7.5 mg/week, perindopril 5 mg/day, symptomatic and restorative therapy.
Operations:
11/24/08: plasmapheresis (1000ml) and plasmasorption (1200ml), mass transfer device - column SKN-1D, "Solu-medrol" 500 mg
11/27/08: plasmapheresis (900ml) and plasmasorption (1200ml), mass transfer device - column SKN -1D
01.12.08: hemosorption (4000 ml), mass transfer device - column SKN-1D, "Solu-medrol" 250 mg
Against the background of the therapy, the patient's condition improved.
Does not require sick leave. Discharged in a satisfactory condition.
Recommended:
20. Outpatient observation of a rheumatologist.
21. Annual inpatient treatment in a specialized hospital.
22. Dispensary observation:
a. Frequency of observations by a rheumatologist: - 4 times a year.
b. Examination by an ENT doctor, gynecologist, ophthalmologist 2 times a year; gastroenterologist - 1 time per year.
c. clinical blood test (with counting platelets and reticulocytes), urinalysis - 4-6 times a year; when changing the dose of cytostatic drugs - monthly control;
d. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - at least 2 times a year;
e. x-ray (fluorography) of the chest organs 2 times a year; x-ray of the joints - according to indications;
f. a blood test for the content of antinuclear factor and antibodies to double-stranded DNA and the level of complement C3 and C4 - 3 times a year and during exacerbation.
g. Echocardiography - 2 times a year;
h. FGDS - 1 time per year, with a biopsy of dubious areas of the lower third of the esophagus. If signs of Barrett's esophagus are detected (the presence of gastric metaplasia of the esophageal mucosa proximal to 2.5 cm from the gastroesophageal junction) - consultation of an abdominal surgeon
i. Dental consultation and oral hygiene
23. Lifestyle changes:
a. Exclusion of a strictly horizontal position during sleep (raise the head end of the bed by 15 cm)
b. Exclusion of wearing corsets, bandages, tight belts
c. The exclusion of lifting weights over 4-5 kg, work associated with tilting the torso forward, physical exercises associated with overstrain of the abdominal muscles (including yoga classes)
24. Changing the mode and nature of nutrition:
a. Avoid overeating, snacking, eating at night, lying down after eating
b. Exclude from the diet foods rich in fat (whole milk, cream, fatty fish, goose, duck, pork, fatty beef, lamb, cakes, pastries), drinks containing caffeine (coffee, strong tea, Coca-Cola), chocolate, foods containing mint and pepper, citrus fruits, tomatoes, onions, garlic, fried foods.
c. Do not use alcoholic drinks, carbonated mineral water
d. Limit consumption of butter and margarine
e. 5 meals a day in small portions with a high protein content
f. Eat at least 3 hours before bedtime, after eating take a 30-minute walk.
25. Continue taking:
a. Prednisolone 5mg - 4 tab. in the morning with breakfast until 9 am – all the time
b. Methotrexate 2.5 mg - 1 tab. 3 times a week (Saturday morning and evening 1 tab, Sunday morning 1 tab) - constantly
c. Wobenzym - 5 tablets × 3 times a day × a month, then 3 tablets × 3 times a day - at least 6 months.
d. Ca-D3-Nycomed-forte - 1 tab. in the evening daily
e. Multivitamin preparations: "Complivit" 1 tablet daily for 3 months
f. Sorbifer durules - 1 capsule in the morning for 3 months
g. Venter 0.5 op 1 tab 1-1.5 hours after meals 4 times a day, in the absence of effect - 8 times a day after 3 hours, regardless of food
h. Motilium - 10 mg in the morning 30 minutes before meals for 1 month
i. Omeprazole 20mg - 1 capsule in the morning on an empty stomach for 1 month
j. Maalox on demand
MILITARY MEDICAL ACADEMY
Clinic of hospital therapy
Discharge summary №
1968 b. (40 years old), was on examination and treatment in the hospital therapy clinic with a diagnosis of
Hypertension Stage I. (AH grade 2, risk 3). NC I Art. Initial manifestations of cerebrovascular insufficiency with diffuse neurological symptoms.
He was admitted to the clinic in a planned manner with complaints of aching headaches with increased blood pressure, impaired concentration, and memory loss.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
CP
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
10.12
155
4.69
5.5
2
270
2
42
14
1
41
Complete urinalysis dated 10.12.08 without features
Biochemical blood test:
Name
Unit. rev.
Norm
22.03
Name
Unit. rev.
Norm
11.12
Creatinine
mmol / l
53-124
CS
mmol/l
3.7-7
2.87
Urea
mol/l
3-8.4
6.4
TG
mol/l
0-2.37
0.44
Prothromb.index
%
70-120
β-LP
U
350-650
450
Fibrinogen
g/l
200-400
HDL
mol/l
0.78-2.33
Total protein
g/l
63-87
65
LDL
mol/l
1.9-4
Albumin
%
50-70 Cholesterol
/HDL
Times
3-5
1
%
3-6
VLDL
Mole/l
0.6-1.2
2
%
9-15
odds atheros.
Unit
0-3
%
8-18
amylase
U/L
28-100
%
15-25
trypsin
u/l
0-0.35
a/g
1.1-2.5
Ig M
g/l
0.65-1.65
ALT
U/L
8.4-53.5
14.6
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
11.02
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
CEC
U
6-66
LDH
U/L
100-220
Cl
Mol/l
95-108
GGTP
U/L
11-63
11.8
Na
Mole/l
130-150
Glucose
mmol/l
4.2-6.4
4.5
Ca
Mole/l
2.0-2.7
1.85
Tot. bilirubin
µmol/l
6.8-26
5.6
K
mmol/l.
4-6
ALK pos
U/L
36-92
102.3
T3
Mol/l
66-181
Urinary
acid fmol/l
150-420
T4
Mol/l
1.3-3.1
CPK
u/l
10-160
RW
qual
Results of instrumental studies:
ECG from. 03/21/2007, Sinus rhythm with a heart rate of 58 beats, horizontal EOS. Left ventricular hypertrophy. Syndrome of early repolarization. Local violations of intraventricular conduction, violations of repolarization in the region of the lower wall.
Ultrasound examination from 30.03.2007. The liver is not enlarged, the right lobe is 13.8 cm, the left lobe is 6.4 cm. The contours are even, the structure is homogeneous, the echogenicity is medium, the vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape (curved, partially reduced). The pancreas is located indistinctly, it is not enlarged, the contours are fuzzy, even, the structure is homogeneous echogenicity is average, the Wirsung duct is not dilated. Kidneys: location and size are normal. Right - the contours are even, the parenchyma is homogeneous 16 mm, the cavity system is not expanded, there are no stones: the left one - the contours are not even, the parenchyma is homogeneous 18 mm, the cavity system is not expanded, there are no stones. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 8.8x3.6 cm, the structure is homogeneous. Flatulence.
EchoCG from 03/29/2007. Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed, calcifications in the AC. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no pericardial effusion.
The results of VEM and ECG Holter monitoring are on hand
X-ray of the chest organs dated 30.03.2007. In the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is slightly dilated to the left. The aorta is elongated.
X-ray of the skull from 30.03.2007. On survey craniograms in two projections, the Turkish saddle is normal. There is thinning of the bones of the cranial vault.
Radiography of the right hip joint dated April 2, 2007: on the radiograph of the right hip joint in two projections. Condition after metal osteosynthesis in the area of comminuted fracture of the upper third of the femur. The callus is expressed satisfactorily. The bolt of a metal structure protrudes into the soft tissue by 2.5 cm.
Specialist consultations
Optometrist: VIS OD 1.0; OS 1.0 IOP OD,OS - 18mm Hg
The auxiliary apparatus and the outer parts of the eyeballs are not changed, the optical media are transparent. The fundus of the eye: optic nerve disc of satisfactory nutrition, the contours are clear. The veins are moderately dilated, the arteries are sealed. Focal pathology is not defined.
Neurologist: Dyscirculatory encephalopathy of the 2nd stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders.
ENT: Endoscopic ENT organs without visible pathology. SR 6 m.
Traumatologist: Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (02/27/02) due to a closed fracture of the surgical neck of the shoulder (02/15/02) and its repeated fracture (07/18/02) with moderate dysfunction of the left upper limb . A consolidating fracture of the neck of the right femur with a construction (25.09.2006) with a slight dysfunction of the right lower limb.
Treatment was carried out: regimen, diet, olicard, ACC thrombosis, metoprolol, phenazepam.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
1. Observation of a therapist, neuropathologist, traumatologist of the TsKDP VMA.
2. Optimization of the regime of work, rest, nutrition.
2. Continue taking
• Olikard 0.04 1 caps. 1 r / d after breakfast
• Thrombo ACC 0.1 1 tab. 1 r / d after breakfast
• Metoprolol 0.05 ½ tablet 2 r / d (after breakfast and dinner)
• Asparkam 1 tablet 3 r / d the first 10 days of each month.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate No.
1932 (76 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis:
ischemic heart disease. Angina pectoris II FC. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (1983) cardiosclerosis. Hypertension stage III (AH 2st, Risk 4) NK-II, CHF-II FC. Diabetes mellitus type II, moderate, compensated. Dyscirculatory encephalopathy II st. in the form of scattered neurological symptoms. Benign prostatic hyperplasia.
He was admitted to the clinic for urgent indications with complaints of discomfort in the region of the heart during moderate (ascending to the 2nd floor) physical activity, shortness of breath, frequent nighttime urination, memory loss.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
CP
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
11.12
141
4.88
8.0
-
16
2
34
6
2
55
17.12
142
4.8
9.4
-
15
2
35
10
3
50
General clinical analysis urine:
Date
Clarity
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
11.12
prose
1015
yellow.
sour
no
no
no
no
no
no
no
no
no
no
Biochemical blood test:
Name
Unit. rev.
Norm
11.12
Name
Unit. rev.
Norm
11.12
Creatinine
mmol/l
53-124
0.09
cholesterol
mmol/l
3.7-7
5.48
Urea
mol/l
3-8.4
4.7
TG
mmol/l
0-2.37
0.85
Prothrombindex
%
70-120
106
β-LP
u
350-650
Fibrinogen
g/l
200-400
385
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
67.1
LDL
mmol/l
1.9-4
ALT
U/L
8.4-53.5
32.5
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
35, 0
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
60.2
CEC
units
6-66
LDH
U/L
100-220
Cl
mmol/l
95-108
GGTP
U/L
11-63
8.7
Na
mmol/l
130-150
146.1
Glucose
mmol/l
4.2-6.4
6 .42
Ca
mmol/l
2.0-2.7
Tot. bilirubin
µmol/l
6.8-26
14.0
K
mmol/l.
4-6
4.8
Daily fluctuation of blood sugar from 12/17/08: 8.00-4.7 mmol/l; 10.00-5.5 mmol/l; 12.00-5.4 mmol/l.
ECHO-KG No. 32 dated 12/15/08: Aorta - 31 mm, AV dilatation - 17 mm, RA - 36 mm, RV EDR - 26 mm, LA - 44 mm, LV ECR - 27 mm, LV EDR - 44 mm, FU - 37%, EF - 67%, IVS=14mm, WS=14mm, LA - 19 mm Hg, e/a = 0.62 symmetrical concentric hypertrophy of the left ventricular myocardium, hypokinesia of the posterior and posterolateral segments in the basal region. LP dilatation. The aorta is sealed. Calcification of the aortic crescents, limiting the opening of the valves. Flattening of fibrous rings and cusps of AC and MK. Applied regurgitation on PC and MC, TC. The pericardium is not changed.
Ultrasound of the abdominal organs dated 12.12.08: The liver is not enlarged, the thickness of the right lobe is 13 cm, the contours are even, the structure is homogeneous. Gallbladder without stones. Portal vein - 13 mm., Hepatocholedoch - 4 mm. The pancreas is not enlarged, the contours are even, the structure is hyperechoic, moderately heterogeneous. Kidneys without visible pathology. The spleen is not enlarged.
ECG No. 85 dated 10.12.08: sinus rhythm with a frequency of 60 beats per minute, horizontal EOS, left ventricular hypertrophy, impaired conduction along the right branch of the His bundle.
Treatment: regimen, diet, polarizing mixture, vinpocetine, enalapril, cordaflex, siofor, restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
26. Outpatient supervision of a polyclinic therapist.
27. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
28. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
29. Continue taking:
a. Enalapril 0.01 - 1 tab. 2 times a day (morning and evening) continuously
b. Cordaflex (retard) 0.02 - ½ tab. 2 times a day (morning and evening) continuously
c. Verapamil 0.08 - ½ tab in the morning and in the evening constantly
d. Siofor 500 - 1 tab in the morning and in the evening 15 minutes before meals
MILITARY MEDICAL ACADEMY. HOSPITAL THERAPY CLINIC
Reference No.
born in 1970 (39 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy Diagnosis: community-acquired focal pneumonia in the lower lobe of the left lung, mild severity DN-0. Astheno-vegetative syndrome. Right-sided nephroptosis I degree, lipoma of the left kidney, CRF-0.
She was admitted to the clinic for urgent indications with complaints of shortness of breath with moderate physical exertion, general weakness, cough with green discharge, and fever.
Laboratory results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l MSI
,
pg
n, %
e, %
b, %
l, %
m, %
p %
c, %
ESR, mm/h
12.11
139
4.13
5.6
300
33.8
1
1
48
15
2
34
23
16.11
148
4.43
6.3
325
33.5
4
4
29
10
1
52
22
Urine analysis
Date
Clear.
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
12.11
clear
1.025
Yellow
7.0
-
-
-
-
-
-
-
-
-
-
Feces per I/g 13.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11.09
Total protein
G/l
63.0-87.0
67.2
Cholesterol
Mmol/l
3.7-6.0
5.32
triglycerides
Mmol/l
0-2.37
0.94
Glucose
Mmol/l
4.2-6.4
4.86
Prothrombin
%
80-105
98
Fibrinogen
g/l
2-4
2.9
Sialic acids
Mmol
/
l
1.9-2.5 infiltrative changes. The roots of the lungs are structural, not expanded. The heart is not enlarged.
On the survey radiograph and fluoroscopy of the chest in the direct and right lateral projection No. 317 (D = 0.52 mSv) dated 11/19/09: a stranded pattern is noted in the basal segments of the left lung. Pleural cords in the C8 projection on the left. The roots of the lungs are structural, not expanded. The heart is not enlarged.
ECG No. 2528 dated 11/11/09: sinus rhythm with a heart rate of 80/min. EOS is deflected to the left. Partial violation of intraventricular conduction. The predominance of the potentials of the left ventricle.
ECHO-KG No. 790 dated 11/18/09 Ao=27mm, ascending Ao=23mm, opening AC=19mm, LA=30mm, RA=34mm, RV=22mm, LV=43/30mm, IVS=9mm, AP=8mm, EF=58%, FU=31% , SV=55ml, E/A=1.39 The myocardium is not thickened, the kinetics is not disturbed, the cavities of the heart are not dilated. The aorta is not changed. The blood flow on the valves is laminar. Systolic and diastolic functions are not disturbed. The free edge of the anterior leaflet of the mitral valve is thickened, loosened. Applied regurgitation on MK and TK. The pericardium is not changed.
Ultrasound of the OBP from 23.11.09. No. 1278: the liver is not enlarged, the right lobe is 10 cm, the left lobe is 3.7x7.6 cm, the contours are even, the structure is homogeneous, echogenicity is average, the vessels are not dilated. The gallbladder is bent in the middle third 4.5x1.6 cm, the contours are even, the walls are 2 mm, it contains bile, calculi and polyps are not detected, the common bile duct is 3 mm. The pancreas is located clearly, the contours are clear, even, the head is 13mm, the body is 10mm, the tail is 11mm, echogenicity is increased, the structure is homogeneous, the Wirsung duct is not dilated. The lower pole of the right kidney to the edge of the liver is 10x3.4 cm, the parenchyma is homogeneous 15 mm, the PCS is not changed; the left kidney is located typically 8.5 x 4.4 cm, the parenchyma is homogeneous 19 mm, the PCS is not changed. In the projection of the adrenal glands, no pathological formations were revealed, the spleen was not changed.
FVD No. 106 dated 11/18/2009 results in hand.
Treatment: regimen, diet, antibacterial, anti-inflammatory, expectorant, sedative and restorative therapy.
Against the background of the therapy, the patient's condition improved: the general intoxication syndrome was stopped, there is no compaction of the lung tissue. However, a cough persists with a slight discharge of a light color, signs of asthenia. Discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
30. Outpatient supervision of a doctor in accordance with DM-1.
31. Control general blood test as of 30.11.2009.
32. Release from the performance of official duties for a period of 3 (three) days.
33. Exemption from physical. preparation for 30 days.
34. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
35. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
36. Continue taking:
a. Linex - 1 capsule 3 times a day for 1 month
b. Ascoril - 1 tablespoon in the morning for 7 days
c. Antigrippin – 1 powder 2 times a day for 3 days
d. Eleutherococcus - 1 teaspoon in the morning (dilute in 1/3 cup of water).
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Reference No.
1925 (83 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis:
ischemic heart disease. Progressive angina from 12/17/08, with stabilization at the level of angina pectoris III FC from 12/22/08. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and post-infarction (of unknown duration) cardiosclerosis complicated by paroxysmal form of atrial fibrillation (paroxysm of unknown duration) was stopped on 18.12.08. Hypertension stage III (AH 2st, Risk 4) NK-I, CHF-IV→II FC. Obesity of the first degree, alimentary genesis. Chronic cholecystitis without exacerbation. Chronic pyelonephritis without exacerbation, multiple (two) cysts of the left kidney, CRF-I st. Benign prostatic hyperplasia.
He was admitted to the clinic for urgent indications with complaints of discomfort in the region of the heart during moderate (ascending to the 2nd floor) physical activity, shortness of breath, frequent nighttime urination, memory loss.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
17.12
146
4.87
8.0
47
8
1
1
19
7
72
19.12
144
4.62
6.4
44.7
9
5
27
8
60
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MV epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
11.12
mutn
1014
yellow
sour
0.04
no
no
++
no
no
0-2
no
2-4
12-15 Rehberg's
test
Date
Blood
creatinine Urine creatinine
Diuresis in 1 min
Glomerular filtration
Tubular reabsorption
24.12
0.16
14.53
0.95
86.3
98.9
Biochemical blood test:
Name
Unit. rev.
Norm
17.12
24.12
Name
Unit. rev.
Norm
17.12
24.12
Creatinine
mmol/l
53-124
160
160
CS
mmol/l
3.7-7
6.11
Urea
mol/l
3-8.4
9.0
11.3
TG
mmol/l
0-2.37
Prothrombindex
%
70-120
95
β-LP
u
350-650
Fibrinogen
g/l
200-400
330
HDL
mmol/l
0.78-2.33
Total protein
g/l
63- 87
67.5
72.2
LDL
mmol/l
1.9-4
ALT
U/L
8.4-53.5
12.6
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
16.0
Ig A
g/l
1.25-2.5
AP
U/L
36-92
CPK
U/L
10-160
46.5
LDH
U/L
100-220
Cl
mmol/l
95-108
111.6
GGTP
U/L
11-63
Na
mmol/l
130-150
148.4
148.2
Glucose
mmol/l
4.2-6, 4
5.52
5.77
Ca
mmol/l
2.0-2.7
2.32
2.43
Total bilirubin
µmol/l
6.8-26
25.4
K
mmol/l.
4-6
5.14
5.06
ECHO-KG No. 32 dated 12/15/08: Aorta - 36 mm, AV dilatation - 17 mm, RA - 50 mm, RV EDR - 32 mm, LA - 53 mm, LV ECR - 39 mm, LV EDR - 50 mm, FU - 30%, EF - 60%, IVS=14mm, WS=14mm, LA - 21 mm Hg, Dla - 38 mm Hg e/a = 0.89. Symmetrical concentric hypertrophy of the left ventricular myocardium. Dilatation of the left atrium and right chambers of the heart. The aorta is sealed. Regurgitation on the TC 2 degrees, applied to the mitral valve. Pulmonary hypertension of the first degree. The pericardium is not changed.
Ultrasound of the abdominal organs dated 23.12.08: The liver is not enlarged, the thickness of the right lobe is 13 cm, the contours are even, the structure is homogeneous. The gallbladder is without calculi, the walls are compacted, thickened up to 4 mm. Portal vein - 12 mm., Hepatocholedochus - 5 mm. The pancreas is not enlarged, the contours are even, the structure is hyperechoic, homogeneous. Kidneys: right - 9 × 4 cm, parenchyma up to 12 mm, uneven contours, expansion of individual cups up to 16 mm, PCS deformed; left - 11.5 × 6 cm, parenchyma up to 10 mm, expansion and deformation of the PCS, in the middle third, two cysts 2.6 and 2.2 cm in diameter. The spleen is not enlarged.
ECG No. 156 dated 12/17/08. atrial fibrillation, tachysystole 85-120 per 1 min, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 161/162/177 dated December 18-22, 08: sinus rhythm with a frequency of 60-78 beats per minute, vertical EOS, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 185 dated 12/23/08. sinus rhythm with a frequency of 82 per 1 min., vertical EOS, hypertrophy of both ventricles, more than the right one, in dynamics some worsening of repolarization of the apical-lateral region of the left ventricle
Treatment: regimen, diet, polarizing mixture, vinpocetine, enalapril, cordaflex, siofor, restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
37. Outpatient supervision of a polyclinic therapist.
38. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
39. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
40. Continue taking:
a. Enalapril 0.01 - 1 tab. 2 times a day (morning and evening) continuously
b. Cordaflex (retard) 0.02 - ½ tab. 2 times a day (morning and evening) continuously
c. Verapamil 0.08 - ½ tab in the morning and in the evening constantly
d. Siofor 500 - 1 tab in the morning and in the evening 15 minutes before meals
MILITARY MEDICAL ACADEMY
Hospital therapy clinic Discharge
summary
No.
(43 years old), was examined and treated at the hospital therapy clinic with a diagnosis of:
Hypertension stage II. (AH grade 2, risk 3). ischemic heart disease. Angina pectoris II f.k. Atherosclerosis of the aorta, coronary arteries. Atherosclerotic cardiosclerosis. NC I Art. Dyscirculatory encephalopathy of the second stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders. Chronic toxic steatohepatitis with moderate activity. Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (27.02.02) due to a closed fracture of the surgical neck of the shoulder (15.02.02) and its repeated fracture (18.07.02) with moderate dysfunction of the left upper limb. A consolidating fracture of the neck of the right femur with the presence of a construct (September 25, 2006).
He was admitted to the clinic in a planned manner with complaints of compressive pain in the chest, shortness of breath during exercise, aching headaches with increased blood pressure, dizziness, general weakness, impaired concentration, memory loss, pain in the right shoulder and right thigh.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
22.12
138
4.36
15.0
42.4
33
396
1
10
7
7
75
Biochemical analysis of blood:
Name
Unit. rev.
Norm
22.12
Name
Unit. rev.
Norm
22.12
Creatinine
mmol/l
53-124
70
CS
mmol/l
3.7-6.0
6.31
Urea
mol/l
3-8.4
3.1
TG
Mole/l
0-2.37
1.32
Prothromb. index
%
70-120
102
β-LP
Unit
350-650
540
Fibrinogen
g/l
200-400
320
HDL
mol/l
0.78-2.33
Total protein
g/l
63-87
72.9 Cholesterol
/HDL
Times
3-5
Albumin
%
50-70
49.5
VLDL
mol/l
0.6-1.2
1
%
3 -6
6.2
odds atheros.
Unit
0-3
2
%
9-15
14.5
amylase
U/L
28-100
82.4
%
8-18
16.2
trypsin
u/l
0-0.35
%
15-25
13.6
Ig M
g/l
0.65-1.65
a/ G
1.1-2.5
0.98
Ig G
g/l
7.5-15.5
ALT
U/L
8.4-53.5
72.6
Ig A
g/l
1.25-2.5
AST
U/L
7-39.7
37 .0
CEC
U
6-66
ALP
U/L
36-92
54.6
Fe
Mmol/l
10.5-25
5.76
LDH
U/L
100-220
Na
Mmol/l
130-150
141.4
GGTP
U/L
11-63
77 .8
Ca mmol/
l
2.0-2.7
2.12
Glucose
mmol/l
4.2-6.4
5.49
K
mmol/l.
4-5.5
4.63
Tot. bilirubin
µmol/l
6.8-26
8.1
Sialic
acids mmol/l
1.9-2.5
3.1
Urinary
acid fmol/l
150-420
287
T3
mmol/l
66-181
CPK
units/ l
10-160
148.1
T4
Mmol
/l
1.3-3.1
HBsAg, antiHCV qual negative ref
RW
qual
Results
of
instrumental studies:
X-ray examination and ECG registration was refused due to a "recent study".
Ultrasound examination from 30.03.2007. The liver is enlarged, the right lobe is 17.8 cm, the left lobe is 10.4 cm. The contours are even, the structure is homogeneous, echogenicity is increased, the vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape (curved, partially reduced). The pancreas is located indistinctly, it is not enlarged, the contours are fuzzy, even, the structure is homogeneous, echogenicity is average, the Wirsung duct is not dilated. Kidneys: location and size are normal. Right - the contours are even, the parenchyma is homogeneous 16 mm, the cavity system is not expanded, there are no stones: the left one - the contours are not even, the parenchyma is homogeneous 18 mm, the cavity system is not expanded, there are no stones. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 8.8x3.6 cm, the structure is homogeneous. Flatulence.
EchoCG from 12/25/2008. Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed, calcifications in the AC. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no pericardial effusion.
Treatment was carried out: regimen, diet, olicard, ACC thrombosis, metoprolol, phenazepam.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
1. Observation of a therapist, neuropathologist, traumatologist of the TsKDP VMA.
2. Optimization of the regime of work, rest, nutrition.
2. Continue taking
• Olikard 0.04 1 caps. 1 r / d after breakfast
• Thrombo ACC 0.1 1 tab. 1 r / d after breakfast
• Metoprolol 0.05 ½ tablet 2 r / d (after breakfast and dinner)
• Asparkam 1 tablet 3 r / d the first 10 days of each month.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1957 (52 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis: Seropositive rheumatoid arthritis (M.05.8), very early stage, III degree of activity, stage I, with systemic manifestations (myocardial dystrophy, mild secondary normoregenerative normoblastic anemia, right-sided exudative pleurisy), anti-CCP (+), FC I, FNS I. Symptomatic arterial hypertension (AH 1, CVE risk 3)
She was admitted to the clinic on a planned basis with complaints of palpitations, fever up to 38.8 ° C, swelling and stiffness of the small joints of the hands and feet, "flying" swelling and pain of the large joints of the legs .
Laboratory results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l
MSN,
pg
Rt,
‰
e, %
b, %
l, %
m, %
p %
s, %
ESR, mm/h
11.11.
98
3.06
10.4
630
32.1
6.9
1
19
7
5
68
70
13.11
101
3.55
8.5
824
28.4
6.6
1
30
5
2
62
70
25.11
122
4.29
13.5
593
28.6
6.2
25
7
1
69
40
Complete urinalysis
Date
Clear
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
11.11
clear
1.020 Yellow
5.5
-
-
-
-
-
-
-
-
-
-
Nechiporenko
test 11.11.09 L=0.75х106/l, E=2.0х106/l
Cal on I/g 11.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11
Total protein
G/l
63.0-87.0
77.5
Cholesterol
Mmol/l
3.7-6.0
5.17
Creatinine
Mmol/l
0.05-0.12
0.06
Glucose
Mmol/l
4.2-6.4
5, 54
Prothrombin
%
80-105
Fibrinogen
g/l
2-4
Potassium
Mmol/l
3.5-5.1
4.38
Calcium
Mmol/l
2.0-2.7
2.07
AST
U/l
11-50
23, 3
ALT
U/l
11-50
25.9
CPK
U/l
10-160
12.3
CEC
U
6-66
567
Beta-lipoproteins
AU 350-650
Serology
for HIV, hepatitis - negative.
* Detailed serology of rheumatoid arthritis (AKA, ACE, ACCP/anti-SSR, RF) 11/17/09.
* Antibodies to cyclic citrulline-containing peptide
- Result options
* <5 U/ml - no antibodies to CCP detected
* 5-50 U/ml - low concentration
* >50 U/ml - high concentration
- Result 56.9 U/ml
* Rheumatoid factor
- normal <1:20 (less than 25 IU/ml), result - 1:80 (100 IU/ml)
* Antikeratin antibodies
- normal <1:10 result <1:10
* Antiperinuclear factor
- normal <1:10 result <1:10
Blood test for antinuclear factor with immunoblot from 11/17/09.
on the hands soft tissue compaction is noted at the level of the metatarsophalangeal and interphalangeal joints, more pronounced on the right.
On the survey radiograph of the chest in the direct and right lateral projection from 11.11.09. No. 2613 (D=0.52 mSv): in the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, not expanded. The right dome of the diaphragm is slightly elevated. Encapsulated fluid in the right pleural cavity at the level of the costophrenic sinus. A small amount of fluid in the interlobar fissures. The heart is not dilated, the aorta is sealed.
On the control radiograph of the chest in the direct and right lateral projection from 11.11.09. No. 329 (D=0.52 mSv): no fluid was found in the right pleural cavity, in the lungs without focal and infiltrative changes.
On the radiograph of the left knee joint No. 2662 dated November 13, 2009. (D=0.02 mSv): no pathological changes were detected in 2 projections.
Ultrasound of the abdominal organs No. 1235 dated 11/16/2009: no pathological changes were detected
On ECG No. 2515 dated 11/10/09: sinus rhythm with a heart rate of 80/min. Normal position of the EOS. Partial violation of intraventricular conduction. Violation of repolarization in the region of the posterior wall, apex.
ECHO-KG No. 762 dated 10.11.09. Ao=30mm, ascending Ao=30mm, opening AC=16mm, LA=30mm, RA=32mm, RV=24mm, LV=47/27mm, IVS=10mm, AP=09mm, EF=74%, FU=43% , SV=75 ml, E/A=0.84 myocardium is not thickened, the kinetics is not disturbed, the cavities of the heart are not expanded, free. The aorta, fibrous rings of the aortic and mitral valves are sealed. The blood flow on the valves is laminar. Diastolic dysfunction of the rigid type. Applied regurgitation on the mitral valve. The pericardium is not changed.
Consulted by the rheumatologist of the clinic. Diagnosis was clarified, therapy was adjusted.
Treatment: regimen, diet, prednisolone, methotrexate, noliprel, calcium-D3-nycomed, cytoflavin, diclofenac, omeprazole, almagel, sedative and restorative therapy.
Against the background of the therapy, the patient's condition improved: He is discharged in a satisfactory condition under the supervision of a rheumatologist at the polyclinic.
Recommended:
41. Outpatient observation of a rheumatologist at the place of residence.
42. In case of resumption of pain or stiffness of the joints in the morning - a consultation with a rheumatologist with a decision on the correction of the therapy and the need for inpatient treatment.
43. Control of the general blood test after 1 month (then 1 time in 3 months)
44. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
45. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
46. Continue taking:
a. Noliprel - ½ tab 1 time per day (in the morning) constantly
b. Methotrexate 2.5 mg - 1 tablet on Monday evening, Tuesday morning and evening (total 7.5 mg / week) - constantly.
c. Prednisolone 5 mg - daily 4 tab. in the morning, 1 in the afternoon, with food, drinking kissel. In the absence of pain and stiffness in the joints, starting from December 5, reduce by 0.5 tablets every 4 days until a maintenance dose of 7.5 mg (1.5 tablets) is reached, then constantly 1.5 tablets in the morning.
d. Calcium D3-Nycomed - 1 tab. in the evening all the time.
e. Cytoflavin - 1 tab. 3 times a day for 1 month
f. Asparkam - 1 tab. 3 times a day from the 1st to the 10th day of each month
MILITARY MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1952 (56 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy.
Diagnosis:
Hypertensive disease stage III (AH 2st, Risk 3) Uncomplicated hypertensive crisis of the first type from 08.12.08, stopped by medication on 09.12.08. ischemic heart disease. Angina pectoris I FC. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis. NK-I, CHSN-I FC.
He was admitted to the clinic for urgent indications with complaints of pain in the parietal region of the head, flies before the eyes, nausea, and an increase in blood pressure to 170/100 mm Hg.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
09.12.
145
4.84
10.9
45.3
13
2
17
7
74
Biochemical blood test:
Name
Unit. rev.
Norm
9.12
Name
Unit. rev.
Norm
9.12
Creatinine
mmol/l
53-124
70
CS
mmol/l
3.7-7
6.67
Urea
mol/l
3-8.4
5.8
TG
mmol/l
0-2.37
0.8
Prothromb.index
%
70-120
136
β-LP
u
350-650
540
Fibrinogen
g/l
200-400
399
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
68.3
Ig G
g/l
7.5-15, 5
ALT
U/L
8.4-53.5
17.9
Ig A
g/l
1.25-2.5
AST
U/L
7-39.7
16.4
CEC
u
6-66
ALP
U/L
36-92
Cl
mmol/l
95 -108
114.8
LDH
U/L
100-220
Na
mmol/l
130-150
139
GGTP
U/L
11-63
17.7
Ca
mmol/l
2.0-2.7
Glucose
mmol/l
4.2-6.4
5.7
K
mmol/l.
4-6
4.27
Tot. bilirubin
µmol/l
6.8-26
19.9
ECHO-KG No. 33 dated 12/15/08: Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no effusion in the pericardium
Ultrasound of the abdominal organs dated 12.12.08: The liver is not enlarged, the thickness of the right lobe is 13 cm, the contours are even, the structure is homogeneous. Gallbladder without stones. Portal vein - 13 mm., Hepatocholedoch - 4 mm. The pancreas is not enlarged, the contours are even, the structure is hyperechoic, moderately heterogeneous. Kidneys without visible pathology. The spleen is not enlarged.
ECG No. 67 dated 09.12.08: sinus rhythm with a frequency of 60 beats per minute, horizontal EOS, left ventricular hypertrophy
Treatment: regimen, diet, polarizing mixture, furosemide, vinpocetine, amlodipine, teveten, atenolol, restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
47. Outpatient supervision of a polyclinic therapist.
48. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
49. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
50. Continue taking:
a. Enalapril 0.01 - 1 tab. 2 times a day (morning and evening) continuously
b. Cordaflex (retard) 0.02 - ½ tab. 2 times a day (morning and evening) continuously
c. Verapamil 0.08 - ½ tab in the morning and in the evening constantly
d. Siofor 500 - 1 tab in the morning and in the evening 15 minutes before meals FGU "442 DISTRICT MILITARY
CLINICAL
HOSPITAL
LenVO" RF Ministry of Defense was on examination and treatment at 15 m / o 442 OVKG during the period with a diagnosis of:
Hypertensive disease of the third stage (deterioration). ischemic heart disease. Angina pectoris II f.k. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. HSN II FC. widespread atherosclerosis. Condition after aneurysm resection with its aortoiliac prosthesis and right nephrectomy due to renal artery occlusion (2006).
Dyscirculatory encephalopathy of the first stage in the form of diffuse neurological symptoms pseudoneurotic syndrome
Hospitalized with complaints of headache, burning pain behind the sternum, noise in the head, discomfort behind the sternum and shortness of breath with previously tolerated physical exertion, pain in the left lumbar region.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Nf%
07.07
159
5.22
9.5
4
1.4
0.2
27.6
8.6
62.4
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein , g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
07.07
clear
1020
yellow
5.0
no
no
no
0
0
0
0
0
to 6
0
Nechiporenko test L=0.75*10^6/l, E=0.5*10^6/l
Biochemical blood test:
Name
Unit. rev.
07.07
Name
Unit rev.
07.07
Creatinine
mmol/l
123
TG
u
Urea
mol/l
6.9
Glucose
mmol/l
5.90
Total protein
g/l
69
cholesterol
mmol/l
5.47
ALT
U/L
31
CAT
times
6.8
AST
U/L
19
Na
mmol/l.
131.4
LDH
U/L
124
K
mmol/L
4.28
CPK
U/L
0.94
Cl
mmol/L
106.7
Total Bilirubin
µmol/l
11.7
Prothrombindex
%
100
Uric acid
Mmol/l
Fibrinogen
g/l
2.57
Results of instrumental studies:
ECG from. 07/07/09 .: sinus rhythm with a heart rate of 60 in 1 min. EOS is deflected to the left. Left ventricular hypertrophy with systolic overload.
FLG of the chest organs dated 01/28/2009. Conclusion: chest organs without visible pathological changes.
Echo-CG from 09.07.09: Diameter of the aortic root 30mm, pulmonary artery 20mm, dilatation of AC 19.1mm, LA 39.7mm, ascending aorta 31mm, IVS 13.2mm, AP 14.7mm, LV EDR 52.1mm, LV ESR 31.3mm , EF 70%, FU 48%, LP 37mm, PP 35.7*47.5mm, RV 20.7mm. Symmetrical myocardial hypertrophy of the left ventricle. Fibrosis and adiskinesia of the posterior basal segment. Slight dilatation of the left atrium The aortic ring and the walls of the aorta are sealed. Cavities, pericardium free. Diastolic dysfunction of the hypertrophic type. Applied mitral regurgitation.
Ultrasound of the abdominal organs and kidneys from 9.07.09. Liver. Right share 15.0, left 4.0*6.0 Structure of uniform density. The gallbladder is not enlarged. There are 2 parietal formations 0.3 mm in the cavity, polyps. Choledoch is not expanded. The pancreas is not enlarged, compacted. The contours are clear. contour deformation. The right kidney has been removed. The bed is without features. The left kidney is 12.4*6.8 cm in size. The parenchyma is thickened to 3.0 cm. The contour is deformed due to fibrous inclusion along the lower pole. In the upper part of the kidney, there is a cyst 2.9*1.6 cm. The cavitary system is not expanded. Bladder The bladder is of medium volume.
Treatment: regimen, diet, piracetam, cytoflavin, milgamma, dilatrend, nifecardia, phenylin, thromboass, diclofenac, physiotherapy, acupuncture.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
Recommended:
51. Outpatient monitoring by a cardiologist at a polyclinic.
52. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
53. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
54. Dispensary observation:
a. clinical blood test, urinalysis - twice a year;
b. Echocardiography - 2 times a year;
c. ECG - 1 time per quarter
55. Continue taking:
a. Dilatrend 25 mg - 1/2 tab in the morning and in the evening
b. Niphecardia 30 mg - 1 tab at night
c. Thromboass 50 mg - 1 tab 1 time per day
d. Lescol forte 80 mg - 1 tab at night
e. Control blood test: ALT, AST, lipidogram, coagulogram in a month.
Diagnosis: Hypertensive disease of the second stage (AH-1, Risk-3). IHD. Angina pectoris 1 f.k. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. CHF 1. Condition after prosthetics of the abdominal aorta in 2003, nephrectomy on the right in 2003. Osteochondrosis of the cervicothoracic spine.
Diagnosis: Hypertensive disease of the second stage (AH-1, Risk-3). IHD. Angina pectoris 1 f.k. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. CHF 1. Condition after prosthetics of the abdominal aorta in 2003, nephrectomy on the right in 2003. Osteochondrosis of the cervicothoracic spine.
MILITARY-MEDICAL ACADEMY.
CLINIC OF
HOSPITAL THERAPY
(73 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy .
Diagnosis:
coronary artery disease. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (2008) cardiosclerosis. Permanent form of atrial fibrillation (paroxysm of atrial fibrillation from 05.10.09), tachy-normosystolic variant. Recurrent sustained ventricular tachycardia with the development of MAC-syndrome equivalents from 22.10.09. NK 2a st., CHF 3 FC.
TsVB. Dyscirculatory encephalopathy 2nd stage of mixed genesis. Chronic bilateral pyelonephritis in remission. HPN-1a. Obesity 1 stage, alimentary-constitutional genesis, stable phase.
He was admitted to the clinic for urgent indications with a paroxysm of atrial fibrillation. During the course of treatment, the patient developed paroxysm of sustained ventricular tachycardia twice (one recorded on HM-ECG, lasting 6 minutes, the second on the ICU monitor). Consulted by an arrhythmologist XUV-1 (Skigin I.O.), implantation of a cardioverter-defibrillator was recommended (indication class 1)
Results of laboratory tests:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pya
%
Xia
%
08.10
133
4.1
9.6
40.5
20
1
1
19
9
7
63
23.10
143
4.55
8.3
45.3
8
26
5
1
68
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epithelium of urinary tract in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
23.10
transparent
1020
yellow
sour
No
no
no
-
no
no
0-2
no
0-1
0-1
Biochemical blood test:
Name
Unit. rev.
Norm
08.10
23.10
Name
Unit. rev.
Norm
08.10
Creatinine
mmol/l
53-124
130
CS
mmol/l
3.7-7
3.76
Urea
mol/l
3-8.4
9.5
TG
mmol/l
0-2.37
Prothrombindex
%
70-120
75
β-LP
units
350-650
Fibrinogen
g/l
200-400
3.8
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
60.2
LDL
mmol/l
1.9-4
ALT
U/L
8.4-53.5
36.4
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
27.5
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
CPK
U/L
10-160
143.7
LDH
U/L
100 -220
Cl
mmol/l
95-108
GGTP
U/L
11-63
Na
mmol/l
130-150
Glucose
mmol/l
4.2-6.4
4.75
Ca
mmol/l
2.0-2.7
1.98
Total. bilirubin
µmol/l
6.8-26
23.6
K
mmol/l.
4-6
ECHO-KG No. 702 dated 10/22/09: Aorta - 34 mm, AV dilatation - 17 mm, RA - 46 * 64 mm, RV ERD - 28 mm, LA - 50 * 55 * 52 mm, LV ESR - 50 mm, LV EDR - 60 mm, FU - 13%, EF - 27%, IVS=11mm, WS=11mm, LA - 28 mm Hg, Dla - 60 mm Hg e/a = 0.89. the myocardium is not thickened, dilatation of the atria, left ventricle, total LV myocardial hypokinesia (akinesia and fibrosis of the posterior, lower walls and the adjacent part of the septum in the basal and middle sections) with a decrease in systolic heart function (EF ≤ 30%, VR ≤ 55 ml). The aorta, fibrous rings of AK and MK, aortic crescents and mitral leaflets are sealed. Expansion of the pulmonary artery up to 29mm (above the valve). Moderate pulmonary hypertension (according to Kitabatake). Regurgitation on all valves: 1-2st on MK, 1st on AK, PC and TK.
ECG No. 1568 dated 07.10.09. atrial fibrillation, tachysystole 85-120 per 1 min, hypertrophy of both ventricles
X-ray 08.10.09. - in the lungs without fresh focal and infiltrative changes. The pulmonary pattern is reinforced and deformed due to diffuse pneumosclerosis. The roots of the lungs are moderately compacted. Sinuses are free. The heart is dilated to the left. The aorta is compacted and deployed.
HM-ECG with VT episode is attached.
Treatment: regimen, diet, polarizing mixture, heparin, warfarin, cordarone, metoprolol, enalapril, sedative and restorative therapy.
He is transferred to the XUV-1 clinic for implantation of a cardiovarter-defibrillator.
Works foreman as a researcher, issued a certificate of temporary disability
No. ____________________________________
56. Regularly adopts:
a. Kordaron 0.2 - 1 tab. 3 times a day continuously
b. Metoprolol 0.05 - ½ tab. 2 times a day (morning and evening) continuously
c. Mildronate 0.5 1 caps. 2 times a day
d. The last injection of heparin (5000 units s.c.) today, 26.10.09 at 9:00 am
Discharge
summary No.
Hospital Therapy Clinic Military Medical Academy named after S.M. treatment of VMedA with a diagnosis of:
Main - Community-acquired focal pneumonia in the lower lobe of the left lung of mild severity. YN0
Results of the examination:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l MSI
,
pg
n, %
e, %
b, %
l, %
m, %
p %
s, %
ESR, mm/h
12.11
139
4.13
5.6
300
33.8
1
1
48
15
2
34
22
16.11
148
4.43
6.3
325
33.5
4
4
29
10
1
52
23
Urinalysis
Date
Transl.
Rel. Density
Colour
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
12.11
clear
1.025
Yellow
7.0
-
-
-
-
-
-
-
-
-
-
Feces per I/g 13.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11.09
Total protein
G/l
63.0-87.0
67.2
Cholesterol
Mmol/l
3.7-6.0
5.32
Triglycerides
Mmol/l
0-2.37
0.94
Glucose
Mmol/l
4.2-6.4
4.86
Prothrombin
%
80-105
98
Fibrinogen
g/l
2-4
2.9
Sialic acids
Mmol/l
1.9-2.5
2.3
ECG from 11.11.2009 g No. 2528 .: sinus tachycardia, deviation of the electrical axis of the heart to the left. Partial violation of intraventricular conduction. The predominance of the potentials of the left ventricle.
According to the results of Rg-graphy of the organs of the chest cavity on November 12, 2009 in frontal and lateral projections without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The median shadow is not expanded.
According to the results of FVD 13.11.09 - slight violations of bronchial conduction. moderate decrease in
Against the background of therapy (regime, diet, bromhexine) notes an improvement in the condition (normalization of body temperature, a decrease in the frequency and intensity of cough, a decrease in weakness).
Recommended:
1. Observation of the doctor's part;
2. Mode of work and rest, dietary nutrition;
3. Complivit 1 tablet 2 times a day after meals for 2 weeks.
4. Exemption from physical exercises, outfits, work for 15 days.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1969 (40 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis: Hypertension stage II (AH-3, Risk of CVE-4). Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis. NK-1. Osteochondrosis of the cervical, thoracic and lumbar regions, left-sided scoliosis of the II degree of the thoracic region, Schmorl's hernia Th6-7 and Th7-8 without dysfunction of the spine with pain syndrome. Initial manifestations of cerebrovascular insufficiency with scattered neurological symptoms, cephalgic, astheno-neurotic syndrome. Obesity II degree, alimentary-constitutional genesis, stable phase. Sliding hernia of the esophageal opening of the diaphragm 1 degree. GERD, reflux esophagitis without obstruction. Chronic gastroduodenitis, exacerbation. Fatty hepatosis without liver dysfunction. Mild catarrhal proctitis, anal fissure. External hemorrhoids without exacerbation.
She was admitted to the clinic for urgent indications with complaints of episodes of severe headache in the head with increased blood pressure, increased sweating after minor physical exertion, indoors at normal room temperature, fresh blood in the feces.
Laboratory results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l MSI
,
pg
e, %
b, %
l, %
m, %
n %
s, %
ESR, mm/h
09.11
149
5.13
8.4
484
29
1
32
4
3
60
10
Urinalysis
Date
Transpar.
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
09.11
clear
1.025
Yellow
5.5
-
-
-
-
-
-
-
-
3-5
2-4
Nechiporenko test 11.11.09
L= 0.75x106 /l, E=2.0x106/
l
Name
Unit
Norm
09.11
Total protein
G/l
63.0-87.0
74.4
Cholesterol
Mmol/l
3.7-6.0
6.41
Triglycerides
Mmol/l
0-2.37
1.13
Glucose
Mmol/l
4.2-6.4
4.84
Prothrombin
%
80 -105
98
Fibrinogen
g/l
2-4
2.8
potassium
Mmol/l
3.5-5.1
4.56
iron
mmol/l
10.5-25
7.4
AST
U/l
11-50
24.2
ALT
U/l
11-50
13.6
Total
bilirubin Umol/l
6.8-26
9.1
Beta-lipoproteins
U
350-650
660
T3
Nmol/l
1.0-2.8
1.4
T4
Nmol/l
53-158
79
TSH
μIU/ml
0.23-3.4
1.58
A/T
U/ml
0-65
0
Ab to TPO
U/ml
0-30
3
Ab for HIV, hepatitis – negative.
Ultrasound of the thyroid gland from 11/17/09. No. 1034: the thyroid gland is enlarged: the right lobe is 16x53x19mm, the left lobe is 19x51x21mm. In the right lobe, a rounded anechoic formation 11 mm in size, in the left lobe, two nodular formations 3-5 mm in diameter and one with a diameter of 9 mm are visualized.
Ultrasound of the OBP dated 12.11.09. No. 1221: the liver is enlarged in size (the thickness of the right lobe is 15 cm), the contours are even, the structure is compacted, the vascular pattern is "depleted" (fatty hepatosis). The gallbladder without calculi, a kink in the body area, the walls are unevenly compacted, thickened up to 2-3 mm. Portal vein 11 mm, hepatocholedochus - 4 mm. The pancreas is of normal size, the contours are even, the structure is hyperechoic, homogeneous. Kidneys of normal size, in both kidneys, more on the right, hyperechoic inclusions (microliths?, calcification?) are visualized. The spleen is not changed.
ECHO-KG No. 791 dated 11/18/09 Ao=28mm, ascend.Ao=26mm, opening AK=16mm, LA=38mm, PP=36mm, RV=26mm, LV=44/24mm, MZHP=WS=11mm, EF=77%, FU=45%, UV =67ml, E/A=1.09 Symmetric concentric LV myocardial hypertrophy, kinetics is not disturbed, heart cavities are not dilated. The aorta is sealed. The blood flow on the valves is laminar. Applied regurgitation on MK and TK. The pericardium is not changed.
ECG #2518 dated 11/10/09: Sinus rhythm with HR 64 per minute, EOS deviated to the left. Left ventricular hypertrophy, local disturbances of intraventricular conduction.
Radiography of the cervical spine No. 2728 dated 11/20/09. (D=0.22 mSv) in 2 projections, the physiological lordosis is straightened, the curvature of the neck to the right. Osteochondrosis of C4-5 C5-6 motor segments with a moderate decrease in the height of the discs, subchondral sclerosis and marginal exophytes 0.1 cm at the same levels in the projection of the discs.
Radiography of the thoracic and lumbar spine No. 2684 (D=1.92 mSv): on radiographs of the thoracic spine in 2 projections, left-sided scoliosis with an angle of deviation from the vertical of 150 with the center of the arc at the level of Th8 (II degree according to Chaklin). Osteochondrosis of Th6-7 and Th7-8 motor segments with reduced disc height, subchondral sclerosis, and marginal exophytes. Schmorl's hernia at the level of Th6-7 and Th7-8.
On spondylograms of the lumbar spine in 2 projections, the physiological lordosis is smoothed. Osteochondrosis L3-4 L4-5 motor segments with a decrease in the height of the discs, subchondral sclerosis and marginal exophytes 0.1 cm in the projection of the discs.
She was consulted by a neurologist at the Clinic of Nervous Diseases of the Military Medical Academy, the diagnosis was supplemented, and recommendations were made. In order to exclude volumetric formation of the brain, an MRI of the brain was recommended (3.12.2009 at 10:30 am).
Radiography of the stomach No. 327 dated November 25, 2009. the esophagus is freely passable for the barium mixture. The cardia does not close completely on inspiration. In a horizontal position, the patient's gastric mucosa falls into the esophagus. The stomach is hypertonic, located high, start on an empty stomach. Its contours are even. The walls are elastic, mucosal folds can be traced throughout, longitudinal. Peristalsis is segmented, waves of medium depth. Evacuation begins after a short spasm of the pylorus. Bulb and loop of the duodenum without features. There is duodeno-bulbar reflux. Conclusion: sliding hiatal hernia of the 1st degree. Functional disorders of the stomach and duodenum.
Sigmoidoscopy of 25.11.09, the tube of the proctoscope was inserted up to 30 cm - no organic pathology was detected. The mucosa is moderately hyperemic, somewhat edematous, dull, the vascular pattern is blurred. A collapsed, non-inflamed external hemorrhoid is noted. At 12 o'clock shallow crack. Conclusion: moderately pronounced catarrhal proctitis. Anal ring fissure. External hemorrhoids without exacerbation.
Treatment: regimen, diet, metoprolol, hypothiazide, enalapril, omeprazole, vascular and anti-inflammatory, sedative and restorative therapy.
Against the background of the therapy, the patient's condition improved: He is discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
57. Outpatient medical supervision of the unit according to DM-1.
58. MRI of the brain December 3, 2009 at 10.30.
59. Repeated consultation with a neurologist with the results of MRI
60. Release from duty for a period of 3 (three) days.
61. Exemption from physical. preparation for 10 days.
62. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
63. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
64. Continue taking:
a. Enap N - 1 tab 2 times a day constantly
b. Metoprolol 50 mg - 1 tab. 2 times a day continuously
c. Troxevasin 0.3 - 1 tab. 3 times a day for 3 weeks
d. Vazobral 2.0 - 1 tab. 2 times a day for 3 weeks.
e. Grandaxin - 1 tab at 9:00 and at 14:00 1 month
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1988 (21 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy
. Diagnosis:
Cardiac neurocirculatory dystonia without signs of heart failure. Mild myopia in both eyes. Deviated septum without obstruction of nasal breathing.
The clinic was hospitalized in a planned manner with complaints about.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuc., *109/l
Ht
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pi
%
Xia
%
24.11
151
4.85
5.1
44
7
35
8
4
53
Urinalysis, coprogram dated 24.11.09. – without pathology
Biochemical analysis of blood:
Name
Unit. rev.
Norm
24.11
Name
Unit. rev.
Norm
Creatinine
mmol/l
53-124
110
CS
mmol/l
3.7-7
2.8
Urea
mol/l
3-8.4
TG
mmol/l
0-2.37
0.44
Prothromb.index
%
70-120
86
β-LP
u
350-650
280
Fibrinogen
g/l
200-400
3.2
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
74.6
Ig G
g/l
7.5-15.5
ALT
U/L
8.4-53.5
17
Ig A
g/l
1.25-2.5
AST
U/L
7-39.7
13
CEC
u
6-66
amylase
U/L
28-100
17.1
Cl
mmol/l
95-108
LDH
U/L
100-220
Na
mmol/l
130-150
136
GGTP
U/L
11-63
13
Ca
mmol/l
2.0-2.7
2.4
Glucose
mmol/l
4.2-6.4
5.2
K
mmol/l.
4-6
3.87
Tot. bilirubin
µmol/l
6.8-26
26
Sialic acids
mmol/l
1.9-2.5
2.0
ECHO-KG No. 810 dated 11/25/09: Aorta 27 mm, aortic ring 20 mm, asc. aorta 26 mm, aortic valve dilatation 21 mm, LA 33 mm, LV CR 30 mm, LV CR 49 mm, FU 39%, fr choice 65%, WS 9 mm IVS 9 mm, PP 34 mm, RV 24 mm; the myocardium is not thickened, the cavities are not dilated, the kinetics is not changed. Systolic and diastolic functions of the left ventricle are not disturbed. Aorta, valves intact, laminar blood flow, first degree regurgitation on the pulmonic valve. The pericardium is unchanged, there is no pericardial effusion.
Daily ECG monitoring by Holter from 30.11.09. sinus arrhythmia, rhythm and conduction disturbances, ischemic ST changes were not detected.
Ultrasound of the abdominal cavity and thyroid gland dated November 25, 2009: no pathological changes were detected.
Bicycle ergometry No. 4 of December 2, 2009: negative test. Tolerance to physical activity is high. BP response is adequate.
ECG No. 2636 dated 11/24/08: sinus tachycardia with a frequency of 94 beats per minute, posterior rotation of the apex.
Consulted by specialist doctors: surgeon, ENT, neurologist, dentist, ophthalmologist. Conclusion: "A" - fit for military service.
Treatment: regimen, diet, metabolic and restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged under the supervision of a doctor of the unit in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
65. Outpatient supervision of a doctor in accordance with DM-1.
66. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
67. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1964 (45 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis:
IHD: angina pectoris 1 FC. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and postinfarction (30.08.09) cardiosclerosis. Stenting of LEVZ from 08.11.2009. Hypertension III Art. (AG-2, R-4). Dyscirculatory encephalopathy II st. mixed genesis (atherosclerotic, hypertensive, vertebrogenic) in the form of scattered neurological symptoms and pseudoneurotic syndrome. Chronic gastroduodenitis in remission. Steatohepatitis without liver dysfunction. Nodule of the left lobe of the thyroid gland, euthyroidism. Osteochondrosis of the cervical spine, hypoplasia of the transverse processes of the seventh cervical, first thoracic vertebrae. Chronic vertebrogenic cervicothoracic sciatica with a predominant lesion of the V-VI roots without impaired spinal function. Longitudinal flat feet II st. both feet without arthrosis of the talonavicular joints. Hyperopia degree of 0.5 diopters in both eyes.
He was admitted to the clinic for urgent indications with complaints of episodic discomfort in the region of the heart, which occurs during psycho-emotional stress, which is relieved by rest; palpitations, shortness of breath during exercise above average; for recurrent headaches and dizziness with an occasional increase in blood pressure (BP max. = 160/100 mm Hg, blood pressure work. = 130/80 mm Hg).
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuc., *109/l
Ht,
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
02.12
140
4.31
5.7
42.9
5
3
35
8
2
52
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
01.12
mutn
1020
yellow
sour
0.04
no
no
no
no
no
0-2
no
2-4
-
Biochemical blood test:
Name
Unit. rev.
Norm
02.12
Name
Unit. rev.
Norm
02.12
Creatinine
mmol/l
53-124
90
CS
mmol/l
3.7-7
4.63
Urea
mol/l
3-8.4
TG
mmol/l
0-2.37
0.85
Total protein
g/l
63- 87
75.2
CPK
mmol/l
10-160
74.3
ALT
U/L
8.4-53.5
27.0
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
15.8
Ig A
g/l
1.25-2.5
GGTP
U/L
11-63
Na
mmol/l
130-150
136.4
Glucose
mmol/l
4.2-6.4
Ca
mmol/l
2.0 -2.7
2.43
Total bilirubin
µmol/l
6.8-26
K
mmol/l.
4-6
3.90
ECHO-KG from 2.12.09: Aorta - 31 mm, PP - 40 mm, LA - 53 mm, LV ECR -33 mm, LV EDR - 54 mm, FU - 38%, EF - 68%, IVS 10 mm, GS 10 mm, LA - 21 mmHg, e/a = 1.05. Dilatation of the left atrium. The myocardium is not thickened, akinesia of the posterior and lower segments in the middle and basal regions. Global systolic function is not impaired. The aorta and fibrous rings of AC and MC are sealed, the blood flow is laminar. Regurgitation of the 1st degree on the tricuspid and mitral valve. The pericardium is not changed.
Ultrasound of the abdominal organs dated 23.12.08: The liver is not enlarged, the thickness of the right lobe is 13 cm, the contours are even, the structure is homogeneous. The gallbladder is without calculi, the walls are compacted, thickened up to 4 mm. Portal vein - 12 mm., Hepatocholedochus - 5 mm. The pancreas is not enlarged, the contours are even, the structure is hyperechoic, homogeneous. Kidneys: right - 9 × 4 cm, parenchyma up to 12 mm, uneven contours, expansion of individual cups up to 16 mm, PCS deformed; left - 11.5 × 6 cm, parenchyma up to 10 mm, expansion and deformation of the PCS, in the middle third, two cysts 2.6 and 2.2 cm in diameter. The spleen is not enlarged.
ECG No. 156 dated 12/17/08. atrial fibrillation, tachysystole 85-120 per 1 min, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 161/162/177 dated December 18-22, 08: sinus rhythm with a frequency of 60-78 beats per minute, vertical EOS, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 185 dated 12/23/08. sinus rhythm with a frequency of 82 per 1 min., vertical EOS, hypertrophy of both ventricles, more than the right one, in dynamics some worsening of repolarization of the apical-lateral region of the left ventricle
Treatment: regimen, diet, polarizing mixture, vinpocetine, enalapril, cordaflex, siofor, restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
68. Outpatient supervision of a polyclinic therapist.
69. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
70. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
71. Continue taking:
a. Enalapril 0.01 - 1 tab. 2 times a day (morning and evening) continuously
b. Cordaflex (retard) 0.02 - ½ tab. 2 times a day (morning and evening) continuously
c. Verapamil 0.08 - ½ tab in the morning and in the evening constantly
d. Siofor 500 - 1 tab in the morning and in the evening 15 minutes before meals FGU "442 DISTRICT MILITARY
CLINICAL
HOSPITAL LenVO" RF Ministry of
Defense (54 years old), was examined and treated at 15 m/o 442 OVKG with a diagnosis of:
Hypertensive disease of the second stage (AH-1; Risk of CVE -3). Initial manifestations of atherosclerosis of the aorta and coronary arteries. NK-1, KhSN-1 f.cl. Peptic ulcer of the duodenal bulb in remission. Biliary dyskinesia of the hypomotor type. Chronic vertebrogenic cervicalgia and thoracalgia in the stage of unstable remission. Osteochondrosis of the cervicothoracic spine.
Hospitalized in a planned manner with complaints of recurrent pain in the epigastric region with errors in diet, headache, dizziness, pain in the cervical spine.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht, %
ESR, mm/h
Thrombus
*109/l
Lf
%
M
%
Granulocytes
%
18.12
133
4.67
7.1
37.9
6
163
30.1
5.5
64.4
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
21.12
transparent
1025
yellow
5.5
no
no
no
no
no
no
1-2
no
1-2
no
_
_
_ rev.
Norm
18.12
22.12
Name
Unit. rev.
Norm
18.12
22.12
Creatinine
mmol/l
53-124
93
cholesterol
mmol/l
3.7-7
5.9
Urea
mol/l
3-8.4
9.1
TG
mmol/l
0-2.37
Prothrombindex
%
70- 120
120.6
β-LP
u
350-650
Fibrinogen
g/l
200-400
2.61
HDL
mmol/l
0.78-2.33
1.17
Total protein
g/l
63-87
67
73
LDL
mmol/l
1.9-4
Albumin
%
37-50
40
CS/ HDL
times
3-5
1
%
3-6
VLDL
mmol
/l
0.6-1.2
2
%
9-15
atheros.
Unit
0-3
4.0
%
8-18
amylase
U/L
28-100
71
71
%
15-25
trypsin
u/l
0-0.35
Globulins
g/l
17-35
33
ing. trypsin
u
18-36
a/g
1.1-2.5
1.2
Ig M
g/l
0.65-1.65
ALT
U/L
8.4-53.5
128
99
Ig G
g/l
7.5-15, 5
AST
U/L
7-39.7
59
Ig A
g/l
1.25-2.5
ALP
U/L
0.7-2.3
1.2
CEC
u
6-66
LDH
U/L
100-220
194
224
Cl
mmol/l
95-108
GGTP
U/L
11-63
29
Na
mmol/l
130-150
Glucose
mmol/l
4.2-6.4
5.88
6.09
Ca
mmol/ l
2.0-2.7 Tot
. bilirubin
µmol/l
6.8-26
23.7
28.2
K
mmol/l.
4-6
CPK
u/l
0.46-2.96
5.15
RW
quality
Results of instrumental studies:
ECG from. 11/21/2009: sinus rhythm with a heart rate of 70 beats per minute, horizontal EOS. Indirect signs of left ventricular hypertrophy.
VEM No. 59 dated 12/23/2009: ECG at rest is normal. Load tolerance is high. The response of blood pressure to exercise is a hypertensive response. No chest pains were noted. Arrhythmias: no. There were no changes in the ST segment. The test is negative.
ECHO-KG No. 219 dated 12/18/09 Ao=35mm, AC expansion=17mm, LA=38mm, RA=45mm, RV=30mm, LV=59/40mm, IVS=WS=8.5mm, EF=59%, FU=32% Myocardium is not thickened, kinetics are not violated. The cavities of the left ventricle and atrium are dilated. The valves are intact. The aorta is sealed. The blood flow on the valves is laminar. Regurgitation 1 degree on the mitral valve. The pericardium is not changed.
X-ray of the chest organs from 12/17/2009. Conclusion: in the lung tissue without visible focal and infiltrative changes. The roots are structural, the sinuses are free. Heart with enlarged left ventricle. The aorta is not changed.
Ultrasound of the abdominal organs from 12/22/2009: no pathological changes.
Consulted by an ophthalmologist: the conclusion is a thorn in the right eye.
Treatment was carried out: regimen, diet, metabolic and antihypertensive therapy.
Against the background of the therapy, the patient's condition improved, he is discharged under the dynamic supervision of the doctor of the unit.
Recommended:
1. Observation of a therapist (cardiologist).
2. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
3. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
4. Amlodipine 0.005 - 1 tab 1 time per day, in the morning.
Federal State Institution "442 DISTRICT MILITARY CLINICAL HOSPITAL LENVO" Ministry of Defense of the Russian Federation
Discharge summary No. 7349
Lieutenant colonel of the medical service, born in 1972 was on examination and treatment at 15 m / o 442 OVKG in the period from 14.05. on May 31, 2010 with a diagnosis of
Reiter's syndrome with damage to the right ankle joint and II and III metatarsophalangeal joints of the left foot of the II degree of activity. Hemorrhagic vasculitis, cutaneous form. Hypertensive disease of the first stage (Risk of CVE is moderate) without signs of heart failure. Polyp of the gallbladder. Chronic gastritis in remission.
He was hospitalized with complaints of rashes on the skin of the legs (small petechial confluent rash), subfebrile condition in the evening, pain during movement in the ankle joints, headaches and general weakness.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Xia
%
Pya%
Gran.
%
14.05
117
3.5
5.3
20
4
1
13
9
59
14
25.05
124
4.05
5.1
5
25.8
2.8
71.4
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MV epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
16.05
mud
1020
yellow
acid
0.15
no
no
0
0
0
0
0
1-2
0-0-1
In daily urine from 18.05.2010 protein not found
Biochemical blood test:
Name
Unit. rev.
14.05
Name
Unit. rev.
14.05
Creatinine
mmol/l
106
TG
units
Urea
mol/l
5.9
Glucose
mmol/l
6.42
Total protein
g/l
75
cholesterol
mmol/l
3.87
ALT
U/L
21
CAT
times
AST
U/L
13
Na
mmol/ l.
145
LDH
U/L
122
K
mmol/l
4.6
CPK
U/L
0.83
Cl
mmol/l
104
Tot. Bilirubin
µmol/l
14
Prothromb.index
%
100
Uric acid
mmol/l
Fibrinogen
g/l
4.08
Sowing from the pharynx for flora dated 05/17/2010: Staphylococcus epidermidis, Staphylococcus viridans
Nasal swab for flora dated 05/17/2010: Staphylococcus epidermidis in a small amount
Results of instrumental studies:
ECG from. 05/12/10 .: sinus rhythm with a heart rate of 60 in 1 min. EOS is horizontal.
FLG of the chest organs dated 14.05.2010. Conclusion: chest organs without visible pathological changes.
Echo-CG from 12.04.10: Aortic root diameter 33mm, pulmonary artery 20mm, dilatation of AC 19.1mm, LA 37x46x45mm, IVS 10mm, AP 8mm, LV EDR 53mm, LV ESR 35mm, EF 63%, FU 34%, PP 33*44mm, RV 25mm. Without dynamics with ECHO-KG from 04/09/2010. (see discharge summary).
Ultrasound of the abdominal cavity and thyroid gland from 17.05.10. Sick after eating Liver. Right lobe 14.6, left 9.0*7.0 Structure of uniform density, echogenicity is not changed. Gallbladder contracted (after eating). On the front wall there is a polyp 0.6 cm. The right kidney is 10.6x5.6 cm. The parenchyma is 2.8 cm. The left kidney is 11x5.6 cm in size. The parenchyma is up to 2.5 cm. The echogenicity of both kidneys is increased, the structure is homogeneous. PCLS with fibrosis. Ultrasound signs of toxic kidneys. The spleen is not enlarged 11x4.6 cm, the structure is homogeneous, echogenicity is not changed. The splenic vein is not changed. The prostate gland is not enlarged 3.6x2.8x3.4 cm (volume 21.6 cm3), the structure is homogeneous, echogenicity is not changed, there are no nodes. The thyroid gland is not enlarged: S=6.9 cm3, D=8.1 cm3 the structure of both lobes is homogeneous, there are no nodes. Echogenicity, blood flow are not changed.
Treatment: regimen, diet, nise, clexane, sulfasalazine, prednisolone, physiotherapy, acupuncture.
On the background of the therapy, the patient's condition improved. Discharged to the unit in a satisfactory condition.
Recommended:
72. Outpatient observation of therapists, rheumatologist.
73. Dispensary observation:
a. clinical blood test, urinalysis - twice a year;
b. Echocardiography - 1 time per year;
c. ECG - 1 time in 6 months
74. Continue taking:
a. Sulfasalazine at 2.0/day
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCUSSION REPORT CASE
HISTORY No. ARCHIVE No. _________
Last name, first name, patronymic
Was hospitalized
at the hospital therapy clinic
Total treatment days 9
Final diagnosis established ICD Code I 25.5 MES 291060;
Diagnosis:
Ischemic heart disease: stable angina pectoris 3 functional class. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and post-infarction (2004) cardiosclerosis with impaired conduction by the type of complete blockade of the left leg of the His bundle. Secondary ischemic cardiomyopathy. Chronic aneurysm of the apex of the left ventricle. Insufficiency of the tricuspid valve of the 3rd degree, mitral and pulmonary valve of the first degree.
Hypertensive disease of the third stage, drug normotension, the risk of CVE is extremely high.
Chronic heart failure stage 2B, IV functional class. Middle fibrothorax on the right. Chronic decompensated pulmonary heart of mixed (broncho-pulmonary, vascular, thoraco-diaphragmatic) genesis. Secondary severe pulmonary hypertension. Diffuse pneumofibrosis. DN 1st.
Liver fibrosis of mixed (cardiac, infectious (HBV), dysmetabolic) genesis (Child-Pugh class B). Chronic hepatocellular insufficiency of the 1st stage, compensation. Portal hypertension syndrome, ascites. Hepatosplenomegaly.
Chronic atrophic gastritis.
Chronic pyelonephritis, latent course, remission. Nephropathy of mixed (atherosclerotic, dysmetabolic, diabetic, hypertensive) genesis. CKD stage C3a (GFR=54ml/min).
Encephalopathy of the second stage of mixed (dyscirculatory, dysmetabolic, hepatic) genesis.
Type 2 diabetes mellitus, HbAc 7.11%, target HbAc<8.0% Diabetic distal sensory polyneuropathy, diabetic microangiopathy.
Varicose veins of the lower extremities, superficial form. Chronic venous insufficiency stage 2.
Unincarcerated easily reducible umbilical hernia.
Degenerative-dystrophic disease of the spine.
Secondary chronic drug gout. Chronic gouty arthritis of the first metatarsophalangeal joint of the left foot, exacerbation.
Clinical outcome: improvement
Outcome: discharged on improvement,
Complaints: on the growing pronounced general weakness, decreased exercise tolerance, an increase in the abdomen in volume, shortness of breath of a mixed, mainly inspiratory nature.
History of present illness. For a long time he suffers from coronary heart disease, hypertension. In 2006, she suffered a massive myocardial infarction. On October 17, 2010, surgical treatment was performed for bleeding (shock 2-3) from a chronic stomach ulcer. During the same hospitalization, decompensated diabetes mellitus was revealed. After discharge, she did not comply with the doctor's recommendations, she began to notice an increase in the volume of the abdomen. On this occasion, she was repeatedly hospitalized in the hospitals of the city, where complex treatment was performed with active diuretic therapy. The last hospitalization in the pulmonology department of City Hospital No. 26. After discharge from the hospital on December 14, 2010, she began to notice a sharp increase in dyspnea at rest, the appearance of a cough without discharge, and an increase in general weakness. On December 23, 2010, she was admitted to the hospital therapy clinic. After discharge, he feels well for 2 weeks, but later on there is a progressive increase in the feeling of weakness, shortness of breath, which requires re-hospitalization. In February, March and April 2011, for the reasons described above, she underwent inpatient treatment, where punctures of the pleural cavity and evacuation of the contents were performed. In June 2011, she was hospitalized in order to exclude a neoplasm (mesothelioma) at the Federal State Institution “Research Institute of Oncology named after N.N. N.N. Petrov” of the Ministry of Health and Social Development of the Russian Federation, where after a comprehensive examination, including pleural biopsy and thoracoscopy, no data for the neoplasm were obtained. Diagnosed with idiopathic right-sided hydrothorax, ischemic cardiomyopathy. Subsequently, she underwent inpatient treatment at the Regional Cardiological Dispensary of the Leningrad Region. After release, within 2 months she felt satisfactory, however, in the future, due to progressive weakness on an outpatient basis, at least 2,000 ml of fluid was evacuated monthly during punctures of the right pleural cavity. During hospitalization in March 2012, during the drainage of the pleural cavity from March 5 to March 8, about 6000 ml of hemorrhagic exudate was obtained, a drop in hemoglobin from 144 to 80 g/l was noted, which was the reason for transfer to a surgical hospital, where data for ongoing intrapleural bleeding was not received, received conservative therapy, terilitin therapy. Discharged with subfebrile fever. Due to the deterioration of health in May 2012 in the form of severe fever, pain in the right half of the chest, she was hospitalized in the hospital surgery clinic, where she underwent inpatient treatment for pleural empyema on the right. After discharge, she felt relatively well. October 2012 general weakness began to progressively increase again, tolerance to physical activity sharply decreased, and the stomach increased in volume. She underwent inpatient treatment in the hospital therapy clinic with a positive effect. During the year, there was a slow progression of ascitic phenomena, which by November 2013. acquired a pronounced decompensated character and required another hospitalization. She was hospitalized by an ambulance to the hospital therapy clinic for further diagnosis and treatment. Diagnosis at discharge: “Chronic viral hepatitis B, cirrhotic stage (Child-Pugh class B). Fibrosis of the liver of mixed (cardiac, dysmetabolic) genesis. Chronic hepatocellular insufficiency of the 1st stage, compensation. Portal hypertension syndrome, ascites. Hepatosplenomegaly. IHD: stable angina pectoris 3 functional class. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and postinfarction (2004) cardiosclerosis. Secondary ischemic cardiomyopathy. Chronic aneurysm of the apex of the left ventricle. CHF 2B stage, III functional class. Middle fibrothorax on the right. Chronic decompensated pulmonary heart of mixed (broncho-pulmonary, vascular, thoraco-diaphragmatic) genesis. Secondary severe pulmonary hypertension. DN 1st. Hypertensive disease of the third stage, drug normotension, the risk of CVE is extremely high. Chronic pyelonephritis, latent course, remission. Mixed nephropathy (atherosclerotic, dysmetabolic, diabetic, hypertonic) genesis. CKD stage C3b (GFR=44ml/min). HPN-1a. Dyscirculatory encephalopathy of the second stage of mixed (hypertonic, atherosclerotic, dysmetabolic) genesis. Degenerative-dystrophic disease of the spine. Type 2 diabetes mellitus, target HbAc<8.0%.” During hospitalization, there was a pronounced tolerance to the ongoing complex diuretic therapy in high doses. After discharge from the hospital, she was under dispensary dynamic supervision of a polyclinic doctor at her place of residence, she did not take the recommended therapy. There was a progressive increase in body weight, during the last month there was a pronounced general weakness, an increase in the volume of the abdomen, shortness of breath of a mixed, mainly inspiratory, nature with previously tolerated exercise tolerance.
Past diseases, injuries, contusions, operations: myocardial infarction-2006, suturing of a perforated stomach ulcer - 17.01.2010. Since 2010, more than 30 pleural punctures, in March 2012, intrapleural bleeding on the right, May 2012. empyema of the pleura on the right. Since 2012 - continuously recurrent ascites, since 2013 - tolerance to diuretic therapy.
Insurance anamnesis: disabled person of the 1st group due to a general disease.
Objective status at admission: Height 165 cm Body weight 82.6 kg BMI-29.4 kg/m2.
The general condition is moderate, due to signs of portal hypertension, heart failure. Consciousness is clear (SHG=15b). The situation is forced. The physique is correct, corresponds to age and sex. Normosthenic constitution. The skin is swarthy, dry, thinned. Icteric sclera. The elasticity of the skin is reduced. Subcutaneous tissue of a homogeneous consistency, no edema. The hairline is developed in accordance with age and sex. Swelling of the cervical veins is noted, which increases during the test with an increase in intrathoracic pressure. Peripheral lymph nodes are not enlarged. The muscular system is developed satisfactorily. On palpation of the radial arteries, the pulse is rhythmic, with a frequency of 80 beats. per minute, satisfactory filling, uneven, not tense. Sat O2 at rest 96%. Arterial pressure - 120/80 mm. rt. Art. The boundaries of relative cardiac dullness are extended to the left to the middle clavicular line, the right one is not defined. The width of the vascular bundle does not extend beyond the edges of the sternum. The number of heartbeats corresponds to the pulse. Heart sounds are muffled, the first tone at the apex is weakened, at the apex of the heart there is a coarse systolic murmur, the emphasis of the second tone is on the pulmonary artery. The chest is symmetrical. The respiratory rate at rest is 22 per minute, the respiratory movements are rhythmic, the right half of the chest lags sharply in the act of breathing. On percussion, dullness over the sinus on the right. On auscultation over the lungs, breathing is hard, on the right, breathing over the sinus is not heard, single congestive rales over the right lower lobe. Tongue wet, pink. The abdomen is significantly enlarged due to the accumulation of free fluid, the correct shape, symmetrical, soft, peritoneal symptoms are negative. The edge of the liver +2 cm from under the edge of the costal arch, dense texture, bumpy, painless on palpation. The size of the liver according to Kurlov is 18x14x10 cm. The spleen is 08/8 cm. Ragosa's symptom is positive. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless.
Treatment: mode 1, diet No. 9, metabolic therapy, hypoglycemic, diuretic metabolic, hepato- and cardioprotective therapy.
Results of instrumental studies:
ECG on admission dated February 05, 2014 shows sinus rhythm with a heart rate of 80 beats per minute. EOS is deflected to the right. Hypertrophy of the right and left ventricles. Widespread cicatricial changes in the anterior-septal-apical-lateral LV. Diffuse disorders of repolarization. Complete blockade of the left branch of the His bundle
ECHO-KG from 02/05/14:
PARAMETERS
Val.
NORMAL
PARAMETERS
Value
NORM
Aortic root diameter
21.1
20-37 mm
Left ventricular
EDR 69.5
38-56 mm
Opening of the leaflets of the aortic valve
17.4
more than 15 mm ESR of the
left ventricle
61.4
22-38 mm
Antero-posterior dimension of the left atrium
51.6
25-40 mm
Thickness of the free wall of the right ventricle
4.5
less than 5 mm
Frontal dimension left atrium
55.5
25-45 mm
Left ventricular ejection fraction
25
more than 55%
Vertical size of the left atrium
64.8
29-53 mm
Right atrial size
50.2
30-46
Interventricular septal thickness
7.4
7-11 mm
Vertical size of the right atrium
51.5
34-49 mm
Thickness of the posterior wall of the left ventricle
8.1
7-11 mm
EDR of the right ventricle anteroposterior
47.7
Less than 30 mm
Systolic pressure in the LA
69
to 30 mm Hg
Pulmonary trunk diameter
26, 8
12-23 mm
Conclusion: Dilatation of all chambers of the heart. Spherical deformation of the heart cavities, the phenomenon of spontaneous pseudocontrasting of the cavities Paradoxical movement of the IVS. Against the background of total myocardial hypokinesia, fibrosis and thinning of the IVS. Dyskinesia of the apex in the area of the IVS, anterior and lateral walls with a transition to akinesia of the anterior and lateral walls in the middle section without signs of parietal thrombus formation. Dilatation of the pulmonary artery up to 26 mm. Regurgitation in all valves. The aorta, the fibrous rings of all valves are sealed with inclusions of calcifications in the structures of the aortic crescents and mitral cusps. the phenomenon of spontaneous pseudocontrasting. Hypertrophy of the right ventricle. Pulmonary hypertension III degree. Regurgitation in all valves. Pseudonormal type of transmitral blood flow. The leaves of the pericardium are thickened, compacted.
Ultrasound of the abdominal and thoracic cavities on 02/05/2014: the liver is enlarged, the right lobe is 20.5 cm, the left lobe is 9.0 cm, the contours are even, the structure is heterogeneous, the echogenicity is significantly increased, the vascular pattern is depleted, the vessels (portal vein, hepatic veins) are not expanded, volume educations are not revealed. The gallbladder of the correct form, 5.0 - 4.2 cm, the walls are 4 mm, the contents are homogeneous bile, the common bile duct is 0.4 cm. The pancreas is not clearly located, the contours are not clear, not even. 16.0 * 13.5 increased echogenicity, Wirsung's duct is not dilated. The kidneys are located in a typical place, normal mobility, wavy contours; the right kidney is 10.0*5.5, the parenchyma is homogeneous 16 mm, PCS is not expanded, the left kidney is 10.0*5.7 cm, the contours are even, the parenchyma is homogeneous 17.0 mm, PCS is not expanded. No pathological formations were found in the projection of the adrenal glands. The spleen is not enlarged 10.2*6.1, the structure is homogeneous. Conclusion: hepatomegaly, diffuse changes in the liver, pancreas. A significant amount of fluid is located in the right pleural cavity. Ascites.
FLG OGK from 02/06/2014: in the lungs, the phenomena of venous congestion (expressed). The roots of the lungs are sealed due to the vessels. In the right pleural cavity, the encysted fluid is projected at the level of the 15th rib (counting along the anterior segments). The heart is significantly expanded due to all departments. Atriovasal angles are raised (fluid in the pericardium). The aorta is sealed.
Results of laboratory researches:
Analysis of urine:
Indicator
05.02
18.02
Color
Yellow
Yellow
Transparency
Slightly cloudy.
Weak - cloudy.
Specific Weight
1020
1020
Reaction
5.5
6.5
Protein (g/l)
no
no
Sugar
no
no
Urobilin
3.2 umol\l
16 umol\l
Leukocytes in p/
s 2-3-3
2-3
Erythr. unchanged in p/
s 3-4-6
0-1
Erythr. Vyschi. In p / sp
Epithelium pl in p / sp.
up to 5 p/sp
1-2-4 p/sp
Bacteria
1 CBC
:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
MSN
ESR, mm/h
Э
%
Б
%
Лф
%
М
%
Пя
%
Ся
%
04.02.
122
4,62
6,3
6
2
24
6
3
65
05.02
127
4,67
4,7
6
1
22
5
2
70
10.02.
123
4,53
5,6
10
4
3
20
6
4
63
17.02
118
4,29
6,2
7
2
25
6
1
66
Biochemical blood test:
Name
Unit of measure.
Norm
04.02.
10.02
17.02.
18.02
Creatinine
µmol/l
53-124
0.10
0.10
0.19
0.13
Urea
Mole/l
2.5-6.4
12.0
12.3
25.3
26.7
Cholesterol
Mole/l
3.7-6.0
2 .75
1.05
Triglycerides
Mole/L
0-2.37
1.00
1.1
HDL
mmol/L
0.78-2.33
0.97
LDL
ratio
1.9 – 4.4
1.32
VLDL
ratio
0.6 – 1.2
0.46
0.5
Total protein
G/l
63.0-87.0
73
73
62
Calcium
Mole/l
2.1-2.5
2.19
2.15
2.43
Potassium
Mole/l
3.5-5.1
4.78
3.51
4.35
4.86
Sodium
Mole/l
136-145
137.7
146 ,8
142.6
141.9
Prothrombin
%
70-120
48%
61%
72
Fibrinogen
Mg/dl
200-400
2.64
411
CK
U/l
10.0-160.0
52
AST
U/l
11.0-50.0
16
15
ALT
U/l
11 -50
13
9
alkaline phosphatase
U/l
45 - 129
121
Amylase
U/l
30 - 118
52
Uric acid
µmol/l
150-420
655
193
Glucose
Mole/l
4.2-6.4
5.97
4.0
8.64
SK-MB
Mole/l
0-25
10.5
HBs antigen
+
+
Hb A%
7.11
-
INR
2-3
1.55
1.31
albumin
g/l
30-55
40.47
LDH
U/l
120-246
220
o. bilirubin
umol/l
6.8-26
26.9
14.2
GGTP
U/l
8-63
81
Aβ (II) Rh (+) positive (10.02.14 g).
Currently, using the available therapeutic methods of treatment, an unstable, maximum possible compensation for the insufficiency of internal organs and metabolic processes has been achieved. Taking into account the severity of post-infarction myocardial remodeling, severe systolic dysfunction of the left ventricle, lack of prospects for surgical treatment and high risk of mortality during surgical intervention from coronary angiography, active fibrinolytic therapy, it was decided to abstain.
The patient is discharged in a state of moderate severity under the supervision of specialists from the clinic at the place of residence. Body weight at discharge 71.6 kg.
Recommended:
1. Supervision by a cardiologist, endocrinologist, hepatologist at the place of residence.
2. Consultation with a cardiac surgeon-arrhythmologist to resolve the issue of implanting a three-chamber cardioverter-defibrillator (CRT)
3. Diet, normalization of work and rest. Limit salt and liquid intake. Self-monitoring of blood pressure and heart rate, thermometry, body weight.
4. With an increase in body weight over 76 kg - control of the ultrasound of the abdominal cavity and the decision on hospitalization!
5. Control of the general analysis, the level of urea, blood potassium 1 time per month
6. X-ray control of the right chest cavity and ultrasound of the abdominal cavity 1 time per month
7. Continue taking:
• Tab. Digoxin 0.00025 ½ tablet daily in the morning
• Tab. Carvedilol 12.5 mg 1 tablet 2 times a day continuously.
• Tab. Prestarium A 0.005 ½ tablet in the evening constantly.
• Tab. Furosemide 2 tablets 3 times a day continuously
• Tab. Veroshpiron 25 mg 2 tablets 4 times a day continuously.
• Tab. Hepa-Merz inside, after meals, 1 sachet of granulate, previously dissolved in 200 ml of liquid, 2 times a day for a long time.
• Caps. Ursosan 2 capsules 2 times a day for a long time
• Suspension Duphalac 5 ml 2 times a day
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
EXECUTIVE SUMMARY
CASE HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1978
Was on inpatient treatment (in the day hospital mode)
in the clinic of hospital therapy
Total treatment days were 14
The final diagnosis was established ICD code I 11.9
Diagnosis:
First stage hypertension, (AH-3, the risk of CVC is moderate). Initial manifestations of cerebrovascular insufficiency in the form of scattered neurological symptoms and pseudoneurotic syndrome. Left-sided scoliosis of the first degree, osteochondrosis of the thoracic spine without dysfunction. Shoulder periarthritis. Myopia 3.0 D in both eyes
A disability certificate was not issued.
Ability to work restored
Total exposure dose 0.52 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, _____ disability group, degree of disability _______________________________, other _____________________________________________
Outcome: discharged on improvement, discharged on recovery, transferred to another medical institution ( what) ____________________, transferred to rehabilitation treatment (where) _____________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a medical
examination
.
Complaints: headaches mainly in the occipital region of the head, episodic dizziness, absent-mindedness after psycho-emotional stress; fast fatigue; decrease in performance.
Medical history: Episodic headaches against the background of high blood pressure have been noted since 2007, but he did not seek medical help due to fear of being dismissed from military service. Upon admission to the VATT in 2008, the VVK was diagnosed as “healthy”. After admission, against the background of increased psycho-emotional stress, headaches became more frequent. On the recommendation of friends, he began to periodically measure blood pressure, while he noted a stable increase in blood pressure at the level of 140/100 mm Hg. Art. with periodic increases up to 170/100 mm Hg. In 2009, due to a significant increase in blood pressure (220/140 mmHg), he was hospitalized in 17 m / o 442 OVKG from February 18 to March 10, 2009, with a diagnosis of "Hypertension of the first stage (borderline). Hypertensive crisis from 17.02.2009, stopped with medication” (discharge summary No. 3434). After discharge, he does not take regular therapy. Occasionally, with an increase in blood pressure over 150/100 mm Hg. independently takes captopril with a moderate effect (“working” blood pressure 140/90 mm Hg).
A real deterioration in well-being over the past month, when rapid fatigue began to appear with previously tolerated physical exertion, with psychoemotional stress, frequent rises in blood pressure up to 190/110 mm Hg began to be noted, headaches with nausea developed, which required additional intake of antihypertensive drugs. funds (captopril up to 100 mg under the tongue).
Independently applied to the medical service 104 CDC, from where, given the inadequacy of the self-treatment, he was sent for hospitalization in order to diagnose and select adequate therapy.
Objective status: Height 187 cm. Body weight 95 kg. Chest circumference (calmly) 118 cm. The general condition is satisfactory. Consciousness is clear, contact, adequate. The position is active. The physique is correct, corresponds to age and sex. Normosthenic physique, increased nutrition (BMI 27.2). The elasticity of the skin is not changed. Subcutaneous tissue of a homogeneous consistency, no pastosity. The hairline is developed in accordance with age and sex. Hair and nails are not changed. The shape of the neck is normal, its contours are even. The thyroid gland is not visually determined, not palpated. Peripheral lymph nodes are not enlarged. The muscular system is developed satisfactorily. On palpation of the radial arteries, the pulse is synchronous, the same on both hands, rhythmic, with a frequency of 72 beats. per minute, satisfactory filling, uniform, tense, the vascular wall outside the pulse wave is not palpable. Blood pressure: on the right shoulder - 150/100, on the left shoulder - 150/100 mm Hg. Art. Limits of relative cardiac dullness: right and upper are normal; left - 0.5 cm medially from the left mid-clavicular line. The width of the vascular bundle does not extend beyond the edges of the sternum. The number of heartbeats corresponds to the pulse. Heart sounds are muffled, their ratio is not changed. The chest is of the correct form, symmetrical. The respiratory rate is 14 per minute, the respiratory movements are rhythmic, both halves of the chest evenly participate in the act of breathing. Voice trembling is expressed moderately, the same on the symmetrical parts of the chest. With comparative percussion over the entire surface of the lungs, a clear pulmonary sound is determined, which is the same in symmetrical sections of the chest. With topographic percussion, the lower borders of the lungs, the width of the Krenig fields are within normal limits. The mobility of the lower edge of the lungs is 5 cm on both sides. On auscultation over the lungs, breathing with a hard tone, wheezing is not heard. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. the width of the Krenig fields is within the normal range. The mobility of the lower edge of the lungs is 5 cm on both sides. On auscultation over the lungs, breathing with a hard tone, wheezing is not heard. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. the width of the Krenig fields is within the normal range. The mobility of the lower edge of the lungs is 5 cm on both sides. On auscultation over the lungs, breathing with a hard tone, wheezing is not heard. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. The mobility of the lower edge of the lungs is 5 cm on both sides. On auscultation over the lungs, breathing with a hard tone, wheezing is not heard. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. The mobility of the lower edge of the lungs is 5 cm on both sides. On auscultation over the lungs, breathing with a hard tone, wheezing is not heard. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m.
As a result of the treatment: regimen, diet No. 10, β-blockers (Betaloc ZOK - 25 mg 1 time per day), ACE inhibitors (Enalapril 5 mg 2 times a day), Mildronate 500 mg 2 times a day, Aspicor 100 mg in the morning, the state of health improved , BP stabilized at the target level.
The results of instrumental studies:
ECG No. 1271 dated 06/01/2011: sinus rhythm with a frequency of 62 per 1 minute, EOS is normal.
ECHO-KG from 06/02/11: MZHP-11mm, ZS-11mm, KDRLV-44mm, KSRLZh-31mm, Vlzh=85/37 ml, EF-57%, FU-30%, UO-47 ml, LP- 36×48×51mm, PP-40×45mm, RV-24mm, E/A=0.81 Myocardium is symmetrically thickened. The kinetics is not broken. The cavities are not dilated, the cavities are free in the visible areas. The aorta is slightly locally compacted. Systolic function is not broken. Diastolic dysfunction of the rigid type. Regurgitation applied to the MK and TK. Pulmonary blood flow is not changed. The pericardium is intact.
Ultrasound of the abdominal organs No. 903 dated 06/03/2011: the liver is slightly enlarged, the right lobe: 14 cm; left 9.0 cm, smooth contours, homogeneous structure, increased echogenicity; intrahepatic vessels are not dilated; portal vein 10 mm, hepatic veins 8 mm (up to 10 mm). Intrahepatic bile ducts are not dilated. Distal attenuation of the ECHO signal. The gallbladder is reduced after eating, stones are not visualized. The pancreas is located indistinctly, not enlarged, the contours are clear, even, the structure is heterogeneous, echogenicity is increased; Wirsung's duct is not dilated. The kidneys are of normal size (right 11×4.8 cm, left 11×5.3 cm), normal location, with even contours, homogeneous parenchyma 18-22 mm thick, cavitary systems are not dilated. The spleen is 10×5.4 cm in size, not enlarged. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: examination after eating, moderate hepatomegaly.
24-hour monitoring of ECG and blood pressure according to Holter against the background of selected therapy ID:L6602 dated 06/07/2011: during the observation period, sinus rhythm was recorded with a heart rate of 55 to 163 per 1 minute, a decrease in heart rate at night is sufficient. Average heart rate 85/91/74 in 1 minute. Single supraventricular extrasystoles were registered (23 in total). When performing the planned load (staircase test, 180 steps), the heart rate reached 163 in 1 minute, while palpitations, shortness of breath, and weakness in the legs were subjectively noted. Ischemic changes in the ST segment were not detected.
Average systolic and diastolic blood pressure in the daytime, their variability during the day within acceptable limits. Mean systolic BP at night is characteristic of mild stable hypertension, mean diastolic BP at night is characteristic of moderate stable hypertension.
At night, systolic blood pressure and diastolic blood pressure decrease insufficiently (nondipper). Episodes of hypotension were not registered. There is an increase in the rate of the morning rise in systolic blood pressure
. Plain radiograph of the chest No. 1665 dated 06/02/11: in the lungs without focal and infiltrative changes. The heart is not enlarged.
On spondylograms of the thoracic spine in 2 projections No. 1754 dated June 10, 2011: left-sided scoliosis with an angle of deviation from the vertical axis of 90 with the center of the arc at the level of Th4. The height of the disc Th5-6, Th6-7 is reduced, the end plates are compacted, marginal exophytes are 0.1 cm in the anterior parts of the bodies Th 5,6,7 in the projection of the discs. Conclusion: X-ray signs of left-sided scoliosis of the 1st degree (according to Chaklin), osteochondrosis Th5-6, Th6-7, motor segments.
On the radiograph of the left shoulder joint, no bone changes were found.
Results of laboratory tests:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
Rt,
‰
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
02.06
160
5.4
7.2
13.8
4
260
2
38
9
1
56
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar , mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
02.06
clear
1030
yellow
6.0
no
no
no
no
no
no
0-2
no
0-2
no Rehberg's
test - a variant of the norm
Creatinine clearance according to the Cockcroft-Gault formula = 186 ml / min.
GFR according to MDRD = 98 ml / min / 1.73
m2 Coprogram dated 06/02/2011 – without features
Safety factors [HBsAg, Anti-HCV (Core-n NS3-p NS4-n; Core-n NS4-p NS5-n), AT-HIV 1 and 2; Microreaction with cardiolipin antigen (RW)] from 02.06.2011. - negative.
Biochemical blood test:
Name
Unit. rev.
Norm
03.06
Creatinine
mmol/l
53-124
100
urea
mmol/l
2.5-6.4
7.1
Potassium
mmol/l.
3.5-5.1
4.44
glucose
mmol/l
3.9-6.3
Cholesterol
mmol/l
3.7-6
4.61
HDL
mmol/l
0.78-2.33
0.89
LDL
U
1 .9-4.4
3.33
VLDL
Unit.
0.6-1.2
0.39 Atherogenic
coefficient
Unit.
0-3
4.18
TG
mmol/l
0-2.37
0.86
GGTP
U/L
11-63
18.8
ALT
U/L
8.4-53.5
39.3
AST
U/L
7-39.7
19
total protein
g/l
63-87
72
As part of an in-depth medical examination consulted:
• Surgeon - healthy
• Neurologist - Initial manifestations of cerebrovascular insufficiency in the form of scattered neurological symptoms and pseudoneurotic syndrome.
• Optometrist - myopia in 3.0 D, hypertensive angiopathy of the retina in both eyes.
• Traumatologist - left-sided scoliosis of the first degree, osteochondrosis of the thoracic spine without dysfunction. Shoulder periarthritis.
• Dentist - needs oral hygiene (36, 37, 45, 47).
The goals of hospitalization have been achieved - the "target level" of blood pressure has been reached - 120-130 / 70-85 mm Hg.
Discharged in a satisfactory condition under the supervision of doctors of the unit
Recommended:
1. Supervision of the doctor of the unit in accordance with DM-1.
2. Sanitation of the oral cavity in a planned manner in the outpatient department.
3. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
4. Limit the intake of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
5. Continue taking:
a. Tab. Lozap 50 mg ½ tab. in the morning all the time.
b. Tab. Vinpocetine 0.005 - 1 tab 3 times a day for 1 month.
c. Caps. Movalis 0.015 – 1 capsule in the morning for 3 weeks
d. Ointment Voltaren - lubricate the area of the left shoulder 2 times a day for 3 weeks.
6. If conservative therapy of humeroscapular periarthritis is ineffective for 3 weeks, routinely perform MRI of the left shoulder joint, re-examination of the traumatologist of the clinic of Military Traumatology and Orthopedics of the Military Medical Academy with the results of
MRI
Form
12_Un
. St. Petersburg, Suvorovsky pr., 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY No. ARCHIVE No. _________
Surname, name, patronymic: born in 1929
Was on inpatient treatment (in day hospital mode)
in the clinic of hospital therapy
Total days of treatment 8
The final diagnosis was established. ICD code I.24
Diagnosis:
Main: ischemic heart disease. Progressive angina pectoris from 01.11.2010. with stabilization at the level of 3 FC from 12.11.2010. Atherosclerosis of the aorta and coronary arteries Atherosclerotic and post-infarction (of unknown age) cardiosclerosis.
Complications of the underlying disease: Blockade of the anterior branch of the left leg of the bundle of His. Paroxysmal form of atrial fibrillation, without exacerbation. NK stage 2B, CHF 3 FC
Concomitant: Hypertension stage III. (The risk of CVD is extremely high). Diabetes mellitus of the second type, moderate degree, is compensated. Diabetic neuropathy of the lower extremities of the sensory type. Alimentary-constitutional obesity of the 2nd degree, stable phase. Fatty hepatosis without impaired liver function. Dyscirculatory encephalopathy II st. mixed (atherosclerotic, hypertensive, dibetic) genesis. Diffuse nephroangiosclerosis of mixed (atherosclerotic, hypertensive, diabetic) genesis. Microalbuminuria. Chronic pyelonephritis in the acute phase. Chronic kidney disease stage 3. HPN - stage 1a. Focal pneumofibrosis C1-C2 of the right lung. Chronic pancreatitis without exacerbation.
A disability certificate was not issued.
Ability to work restored
Total exposure dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicization, disability, _____ disability group, degree of disability _______________________________, other _____________________________________________
Outcome: discharged on improvement, discharged on recovery, transferred to another medical institution (what) ____________________, transferred to rehabilitation treatment (where) _______________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a medical
examination
.
Complaints: pressing and constricting pain behind the sternum, shortness of breath, mainly of an inspiratory nature, arising from slight physical exertion (walking 50-70 m or climbing 10 steps), stopped by rest for 5 minutes. or taking nitroglycerin; increase in blood pressure up to 180/125 mm. rt. Art., accompanied by a dull headache without a clear localization; discomfort in the left half of the chest against the background of a feeling of interruptions in the work of the heart, moderate general weakness, increased fatigue; memory loss.
Anamnesis of the disease: For a long time suffers from ischemic disease and hypertension, type 2 diabetes mellitus. Repeatedly underwent inpatient treatment in various hospitals of the city. The last hospitalization was in March 2010 in the 26th hospital in St. Petersburg with a diagnosis of progressive angina pectoris (medical documentation not provided). Regularly takes: amlodipine 10+5 mg/day, sotalol 80+40 mg/day, hypothiazide 25 mg/day, diroton 5 mg in the evening, cordarone 100 mg/day, preductal 2+2 tab/day, diabetone MV 30 mg in the morning and siofor 500 mg in the evening. Against the background of ongoing therapy, hemodynamics is stable at the "target" level of blood pressure 130-140/60-70 mm Hg, pulse 56-66 per minute. Over the past 2 weeks, she began to occasionally notice paroxysms of a feeling of palpitations with interruptions in the work of the heart that occur acutely against the background of relative well-being, lasting up to 6 hours, stopping on their own or after taking 400 mg of cordarone. During the last 10 days, she began to notice the occurrence of angina attacks with previously tolerated physical exertion, which required the use of nitroglycerin more often than usual. Given the ineffectiveness of self-administered therapy, she called an ambulance team, which was hospitalized in the ICU of the hospital therapy clinic.
As a child, she suffered from tuberculosis, complicated by pleurisy, in the region of the upper lobe of the right lung in childhood. Withdrawn from the dispensary.
Objective status: general condition of moderate severity, due to signs of instability of the coronary blood flow., heart rate 72 per minute, no deficit, rhythmic pulse, auscultatory heart sounds are muffled, the borders of the heart are moderately expanded to the left, blood pressure 130/80 mm Hg, in lungs breathing is vesicular, "stagnant" wheezing in the lower lobe of the right lung; the abdomen is soft, painless on palpation, tapping on the lumbar region is painless on both sides. Pastosity of the shins, moderate swelling of the ankle joints, feet
As a result of the treatment: regimen, diet No. 10, metabolic therapy (polarizing mixture: NaCl 0.9% -200.0, Sol.KCl 5% -20.0, Sol.MgSO4 25% -10.0, Sol.Insulini 4ED -N3), diuretics (furosemide 40 mg IV once, hypothiazide 25 mg No. 2), amlodipine 15 mg / day, ACE inhibitors (Enalapril 5 mg in the evening), Aspicor 100 mg in the morning, Sotalol 120 mg / day, feeling improved , coronary blood flow is stabilized, manifestations of heart failure are stopped, blood pressure is stabilized at the target level (120-135/80-90 mm Hg).
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuc., *109/l
Ht,
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
12.11.10
138
4.44
6.5
41.0
25
287
3
1
38
8
2
48
18.11.10
140
4.59
7.5
42.4
30
361
5
24
5
2
64
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
12.11
sl.mut
1015
light yellow
5.5
no
no
no
no
no
no
0-1
no
3-5-7
0-0-1
Reberg's test dated 15.11.10. - blood creatinine 0.09 mmol / l (0.044-0.132); urine creatinine - 7.92 mmol / l (5.3-17.6), diuresis in 1 min - 0.5 ml (0.75-1.0), glomerular filtration 44 ml (70-120), tubular reabsorption - 98.9 (97-99%), diuresis per day 710 ml (without stimulation).
Nechiporenko test from 11/13/2010. – leukocytes 5.25×106/l, erythrocytes 2.0×106/l
Zimnitsky's test from 11/17/2010. – daily diuresis 1250ml (580/670ml), bw 1010-1015
Urinalysis for microalbuminemia. 69.4 mg/l (N up to 25 mg/l)
Coprogram dated 11/15/2010 – without features
Safety factors [HBsAg, Anti-HCV (Core-n NS3-p NS4-n; Core-n NS4-p NS5-n), AT-HIV 1 and 2; Microreaction with cardiolipin antigen (RW)] from 11.11.2010. - negative.
Lipoproteins from 11/12/2010:
Alpha 21.35% range (13.00-44.00)
Pre Beta 22.36% range (6.90-42.50)
Beta 56.29% range (30.30-62, 70)
Analysis of daily fluctuations in blood glucose levels from November 12, 2010:
08:00 - 6.4 mmol / l,
10:00 - 9.6 mmol / l,
12:00 - 7.2 mmol / l.
Biochemical blood test:
Name
Unit. rev.
Norm
12.11.10
18.11.10
Creatinine
mmol/l
53-124
72.4
80.0
Na
mmol/l
130-150
145.0
144.6
K
mmol/l.
3.5-5.1
4.3
4.78
serum iron
mmol/l
10.5-25
10.1
Cl
mmol/l
98.0-107.0
115.2
CS
mmol/l
3.7-6
5 .31
TG
mmol/l
0-2.37
1.26
HDL
U
0.60-1.2
0.58
ALT
U/L
8.4-53.5
30,9
АСТ
U/L
7-39.7
20,5
Протромбин по Квику
%
70-130
90
Глюкоза
ммоль/л
3,90-6,20
5,53
КФК
U/l
10-160
95,6
Фибриноген
г/л
2,0-4,0
4,82
общий белок
г/л
63-87
72,8
общий билирубин
ммоль/л
6,8-26
14,0
Результаты инструментальных исследований:
ECHO-KG No. 998 dated 11/17/2010: Aorta: diameter 33 mm, sealed, aortic valve opening 16 mm, ascending Ao 30 mm, MZHP-12mm, ZS-12mm, KDRLZh-56mm, KSRLZh-38mm, PV-55% , FU-29%, LP-41×50×60mm, PP-46mm, KDRPZH-28×4mm, LA=22mm, E/A=0.81. Symmetrical eccentric LV myocardial hypertrophy. The kinetics is not broken. Dilatation of the LA cavity. The aorta is sealed. Fibrous annulus AK, MK, their valves are sealed. The blood flow is laminar. LV diastolic dysfunction. Applied regurgitation on MK, TK. Pulmonary blood flow is not changed. The pericardium is not changed.
ECG #2334 dated 11/18/2010. Sinus rhythm. A sharp deviation of the e.o.s. to the left. Blockade of the anterior superior branch of the left leg of the bundle of His. Intra-atrial blockade Ι degree. Left ventricular hypertrophy. Cicatricial changes in the anterior septal region. Violation of repolarization processes in the region of the posterior wall.
X-ray of the chest organs No. 3033 dated 11/19/2010: Conclusion: On the plain radiograph of the chest cavity organs in the right lung in the C1-2 projection there are dense focal shadows, massive pleural layers in the projection of the upper lobe of the right lung. The roots of the lung are fibrously changed. Calcified paratracheal lymph nodes on the right. The diaphragm is flattened, sinuses are not fully disclosed. The heart is not enlarged. The aorta is compacted and deployed.
Ultrasound examination No. 1358 dated 11/15/2010: The liver is enlarged, the right lobe is 13.4 cm, the left lobe is 7.4 cm, the contours are even, the structure is homogeneous, the echogenicity is increased, the vascular pattern is depleted, the vessels are not dilated, the portal vein is 8 mm (H<13 mm), hepatic veins are normal, intrahepatic bile ducts are not dilated. There are no volumetric formations. The gallbladder was removed (after cholecystectomy). Common bile duct 4-5 mm. The pancreas is not clearly located; the contours are not clear, not even, the head is 27 mm, the body is 26 mm, the tail is 28 mm, echogenicity is increased, the structure is homogeneous, the Wirsung duct is not dilated, there are no volumetric formations. The kidneys are of normal size (right 11.5×4.5 cm, left 11×5 cm), the location is typical, mobile, fibrous contours, the parenchyma of the right kidney is homogeneous 12 mm thickened to 22 mm in the upper pole. The left kidney parenchyma is not homogeneous 13 mm-7-14 mm calcification in the parenchyma 7 mm. The pyelocaliceal region is not expanded. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 9.0×3.8 cm, the structure is homogeneous. Conclusion: Diffuse changes in the echostructure of the liver (hepatosis), pancreas (lipomatosis) condition after cholecystectomy.
The goals of hospitalization were achieved - coronary blood flow was stabilized, manifestations of heart failure were stopped, blood pressure was stabilized at the target level (120-135/80-90 mm Hg). working ability is restored.
Discharged in a satisfactory condition under the supervision of doctors at the clinic at the place of residence
Recommended:
7. Observation of a cardiologist, endocrinologist.
8. Control study of general urine analysis after 1 month. Glucose control (on an empty stomach) once a week.
9. Observe the drinking regime of 1-1.5 l / day; restriction of salt intake (no more than 3 g per day), hypoglycemic diet.
10. Limit the use of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes).
11. Continue taking:
a. Tab. Amlodipine 10 mg - 1 tablet in the morning and ½ tablet in the evening continuously.
b. Tab. Enalapril 10 mg - ½ tablet in the evening constantly.
c. Tab. Hypothiazide 50 mg - 1 tablet 1 time per week.
d. Tab. Thrombo ASS 0.1 - 1 tablet in the morning constantly.
e. Tab. Sotahexal 80 mg - 1 tablet in the morning and ½ tablet in the evening constantly.
f. Tab. Diabeton MB 30 mg - 1 tablet daily in the morning.
g. Tab. Metformin (Siofor) 500 mg - 1 tablet in the evening constantly.
h. Tab. Nitroxoline 50 mg - 2 tablets 4 times a day for 30 days.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr., 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY № ARCHIVE №_________
Surname, name, patronymic: born in 1960 (50 years old),
was hospitalized (in the day hospital mode)
in the hospital therapy clinic
Total days of treatment 8
The final diagnosis was established ICD code I.45
Diagnosis
Atherosclerosis of the aorta and coronary arteries, atherosclerotic and myocardial cardiosclerosis. Dissociation of the atrioventricular node into 2 channels. Paroxysm of reciprocal av-nodal tachycardia (PRAVUT) from 05/09/2011, complicated by arrhythmogenic collapse, was stopped by EIT on 05/09/2011. Mitral valve insufficiency of the first degree. CHF 2A st, 2 FC.
Hypertensive disease of the second stage (Risk of CVE 4).
Systemic lupus erythematosus, chronic progressive course with damage to the skin (Raynaud's syndrome, ecchymosis), joints (arthralgia, osteoporosis of small joints of the hands), myocardium (myocarditis cardiosclerosis), kidneys (secondary nephropathy of autoimmune origin, chronic kidney disease stage 2 (GFR according to MDRD 62 ml / min / 1.73 m2), CRF-0), lungs (diffuse pneumofibrosis, emphysema), nervous system (ataxia, dysarthria, headaches, mnestic disorders), lymphadenopathy, active phase with a moderate (II) degree of activity, FNS- I, DN-0.
Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of unexpressed bilateral pyramidal-cerebellar insufficiency and moderately pronounced astheno-neurotic syndrome.
Widespread osteochondrosis of the spine with moderate pain syndrome in the stage of unstable remission.
Initial cataract, simple myopic astigmatism of the direct type, hypertensive angiopathy of the retina in both eyes.
Subserous uterine myoma of small size, cicatricial deformity of the cervix, bilateral fibrocystic mastopathy.
Secondary partial adentia. Chronic compensated tonsillitis. Lateral pharyngitis.
Condition after posterior crurorrhaphy and fundoplication. gastroptosis.
Chronic iron deficiency anemia of mild severity.
A disability certificate was not issued.
Ability to work restored
Total radiation dose 5.72 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity
, disability, established _____ disability group, degree of disability _______________________________, other _____________________________________________ where) _________________________________________________________________________
Examined by MSEC: yes (no) (group 3 disability, degree of disability ______________) _______________________________________________________________
Complaints at admission: pronounced palpitations, "lump in the throat", pronounced weakness, pressing pain in the region of the heart, pain in the shoulder, knee and small joints of the hands, their stiffness in the morning for 2 hours, swelling of the face in the morning, internal discomfort, itching of the skin of the face, episodic sharp chilliness in the fingers and toes; nausea when taking medications, heaviness in the epigastric region when eating; weight loss within 4 months by 10 kg.
Disease history:
She fell ill acutely in November 2005, when, against the background of relative well-being, severe morning stiffness, soreness, redness and swelling appeared in the area of small joints of both hands, shoulder, elbow and knee joints, fever up to 400C, sweating, severe general weakness, and rapid fatigue. On November 14, she was examined by a general practitioner, and a course of anti-inflammatory therapy (diclofenac retard, prednisone 30 mg/day) was prescribed, which resulted in a significant improvement in her state of health. She underwent inpatient treatment at military unit 25515 with a diagnosis of rheumatoid arthritis, seropositive, articular form. She received cytostatic therapy, mini-pulse therapy with methylprednisolone, movalis, physiotherapy with a positive effect. In the future, against the background of outpatient cytostatic therapy (methotrexate 7.5 mg/week, prednisolone 10 mg/day), pain, heaviness in the epigastrium, left and right hypochondria appeared, and therefore in May 2006 she independently refused to take medications. Against the background of refusal of treatment, the pain in the joints intensified, pains in the right elbow joint joined. She resumed taking medications again without a positive effect.
26.06.06 was hospitalized in the rheumatology department of the NLMK Medical Unit, where she was diagnosed with systemic lupus erythematosus for the first time. Received treatment: methotrexate 10 mg/week, prednisolone 20 mg/day, movalis, chimes, pentoxifylline, physiotherapy with a positive effect. However, against the background of the constant intake of these drugs, at the end of October 2006, pain in the joints increased again, hyperemia of the back of the nose and cheeks, itching of the skin of the face, swelling on the face and hands, periodic pain behind the sternum and in the left half of the chest, palpitations, shortness of breath with slight physical exertion, general weakness, sore throat, pain in the lumbar region during physical exertion.
In 2008, 2009, she underwent inpatient treatment using efferent therapy methods for repeated exacerbations of systemic lupus erythematosus with a moderate effect.
Over the past three years, he has been noted an increase in blood pressure up to 170/110 mmHg, accompanied by dizziness, nausea, and palpitations. From the same time - unsteadiness when walking, numbness in the fingers of the upper limbs.
In May 2010, she underwent inpatient treatment for progressive angina pectoris. Over the next year, there were attacks of stable angina, characteristic of level 2 FC. Occasionally noted attacks of palpitations, mainly at night, lasting up to 20 minutes, stopped on their own.
Episodic pain in the epigastric region notes for ten years, was treated independently, taking a large number of antisecretory and antacid drugs, with a temporary positive effect. On December 22, 2010, laparoscopic surgery was performed to eliminate the incarceration of the paraesophageal hernia (laparoscopic posterior crurorrhaphy, Nissen-Rosetti fundoplication. K 44.9).
At the time of hospitalization, he regularly takes: Prednisone 5 mg - 2 tab. in the morning with breakfast until 9 am - all the time; Methotrexate 2.5 mg - 1 tab. 3 times a week (Saturday morning and evening 1 tab., Sunday morning 1 tab.) - constantly; Sorbifer durules - 1 capsule in the morning; Movalis - 1 suppository in the morning with exacerbation of the articular syndrome; Concor-core - 1 tab. in the morning.
Real deterioration: on May 9, 2011, at about 9 am, I woke up from pressing pain in the left side of my chest, pronounced palpitations, and significant general weakness. Independently took the entire list of medications taken without effect. Given the ineffectiveness of self-therapy, she called an ambulance team, which was taken to the hospital therapy clinic for diagnosis and treatment with a diagnosis of "first-time detected paroxysm of atrial fibrillation."
Objective status at admission: Height 164 cm, body weight at admission 64 kg. The general condition is severe, due to signs of electrical instability of the myocardium, arrhythmogenic shock. The position is passive. Satisfactory nutrition: BMI 24.4 kg/m2. The skin in the "décolleté" area is hyperpigmented, ecchymosis on the skin of the face, chest, abdomen, and extremities. Peripheral (submandibular, maxillary, cervical and axillary) lymph nodes are moderately enlarged, painless on palpation, not soldered to surrounding tissues. Movement in the joints is not limited, in the ankle, knee and small joints of the hands are moderately painful, edematous. On palpation of the radial arteries, the pulse is non-synchronous, the same on both hands, rhythmic, with a frequency of 158 beats. per minute, weak filling, uniform, weak tension, the vascular wall is palpated outside the pulse wave. The monitor registers supraventricular tachycardia with a heart rate of 158/min. SatO2=92%. Blood pressure: on the right shoulder - 80/60, on the left shoulder - 80/60 mm Hg. Art. Limits of relative cardiac dullness: right and upper are normal; left - on the left mid-clavicular line. The heart sounds are deaf, over the apex of the heart the 1st tone is weakened, systolic murmur at the apex. The respiratory rate is 24 per minute. On auscultation over the lungs, breathing is hard, multiple congestive rales are heard in the lower lobes of both lungs. The abdomen is soft and painless. The size of the liver according to Kurlov is 10x9x7 cm. Tapping in the lumbar region is painless. left - on the left mid-clavicular line. The heart sounds are deaf, over the apex of the heart the 1st tone is weakened, systolic murmur at the apex. The respiratory rate is 24 per minute. On auscultation over the lungs, breathing is hard, multiple congestive rales are heard in the lower lobes of both lungs. The abdomen is soft and painless. The size of the liver according to Kurlov is 10x9x7 cm. Tapping in the lumbar region is painless. left - on the left mid-clavicular line. The heart sounds are deaf, over the apex of the heart the 1st tone is weakened, systolic murmur at the apex. The respiratory rate is 24 per minute. On auscultation over the lungs, breathing is hard, multiple congestive rales are heard in the lower lobes of both lungs. The abdomen is soft and painless. The size of the liver according to Kurlov is 10x9x7 cm. Tapping in the lumbar region is painless.
As a result of the treatment: According to vital indications at 11:45 09.05.2011, taking into account the significant hemodynamic significance of tachycardia paroxysm, transthoracic electrical cardioversion was performed - sinus rhythm was restored.
Regime, diet No. 10, metabolic, hypotensive, antianginal, antiarrhythmic, vascular therapy, cytostatics, glucocorticosteroids, health improved, heart rate stabilized, manifestations of heart failure stopped, blood pressure stabilized at the target level (120-135 / 80-90 mmHg. Art.).
The results of laboratory studies in dynamics:
General clinical analysis of blood:
Date
Hb, units.
Er., *1012/l
MCV
fl
Rt
‰ Leuc
., *109/l
Ht
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
10.05
118
5.35
74
5
5.5
39.8
27
302
4
45
7
2
42
Anisopoikilocytosis-1, hypochromia - 1
16/05
109
4.67
75
6
5.6
35
20
258
1
41
5
4
49
Anisopoikilocytosis-1, hypochromia-1
Biochemical blood test:
Name
Unit. rev.
Norm
12.05
Name
Unit. rev.
Norm
12.05
Creatinine
mmol/l
53-124
80
CS
mmol/l
3.7-7
5.75
Urea
mol/l
3-8.4
6.8
TG
mmol/l
0-2.37
PTI
%
70-120
101
T3
nmol/l
1.3-3.1
1.26
Fibrinogen
g/l
2.0-4.0
4.43
T4
nmol/l
66-181
1.56
Total protein
g/l
63-87
79
TSH
uIU/l
0.27-4.2
Glucose
mmol/l
4.2-6.4
4.97
AT to TPO
U/ml
up to 60
47.4
Albumin
g/l
30-55
42.60
AT to TG
U/ml
up to 60
29.8
Vol. bilirubin
µmol/l
6.8-26
7.5
Cl
mmol/l
95-108
111
ALT
U/L
8.4-53.5
18
Na
mmol/l
130-150
148
AST
U/L
7-50.0
14
K
mmol/l .
4-6
4.29
ALP
U/l
45-129
75
Fe (serum)
mmol/l
10.5-25.0
7.17
CPK
U/l
36-160
26
CPK-MB
U/l
0.0-25.0
Safety factors [ HBsAg, Anti-HCV (Core-n NS3-p NS4-n; Core-n NS4-p NS5-n), HIV AT 1 and 2; Microreaction with cardiolipin antigen (RW)] from 10.05.2011. - negative.
Complete
urinalysis
date
_
PH
Protein
sugar
Ley in p / z
Er. in p/z
Epit.
Salts
Slime
18.05.10
1025
clear
6.0
no
no
-
no
no
no
-
Reberg's test dated 12.05.11. - blood creatinine 0.08 mmol / l (0.044-0.132); urine creatinine - 10.55 mmol / l (5.3-17.6), diuresis in 1 min - 0.8 ml (0.75-1.0), glomerular filtration 105.5 ml (70-120), tubular reabsorption - 99% (97-99%), diuresis per day 1160 ml.
Nechiporenko test from 05/11/2011. – leukocytes 1.0×106/l, erythrocytes 0.5×106/
l – daily diuresis 1160 ml (630/530 ml), bw 1014-1022
Results of instrumental studies:
ECG No. 455 on admission dated 09.05.2011 (before EIT): Supraventricular tachycardia with a frequency of 160 bpm, normal EOS (α=650), local violation of intraventricular conduction in the posterior diaphragmatic region of the left ventricle.
ECG No. 456 (after EIT) dated May 09, 2011: Sinus rhythm with a frequency of 64 bpm, horizontal EOS (α=300), local disturbance of intraventricular conduction in the posterior diaphragmatic region, left ventricular hypertrophy.
ECHO-KG dated May 10, 2011: MZHP-9.0mm, ZS-9.0mm, KDRLZh-45mm, KSRLZh-30mm, FV-66%, FU-33%, UO-78ml, LP-33×34×40mm , PP-31×40mm, RV-24mm, E/A=0.7 LV myocardial mass 143 g, IMM 85.1 g/m2, myocardium is not thickened. The kinetics is not broken. The cavities are free, not dilated, the free leaflets of the mitral valve are thickened, there are no vegetations, the rest of the valves are not changed, on the mitral valve regurgitation stage I, on the tricuspid valve I stage. Pulmonary blood flow is not changed. Diastolic dysfunction of the left ventricle of the rigid type. The aorta is sealed. The pericardium is intact.
Transesophageal EPS No. 49 dated May 10, 2011: initially sinus rhythm with an average RR = 713 msec, VSAP 106 msec, VVFSU 793 msec, KVVFSU 80 msec, Wenckebach point 200/min, dissociation of atrioventricular conduction into 2 channels – ERP of β-path 330 ms, α-path 280 ms.
Test with a six-minute walk from 05/14/2011: 490m
Ultrasound of the abdominal organs No. 720 dated May 16, 2011: the liver is not enlarged, the right lobe: 13 cm; left 7×6cm, smooth contours, homogeneous structure, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein 12 mm, hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder is irregularly shaped (with an inflection in the neck area), dimensions 7×2.5 cm, smooth contours, walls 2 mm, stones are not visualized. The pancreas is located clearly 21x11x20mm, homogeneous structure, contours are clear, even, the structure is homogeneous, echogenicity is increased; Wirsung's duct is not dilated. Kidneys of normal size (right 11.5×4.5 cm, left 11×5 cm), normal location, with smooth contours, homogeneous parenchyma 14 mm thick on the right, 10-16 mm on the left; cavity systems are not expanded. The spleen is not enlarged, size 9, 5×4cm. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: diffuse changes in the pancreas, signs of chronic pyelonephritis.
X-ray of the chest organs in the direct and left lateral projection No. 1386 dated 05/10/2011: Conclusion: The lung fields are emphysematous, without fresh focal and infiltrative changes, the pulmonary pattern with fine mesh deformation due to diffuse pneumofibrosis. The roots are structural, no free fluid was found in the pleural cavity. The diaphragm is flattened. The heart is moderately expanded in diameter to the left due to the left ventricle, the aorta is compacted and deployed.
Radiography of the stomach No. 51 dated May 16, 2011: the esophagus is freely passable for barium suspension, its walls are elastic, mucosal folds can be traced throughout, in the lower third they are somewhat thinned. The cardia does not close completely. The stomach is hypotonic, lowered (its bottom is at the level of S1. The fornix of the stomach and the cardial section are located in the abdominal cavity. Condition after posterior crurorrhaphy and fundoplication. The walls of the stomach are elastic in all sections. The relief of the mucosa is not changed. Peristalsis is of medium depth. the loop of the duodenum is usually located.When examined after 24 hours, the contrast agent unevenly fills the loops of the colon.Most of them are in the ascending section.Gaustras are uneven, deep, spastic.Conclusion: Condition after posterior crurorrhaphy and fundoplication. gastroptosis.
On spondylograms of the thoracic spine in 2 projections dated May 16, 2011: physiological kyphosis is enhanced. Osteochondrosis of Th6-7 Th7-8 Th8-9 Th9-10 motor segments with a decrease in the height of the discs, compaction of the endplates and small marginal exophytes in the anterior sections at the same levels.
Monitor observation of ECG and blood pressure according to Holter (against the background of antihypertensive and antiarrhythmic therapy) ID: L5CO2 dated May 13, 2011: during the observation period, sinus rhythm was recorded with a heart rate of 50 to 141 per 1 minute, the decrease in heart rate at night was adequate. Average heart rate 71/77/58 in 1 minute. Registered single polytopic supraventricular extrasystoles (total 16), periodically group. When performing the planned load, the heart rate reached 141 and 132 in 1 minute, while subjectively noted palpitations, shortness of breath, weakness in the legs, ischemic changes in the ST segment were not detected. Mean systolic blood pressure during the day and mean diastolic blood pressure in the daytime, their variability is within acceptable limits, mean systolic blood pressure at night is characteristic of mild labile hypertension. At night, systolic and diastolic blood pressure decrease insufficiently (nondipper). There is an increase in the rate of morning rise in diastolic blood pressure. Episodes of hypotension were not registered.
The patient has signs of disability. Needs social security measures.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition.
A temporary disability certificate was not issued.
The goals of hospitalization were partially achieved - it needs planned hospitalization in the department of surgical arrhythmology in order to perform endocardial EPS with RFA of the slow channel of the atrioventricular node [class 1 (B) of indications of Recommendations ACC / AHA / HRS 2008, VNOA 2009].
Recommended:
75. Outpatient observation of a rheumatologist, cardiologist.
76. Annual inpatient treatment in a specialized hospital.
77. Sanatorium-and-spa treatment once a year, profile - treatment of rheumatological diseases, period - autumn, spring.
78. Consultation of an arrhythmologist-surgeon in order to resolve the issue of conducting endocardial EPS with RFA of the slow canal of the atrioventricular node [class 1 (B) indications of the Recommendations ACC / ANA / HRS 2008, VNOA 2009]
79. Dispensary observation:
a. Frequency of observations by a rheumatologist, cardiologist: - 4 times a year.
b. Examination by an ENT doctor, gynecologist, ophthalmologist, gastroenterologist - 2 times a year;
c. clinical blood test (with counting of platelets and reticulocytes), urinalysis - 6 times a year; when changing the dose of cytostatic drugs - monthly control;
d. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - at least 2 times a year;
e. x-ray (fluorography) of the chest organs 2 times a year; x-ray of the joints - according to indications;
f. a blood test for the content of antinuclear factor and antibodies to double-stranded DNA and the level of complement C3 and C4 - 3 times a year and during exacerbation.
g. Echocardiography - 2 times a year;
80. Lifestyle changes:
a. Exclusion of wearing corsets, bandages, tight belts
b. Exclusion of weight lifting more than 4-5 kg, physical exercises associated with overstrain of the abdominal muscles (including yoga classes)
81. Changing the regimen and nature of nutrition:
a. Avoid overeating, snacking, eating at night
b. Exclude from the diet drinks containing caffeine (coffee, strong tea, Coca-Cola), chocolate, products containing mint and pepper, citrus fruits, tomatoes, cabbage, legumes, onions, garlic, fried foods.
c. Do not use alcoholic drinks, carbonated mineral water.
d. Limit consumption of butter and margarine
e. After eating, take a 30-minute walk.
82. Continue taking:
a. Prednisolone 5mg - 5 tab. in the morning with breakfast (drink with kissel, low-fat yogurt) until 9 am - 4 weeks, then a gradual decrease in the dose to a maintenance dose (7.5 mg) under the supervision of a rheumatologist at the place of residence
b. Plaquenil - 1 tab. in the morning - all the time
c. Wobenzym - 5 tablets × 3 times a day × a month, then 3 tablets × 3 times a day - at least 6 months.
d. Ca-D3-Nycomed-forte - 1 tab. in the evening daily
e. Ferrum Lek - 1 capsule 3 times a day with meals for 3 months, then 1 capsule in the morning.
f. Movalis - 1 suppository in the morning for 4 weeks, then - with an exacerbation of the articular syndrome.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER (TRANSFER) EPICRISIS CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1984
He was on inpatient treatment in the intensive care unit of the hospital therapy clinic
. He left the Military Medical Academy on "___" _____________ 2011.
In total, 3 days of treatment were carried out .
The final diagnosis was established. ICD code
Diagnosis:
Main disease: Sepsis, severe course.
Community-acquired viral-bacterial bilateral focal polysegmental confluent pneumonia, severe,
Complications: infectious-toxic shock of the 2nd degree, stopped medically on 04.03.11.
Bilateral parapneumonic pleurisy, ARF -2 degrees.
Infectious-toxic myocarditis, moderate HF 2 tbsp.,
Infectious-toxic hepatonephropathy, complicated by prerenal acute renal failure from 03/01/11, stopped by medication on 03/02/11.
Infectious-toxic pancreatitis, secondary diabetes mellitus of moderate severity
Secondary immunodeficiency.
Background disease Bronchial asthma, atopic form.
Concomitant disease: Common psoriasis, winter-spring form, exacerbation
Total radiation dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicization, disability, _____ disability group, degree of disability _______________________________, other ____________________________
Outcome: discharged on improvement, discharged on recovery, transferred to the clinic of infectious diseases of the Military Medical Academy.
On admission:
Complaints: severe general weakness; cough with a small amount of yellow discharge; severe general weakness, fatigue; intermittent chills, sweating; intermittent pain in the left hypochondrium with a deep breath.
Anamnesis of the disease He considers himself ill since February 18, 2011, when, against the background of complete well-being, he noted weakness, malaise, body aches, fever to febrile values (39.0 ° C), dry cough. He did not apply for medical help, he independently took NSAIDs, antiviral agents (ingaverin). Over the next 6 days, weakness, fatigue increased, chills periodically occurred, increased sweating, body aches, a cough appeared with a small amount of sputum. 24.02. and on February 25, 2011, he felt better, noted a decrease in body temperature to subfebrile numbers, and went to work. From the middle of the day on February 25, 2011, weakness, chills resumed, an increase in body temperature up to 39.00C was again noted, and the general state of health worsened. In the future, the complaints described above intensified, there was a sharp weakness, making it difficult to move around the room. On March 2, 2011, an ambulance was taken to the HT clinic for urgent indications, at the prehospital stage, due to the identified severe hypotension, 400 ml of Quadrosol solution, 16 mg of Dexamethasone solution were intravenously administered.
Over the past 30 years, he has been suffering from bronchial asthma (atopic form), constantly taking Seretide 25 mcg / 125 mcg PDA. Asthmatic status in 2006. In the 1990s, psoriasis was diagnosed.
Objective status: Height 182 cm, body weight at admission 86 kg,
The condition is extremely serious, unstable. Consciousness is clear (SHG=14 points). The position is passive. The skin is pale, cold, elasticity is not changed. The skin of the lips is pale pink. Acrocyanosis. On the skin of the legs, thighs hyperemic papules with peeling up to 4 cm in diameter (psoriasis). On the radial arteries, a threadlike pulse is palpable, the same on both hands, rhythmic, with a frequency of 118 per minute, weak filling and tension. Arterial pressure: 60/- mm. rt. Art. On auscultation, the heart sounds are muffled, rhythmic, the first tone at the apex is sharply weakened. The chest is of the correct form, symmetrical. The respiratory rate when breathing atmospheric air is 32 per minute, shallow breathing. With comparative percussion, dullness of percussion sound is determined in the projection of the lower loli of the lungs. Auscultation over the lungs on both sides is determined by hard breathing; over all fields of the lungs on both sides, foci of multiple moist sonorous small bubbling rales are heard. SatO2 without inhalation of humidified oxygen 78-82%, with inhalation - 88%. The edge of the liver protrudes from under the costal arch by 3 cm, soft-elastic consistency, sharp, somewhat painful on palpation. The spleen is not palpable. Ragosa's symptom is positive.
As a result of the treatment:
• IVL with PEEP within 3 hours from the moment of admission,
• inotropic support for 2.5 days (maximum dose of dopamine 10 µg/kg×day), removed from inotropic support at 23:30 on 04.03.11 .HELL when transferring = / mmHg
• continuous mask oxygen therapy,
• complex metabolic and detoxification therapy (neoton 4g/day, cytoflavin 10 ml/day, mildronate 10 ml/day, calcium gluconate (correction of significant hypocalcemia), ascorbic acid),
• avelox 400 mg 1 r/day,
• Invanz 1.0×1 time per day,
• Tamiflu 0.075, 1 tab 2 r/day,
• Berotek (Berodual), Lazolvan inhalation through a nebulizer,
• Linex 2 caps. 3 r / day,
• Erespal 0.08 1 tab. 2 times a day,
• Ascoril - 1 tbsp. spoon 3 times a day,
• Prednisolone 60 mg×4 times a day intravenously (from 04.03.11, the dose was reduced to 30 mg×4 times a day intravenously), there was an improvement in the general condition.
The right subclavian vein was catheterized on March 2, 2011.
At present, he is oxygen-dependent (when breathing atmospheric air, Sat O2 = 88%!)
Results of instrumental studies:
X-ray of the chest organs on March 2, 2011: bilateral polysegmental infiltration of the pulmonary pattern with increased pattern of the pleura .
ECG 02; 03.02; 03/04/2011: sinus rhythm with a heart rate of 118 per minute, horizontal EOS, left ventricular hypertrophy. Subsequently, a decrease in heart rate is noted.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Thrombus.
*109/l
MCH
ESR, mm/h
E
%
B
%
Lf
%
M
%
Metamyel
%
Miel
%
Pia
%
Xia
%
02.03.11
131
4.2
3.4
242
31.0
60
-
-
5
1
1
41
52
03.03. 11
137
4.4
12.3
281
30.9
60
0
-
1
1
1
40
57
04.03.11
132
4.2
14.6
287
31.0
66
0
-
4
3
1
4
89
Biochemical blood test: Urinalysis
Name
Unit of measure.
Norm
01/02/11
03/03/11
03/04/11
Indicator
03/02/11
03/03/11
Creatinine
Mkmol/l
53-124
310
240
200
Color
Yellow
Yellow
Total protein
g/l
64.0-83.0
54.2
61.5
55.7
Clarity
Clear
Haze
Glucose
mmol/l
4.2-6.4
5.8
8.9
12.9
Specific. weight
1015
1015
Potassium
mmol/l
3.4-4.5
4.1
4.2
3.5
Reaction
5.0
5.0
Sodium
mmol/l
130-150
138.8
142.9
140.4
Protein (g/ l)
0.3
0.1
Urea
mmol/l
2.5-6.4
23.1
22.2
24.2
Sugar
No
No
Calcium
mmol/l
2.1-2.5
1.75
1.9
2.06
Urobilin
No
No
Creatine kinase
U/l
Up to 190
33.0
Leukocytes in p/sp
7-8
2-4
Erythr. in p/sp
4-5
100-150
Erythr. vysch. in p / sp
-
No
Epit. cells
10-15
General analysis of sputum on 03/04/2011: brown-yellow color, viscous consistency, mucopurulent character, squamous epithelium 0-2 in p / c, ciliated 0-3 in p / c, alveolar 0-5 in p / c, atypical cells were not found, leukocytes up to 30-50 in p / c, erythrocytes 0-40-20 in p / c, eosinophils 0, neutrophils 80%, staphylococci in moderate amounts.
ECHO-KG (in the ward) 03/02/2011: LV 57/42 mm, EF 47%, FU 24%, VR 76 ml, IVS=ZS=9 mm, Ao 30 mm, VosAO 27 mm, LA 33 mm, RV 24 mm, PP 38 mm. Dilatation of the LV cavity, total myocardial hypokinesia. The aorta is not changed. The pericardium is unchanged.
KShchS
(
arterial
blood on the background of inhalation
of
100
%
oxygen
)
03/03/11
08:11
pH
7.3-7.4
7.426
7.407
7.403
7.427
7.433
pCO2
32.0-45.0 mmHg
26.6
28.1
30.4
32.0
32.2
pO2
75.0-100 mmHg
60.1
64.9
77.4
96.0
102
K
3.4-4.5 mmol/L
3.5
3.5
4.1
3.8
3.6
Na
130-150 mmol/L
136
133
133
135
237
Ca
1.15-1.3 mmol/L
0.85
0.94
0.7
1.02
0.76
Cl
95-110 mmol/L
103
105
103
106
102
Glu
4.2-6.4 mmol/L
5.8
8.6
8.4
7.1
7.7
BE
mmol/L
-6.4
-6.5
- 5.3
-2.9
-2.5
RT-PCR 03/04/2011: influenza A (H1N1) virus - positive reaction.
On 04.03.2011, the patient was consulted by telephone ZNK on the KR of the Clinic for Infectious Diseases by Associate Professor Yurkaev I.M., Acting PNK for LR Major Shakhmanov D.M.
In connection with the identification of a pandemic strain of influenza A (H1N1) according to epidemiological indications to the patient for further treatment transfer to the clinic of infectious diseases of the VMA is indicated.
The patient is transportable by resuscitation sanitary transport, accompanied by an anesthesiologist-resuscitator.
Recommended:
1. Continuation of treatment at the Clinic for Infectious Diseases of the Military Medical Academy
With patients transferred:
1. Invanz - 6 bottles (obtained from pharmacy No. 2)
2. Avelox - 1 bottle (obtained from pharmacy No. 2)
3. Neoton - 5 packs (20g)
4. Ascoril - 1 bottle (started)
5. Tamiflu - 3 tablets
6. Lazolvan in solution - 1 bottle (started)
7. Erespal - 5 tablets (received from pharmacy No. 2)
Form 12_Un.VmedA-2010 GT
MILITARY MEDICAL ACADEMY
DISCHARGE
HISTORY CASE HISTORY No.
Surname, name, patronymic: born in 1962
He was examined and treated in the clinic of hospital therapy of the Military Medical Academy on a day hospital
Total days of treatment 7
The final diagnosis was established Code ICD_E-11.1_
Diagnosis:
Main disease: Diabetes mellitus type 2, moderate degree, compensation.
Concomitant diseases: Ischemic heart disease. Angina pectoris II functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis. Hypertensive disease stage II (arterial hypertension of the 2nd degree, the risk of developing cardiovascular disorders is very high). Chronic hepatitis B. Obesity III degree, alimentary-constitutional origin.
Certificate of incapacity for work: No.
Clinical outcome (underline): recovery, improvement, no change, chronicity, disability
Outcome: discharged due to improvement
Admission complaints: moderate weakness, sweating, thirst, dry mouth, shortness of breath and discomfort in the left half of the chest with moderate physical exertion, periodically headaches mainly in the occipital region, weight gain.
History of the disease: in 2006, during inpatient examination and treatment, type 2 diabetes mellitus was first detected. The level of sugar in the blood measures independently when absolutely necessary with the Aku Chek glucometer. The patient has been suffering from ischemic heart disease and hypertension for a long time since 2000. He was repeatedly hospitalized in various clinics of the Military Medical Academy. The last hospitalization in the HT clinic was from 18.01 to 03.02.2010. He did not take antihypertensive and hypoglycemic drugs. Over the past year, he has noted an increase in blood pressure rises, an increase in the severity of headaches.
Present worsening: during the last week he noted an increase in blood glucose levels up to 20 mmol / l (measured independently). In this connection, he turned to the GT clinic and was hospitalized.
Objective status at admission: general condition of moderate severity, due to decompensation of diabetes mellitus, the manifestation of which is diabetic ketosis. Hypersthenic constitution. Increased nutrition. Lymph nodes are not enlarged. Heart rate 88 per minute, no deficit, rhythmic pulse, satisfactory properties. On auscultation, the heart sounds are muffled, the emphasis of the second tone is on the aorta, BP is 120/80 mm Hg, there is vesicular breathing in the lungs, no wheezing. the abdomen is soft, painless on palpation, the liver is along the edge of the costal arch, effleurage along the lumbar region is painless on both sides.
The following treatment was carried out: parenterally: glucose (5%-200 ml/day), MgSO4 (25%-5 ml/day), KCl (5%-30 ml/day), Humulin (12 U/day) . Inside: aspirin 100 mg/day, galvusmet 150/1500 mg/day, enalapril 5 mg/day, verapamil 120 mg/day.
As a result of the treatment, the state of health improved, blood glucose was within acceptable limits, cardiac pain syndrome did not recur, exercise tolerance was satisfactory, blood pressure was within normal values.
The results of instrumental studies:
ECG on December 23, 2011: heart rate - 100 per minute. Moderate sinus tachycardia. The horizontal position of the electrical axis of the heart to the left. Hypertrophy of the left heart. Violation of repolarization processes in the region of the posterior wall.
ECHOCARDIOGRAPHY 20.12.2011 № 47 Aorta: d=29 mm; Aortic valve: opening 21 mm; Left atrium: 40 mm; Mitral valve: S>4 cm2; left ventricle: KSR 33 mm, KDR 50 mm, FU 33%; Ejection fraction (Teicholz)=61%; Posterior wall: diast 11.2 mm, interventricular septum: diast 11.2 mm. Pulmonary artery: 19 mm; Right atrium: 37 mm; Right ventricle: KDR 27 mm, anterior wall: diast <5 mm. Conclusion: Initial manifestations of aortic atherosclerosis. Diastolic dysfunction of the left ventricle. Left ventricular hypertrophy.
24-hour ECG monitoring on December 13, 2011: during the observation period, sinus rhythm was recorded with a heart rate of 64 to 138 per minute. During wakefulness, tachycardia was recorded with an average hourly heart rate of 94 to 122 per minute. The decrease in heart rate at night is adequate. Average heart rate 96 (N to 85)/103/77 per minute. Registered single supraventricular extrasystoles (total 95), periodically paired. When performing the planned load (staircase test, 55 and 56 steps), the heart rate reached 116 and 125 per minute, the patient noted shortness of breath, palpitations. Ischemic changes in the ST segment were not detected.
X-ray of the chest organs No. 84 08.12.11: no pathological changes were detected on the survey chest X-ray.
Results of laboratory researches:
Date
Hb, g/l.
Er., *1012/l
Leuk., 109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
26.12
169
5.10
7.3
33.1
12
1
0
26
6
5
61
Biochemical blood test: Urinalysis:
Name
Unit.
Norm
26.12.11
Indicator
23.12.2011
AST
U/l
11-50
34.0
Color
Yellow
Glucose
mmol/l
3.9-6.2
11.45
Clarity
Clear
Urea
mmol/l
2.5-6.4
3.3
Specific. weight
1010
Creatinine
Mmol/l
0.05-0.12
0.09
Reaction
5.0
Total bilirubin
Mkmol/l
6.8-26
21.1
Protein (g/l)
Traces
Total protein
G/l
63-87
71
Sugar
5.5 mmol/l
ALT
U/l
11-50
26 .0
Ketones
No
LDL
U/l
360-650
700
Urobilin
No
Cholesterol
mmol/l
3.7-6.0
8.12
Leukocytes in p/zr
0-2
K
Mmol/l
3.5-5.1
4.09
Erythrocytes
0-2
Na
Mmol/l
136-145
135.9
Salts
In large amount.
Mucus
+
Urinalysis according to Nechiporenko dated December 20, 2011: leuk-1.25x106 / l .; erythr-0.25 x106/l
Blood coagulation system from 26.12.11. prothrombin-127
%
,
fibrinogen
4.78
g
/
l
,
INR
0.90
Blood
glucose
Blood
glucose
7.0
6.6
6.3
6.5
6.5
10.1
10-00
7.2
12-00
9.2
6.6
15-00
11.1
10.1
8.1
10.6
6.4
6.6
20-00
8.6
7.2
7.6
7.3
Discharged in a satisfactory condition under the supervision of the endocrinologist of the polyclinic at the place of residence.
Employment has been restored. Discharged for work, return to work on 12/29/2011
.
Recommended:
1. Observation of an endocrinologist, a cardiologist.
2. Diet with restriction of easily digestible carbohydrates, animal fats, table salt and liquid.
3. Aspirin 0.5 g ¼ tab x 1 time per day, for a long time.
4. Enalapril 5 mg x1 once a day, long-term;
5. Verapamil 40 mg 1 tab x 3 times a day, for a long time;
6. Galvus Met 50/1000 mg 1 tab x 2 times a day, for a long time;
Form 12 -2010
DISCLAIMER CASE
HISTORY №
Surname, name, patronymic: born in 1967
Was on examination and treatment in the clinic
during the period. In total, 12 days of treatment were carried out
. The final diagnosis was established. ICD code_E-11.1_
Diagnosis: Type 1 diabetes mellitus. Individual target HbA1c<7.0%. Diabetic ketosis from 07/29/2013. Diabetic retinopathy of the first degree in both eyes. Nephropathy of mixed (diabetic, hypertensive, atherosclerotic) genesis, microalbuminuric form, progressive stage. Chronic kidney disease stage 3, chronic renal failure stage 1a. Diabetic symmetrical distal sensory polyneuropathy. Coronary artery disease. Angina pectoris of the third functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis with arrhythmias of the type of frequent ventricular extrasystoles. Hypertensive disease stage II (arterial hypertension 3→1 degree, the risk of developing cardiovascular complications is very high). Chronic heart failure stage 2A, 3→2 functional class. Encephalopathy of mixed (dyscirculatory, hypertonic, dysmetabolic) genesis in the form of bilateral cerebellar symptoms, rare transient disorders of cerebral circulation. Obesity III degree, alimentary-constitutional genesis, stable course. Asymmetric transitional vertebra (sacralization of the fifth lumbar vertebra); non-occlusion of the arches of the sacrum. Chronic gastroduodenitis with rare exacerbations. Fatty hepatosis of the first degree without dysfunction. alimentary-constitutional genesis, stable course. Asymmetric transitional vertebra (sacralization of the fifth lumbar vertebra); non-occlusion of the arches of the sacrum. Chronic gastroduodenitis with rare exacerbations. Fatty hepatosis of the first degree without dysfunction. alimentary-constitutional genesis, stable course. Asymmetric transitional vertebra (sacralization of the fifth lumbar vertebra); non-occlusion of the arches of the sacrum. Chronic gastroduodenitis with rare exacerbations. Fatty hepatosis of the first degree without dysfunction.
Certificate of incapacity for work: No.
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability
Outcome: discharged due to improvement
Complaints at admission: moderate severe general weakness, sweating, thirst, dry mouth, shortness of breath and discomfort in the left half of the chest cell with moderate physical exertion, periodically headaches mainly in the occipital region against the background of an increase in blood pressure to 180/115 mm Hg, weight gain.
Anamnesis of the disease: considers himself ill since 1999, when he first noted the appearance of a headache against the background of an increase in blood pressure to 160/110 mm Hg. Not treated. In 2003, during a hospital examination, hypertension of the second stage was diagnosed. The maximum figures for blood pressure are 220/120 mm Hg. He took enalapril, amlodipine with a temporary positive effect. Since 2008, the disease has acquired a crisis character with an episode of transient ischemic attack in the LSMA pool (November 30, 2010). Significant lability of blood pressure levels (130-220/80-120 mm Hg) over the past 5 years required frequent correction of antihypertensive therapy in stationary conditions with an increase in the doses of drugs taken (currently taking co-exforge 10/160/12, 5 mg, arterial hypertension at the level of mild arterial hypertension). Since 2007 began to notice episodes of palpitations, interruptions in the work of the heart. In 2009, a rhythm disorder was diagnosed according to the type of frequent ventricular extrasystole, against the background of taking antiarrhythmic drugs, extrasystole is less pronounced. Pain in the region of the heart during physical, psycho-emotional stress has been noted since 2007. Coronary heart disease has been diagnosed on a stationary basis, periodically taking kardiket, nitrospray. Since 2003, he has been experiencing an increase in blood glucose levels; he was hospitalized with type 2 diabetes mellitus; he took sorbifer without effect. Since 2010, he has been taking Siofor 850 mg 2 times a day, Protofan 36 units in the morning and 38 units in the evening, which allowed him to maintain a normal level of glycemia throughout the year. Over the past year, he began to notice an increase in blood glucose levels up to 15-16 mmol/l, he did not seek medical help. Independently increased the dose of Siofor taken to 1000 mg 2 times a day with little effect. An increase in microalbumin in the urine since 2007, at the same time, diabetic nephropathy was diagnosed. Increase in body weight for more than 20 years, during the last 3 years the weight is stable. Pain in the spine during physical exertion since 1997. He was treated on an outpatient and inpatient basis with a short-term positive effect. Pain in the epigastric region with an error in the diet since 1994, chronically diagnosed gastroduodenitis on an outpatient basis, occasionally taking Almagel, omeprazole with a positive effect. In May 2009, he was dismissed from the Armed Forces of the Russian Federation for health reasons. Real deterioration: during the last three months, when, against the background of errors in the diet, he began to notice an increase in blood glucose levels up to 20 mmol / l (measured independently),
Objective status at admission: general condition of moderate severity, due to decompensation of diabetes mellitus, the manifestation of which is diabetic ketosis. Hypersthenic constitution. Increased nutrition (BMI 40kg/m2). Lymph nodes are not enlarged. Heart rate 88 per minute, no deficit, rhythmic pulse, satisfactory properties. On auscultation, the heart sounds are muffled, the emphasis of the second tone is on the aorta, BP is 160/95 mm Hg, there is vesicular breathing in the lungs, no wheezing. The abdomen is soft, painless on palpation, the liver is along the edge of the costal arch, effleurage along the lumbar region is painless on both sides. Edema of the lower third of the legs and feet.
Treatment was carried out: parenterally: after stopping ketosis in the ICU according to the standard scheme with the transition to the scheme Protofan HB 40 IU in the morning and 50 IU in the evening, Actrapid 40 IU before meals. Inside: aspirin 100 mg/day, galvusmet 150/1500 mg/day, Co-exforge 10/160/12.5.
As a result of the treatment, the state of health improved, blood glucose was within acceptable limits, cardiac pain syndrome did not recur, exercise tolerance was satisfactory, blood pressure was within normal values.
Results of instrumental studies:
ECG 29.07.2013:. Sinus rhythm with a heart rate of 76 per minute. Deviation of the electrical axis of the heart to the left. Hypertrophy of the left heart. Violation of repolarization processes in the region of the posterior wall.
ECHOCG 07/30/2013 Aorta 29 mm; Aortic valve: opening 21 mm; Left atrium: 43 mm; Mitral valve: S>4 cm2; left ventricle: CFR 42 mm, CDR 57 mm, Ejection fraction (Teicholz) 54%; e/a 0.69; posterior wall: diast 12 mm, interventricular septum: diast 12 mm. Pulmonary artery: 22 mm; Right atrium: 43 mm; Right ventricle: KDR 27 mm, anterior wall: diast <5 mm. Conclusion: the aorta is sealed. Diastolic dysfunction of the left ventricle. Left ventricular hypertrophy. Slight dilatation of the left chambers of the heart.
24-hour ECG monitoring on 08/03/2013: during the observation period, sinus rhythm was recorded with a heart rate of 64 to 138 per minute. During wakefulness, the heart rate is from 64 to 122 per minute. The decrease in heart rate at night is adequate. Average heart rate 76/83/77 per minute. Frequent polytopic ventricular extrasystoles (895 in total), periodically paired, at 18:55 a single episode of unstable VT was registered (6 complexes). When performing the planned load (staircase test, 55 and 56 steps), the heart rate reached 116 and 125 per minute, the patient noted significant shortness of breath, palpitations. ST depression of the ischemic type was recorded against the background of physical activity, a total of 5 episodes, with a total duration of 42 minutes.
Daily monitoring of blood pressure 05.08.2013 (against the background of therapy): mild stable arterial hypertension is recorded during the entire observation period with single rises in blood pressure (max. 182/124 mm Hg). Mean BP during the day 146/97 mmHg, mean BP at night 141/94 mmHg.
X-ray of the chest organs on August 08, 2013: on a survey radiograph in the lungs without infiltrative changes, the aorta was thickened.
Radiography of the lumbar spine on August 08, 2013: left-sided sacralization L5, spina bifida of the sacrum.
Ultrasound of the OBP from 08/07/2013: signs of steatohepatosis of the first degree, diffuse changes in the pancreas.
MRI of the brain on 08/06/2013: MRI-signs of dyscirculatory encephalopathy, moderately expressed substitutive external hydrocephalus.
Results of laboratory researches:
Date
Hb, g/l.
Er., *1012/l
Leuk., 109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
29.07.13
169
5.60
7.3
33.1
4
1
0
26
6
5
61
07/30/13
155
5.1
6.8
32.1
8
1
27
4
2
66
08/07/13
Biochemical analysis of blood: Analysis of urine:
Name
Unit of measure.
Norm
30.07.13
Indicator
29.07.2013
08.08.2013
AST
U/l
11-50
34.0
Color Yellow
Yellow
Glucose
mmol/l
3.9-6.2
15.5
Transparency
Clear
Clear
Urea
mmol/l
2.5-6.4
3.3
Specific
. weight
1035
1015
Creatinine
mmol/l
0.05-0.12
0.12
Reaction
5.0
5.5
Total bilirubin
µmol/l
6.8-26
21.1
Protein (g/l)
No
trace
Total protein
G/l
63-87
71
Sugar
10.5 mmol/l
no
ALT
U/l
11-50
26.0
Ketones
++
-
LDL
U/l
360-650
700
Urobilin
No
No
Cholesterol
Mmol/l
3.7-6.0
7.12
Leukocytes in p/s
2-4
0-2
K
Mmol/l
3.5-5.1
3.62
Erythrocytes
0-2
0-2
Na
mmol/l
136-145
135.9 Oxalate
salts
+.
-
HbA1c
%
<6.5%.
10.2
Mucus
+
+
Urinalysis for microalbumin 08/30/2013: positive. (+++)
Urinalysis according to Nechiporenko dated 08.08.2013: leuk-1.25x106/l.; erythr-0.25 x106/l
Blood coagulation system from 26.12.11. prothrombin
-
127
%
,
fibrinogen
4.78
g
/
l
,
INR
0.90
Blood
glucose
Blood
glucose
Time
_
_
_
7.1
10-00
7.2
12-00
9.2
6.6
15-00
11.1
10.1
8.1
10.6
6.4
6.6
20-00
8.6
7.2
7.6
7.3
Endocrinologist's consultation: The patient has decompensated diabetes mellitus. Diagnosis: Type 1 diabetes mellitus. Individual target HbA1c<7.0%. Diabetic ketosis from 07/29/2013. Diabetic retinopathy of the first degree in both eyes. Nephropathy of mixed (diabetic, hypertensive, atherosclerotic) genesis, microalbuminuric form, progressive stage. Chronic kidney disease stage 3, chronic renal failure stage 1a. Diabetic symmetrical distal sensory polyneuropathy. Obesity III degree, alimentary-constitutional genesis, stable course. Recommended: Protofan HB 40 IU in the morning and 50 IU in the evening, Actrapid 40 IU before meals. Inside: galvusmet 150/1500 mg / day. Independent daily monitoring of glycemic levels, HbA1c levels (1 time / 3 months)
Discharged in a satisfactory condition under the supervision of an endocrinologist of the clinic at the place of residence.
Recommended:
1. Observation of an endocrinologist, a cardiologist.
2. Diet with restriction of easily digestible carbohydrates, animal fats, table salt and liquid.
3. Independent control of glycemic level, HbA1c level (1 time / 3 months)
4. Aspirin 0.5 g, ¼ tab x 1 time per day, for a long time.
5. Co-exforge 10/160/12.5 mg x1 once a day, for a long time;
6. Protofan HB 40 IU in the morning and 50 IU in the evening, for a long time;
7. Actrapid 40 IU before meals
8. Galvus Met 50/1000 mg 1 tab x 2 times a day, for a long time;
.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1978
She was on inpatient treatment in the clinic of hospital therapy
Total days of treatment 10
The final diagnosis was established
ICD Code I 10.0;
Diagnosis:
Hypertensive disease of the second stage (drug normotension, the risk of cardiovascular complications is "medium") without signs of heart failure.
Rarely recurrent neuroreflex syncope. Simple fainting from 10/18/2013
Acute bronchitis complicated by an episode of hemoptysis on 10/25/2013.
Deviation of the nasal septum without persistent obstruction of nasal breathing. Vasomotor rhinitis
Cholelithiasis stage III. Chronic calculous cholecystitis without exacerbation.
Chronic gastritis without exacerbation
Android obesity of the 2nd degree, stable phase.
Kippelfeld anomaly, C2-C3 retrolisthesis. Osteochondrosis of the cervical and thoracic spine with muscular-tonic syndrome.
Certificate of incapacity for work: not issued
Total radiation dose 0.78 mSv
Clinical outcome: improvement.
Outcome: discharged.
Upon enrolment:
Complaints: discomfort in the lower part of the chest, general weakness, shortness of breath with previously tolerated physical exertion, cough with a moderate amount of discharge mixed with blood, episodic nausea, retching with streaks of blood.
History of present illness. In 2012, due to the frequent detection of high blood pressure, its lability, and headaches, he underwent inpatient treatment at the military field therapy clinic (a copy of the medical history No. 56606 is pasted into this medical history). During hospitalization, the patient was diagnosed with the second stage of hypertension (AH 2, CV risk 3), atherosclerosis of the aorta and coronary arteries, CHF 1 fc, chronic calculous cholecystitis, remission, osteochondrosis of the thoracic region with muscular tonic syndrome, obesity of the third degree. Regularly takes amlodipine, valsartan + hypothiazide, Plavix with a positive effect.
Over the past year, I began to notice the frequent appearance of discomfort in the lower part of the chest on both sides, more on the left. From the beginning of October, after physical exertion (ascent to the 5th floor), attacks of nausea, vomiting of bile with episodes of blood streaks in it appeared, and general weakness began to increase. On October 18, 2013, after physical exertion (6-hour service), a sharp weakness developed, blackout in the eyes, followed by a short-term loss of consciousness. As he fell, he hit the corner of the table with his spatula. After this episode, there was a significant weakness, a cough with a bloody discharge (did not occur during the last three days). The presence of seizures denies. According to urgent indications, he was hospitalized in the city clinical hospital No. 40 (Sestroretsk), where, according to the patient, pulmonary embolism was ruled out and this condition was explained by the presence of an anomaly of the cervical vertebrae (copies of the examination results, including the result of a CT scan of the head and chest, are pasted into the present medical history, the discharge summary is not presented). Considering that his state of health does not allow him to properly perform his duties, he turned to the hospital therapy clinic, where, after examination, he was hospitalized to the clinic for further diagnosis and treatment.
As a result of the treatment: regimen, diet No. 10, antiplatelet, antihypertensive, diuretic, metabolic, cardioprotective, mucolytic, antibacterial therapy, the state of health improved. The maximum possible compensation of the functions of internal organs and systems has been achieved.
Results of instrumental studies:
ECG dated October 24, 2013: sinus rhythm with heart rate of 73/min Normal position of the EOS. Incomplete blockade of the right leg of the bundle of His. The predominance of the potentials of the left ventricle. Violation of repolarization processes in the region of the lower wall.
Spirometry dated 25.10.2013 The coefficient of bronchodilation was 6.77%, which is regarded as the physiological variability of the bronchial lumen.
FGDS dated 20.28.13: Cardia insufficiency. Superficial gastritis with atrophy. Duodenogastric reflux. Secondary duodenitis. Papillitis.
Angiography of the chest dated 11/13/2013: CT data for a neoplasm of the chest organs were not obtained. defects in contrasting vessels, AVMs in the scanning area were not detected. In the basal parts of the left lung, there is a single pleurodiaphragmatic adhesion.
Results of laboratory tests
Complete blood count
Date
10/25/2013
Hb, g/l.
143
Erythrocytes *1012/l
4.05
Leukocytes *109/l
7.2
Myelocytes
-
ESR, mm/h
8
Eosinophils %
0
Basophils %
1
Lymphocytes %
27
Monocytes %
15
Stab %
3
Segmented %
55
Urinalysis
Date
25.10.2013
Color
Yellow
Clarity
Transparent
Density
1030
pH
5.5
Protein (g/l)
neg.
Leukocytes
3-4-5-
Erythrocytes
0-1-2
Glucose
neg.
slime
2
bacteria
1
Biochemical blood test from 25.10.2013.
Name
Unit
Norm
Urea
mmol/l
2.5-6.4
3.6
Glucose
mmol/l
4.2-6.4
6.16
Creatinine
mmol/l
0.05-0.12
0.08
Potassium
mmol/l
3.50-5.10
3.81
ALT
U/l
11.0-50.0
55
APTT
U/l
8-63
23.6
Prothrombin
%
70-130
99
Fibrinogen
Mg/dl
200-400
3.64
C-reactive protein
mmol/l
0-5.0
13.4
Consultation of a pulmonologist: Currently, there are no convincing data for the pathology of the respiratory system.
ENT consultation dated 20/25/2013: Deviation of the nasal septum without persistent difficulty in nasal breathing. Vasomotor rhinitis.
Treatment goals have been achieved. In a satisfactory condition, he is discharged to the polyclinic at the place of residence under the supervision of specialist doctors.
Recommended:
12. Observation by a cardiologist of the polyclinic.
13. Observe the drinking regimen 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
14. Limit the consumption of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium.
15. Continue taking:
a. Tab. Valz H 80/12.5 mg 1 tablet in the morning continuously.
b. Tab. Amlodipine 5mg - 1 tablet daily in the morning.
c. Tab. Thrombo ACC 0.05 1 tablet in the morning constantly.
d. Tab
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCUSSION REPORT CASE
HISTORY No. ARCHIVE No. _________
Last name, first name, patronymic: born in 1938.
Was hospitalized at the hospital therapy clinic
Total number of days of treatment 1
Final diagnosis established ICD Code I 69.3
Diagnosis:
cerebrovascular disease. Dyscirculatory encephalopathy 111 st. mixed genesis (atherosclerotic, post-stroke (stroke stroke in the LSMA pool from 1991), hypertensive) in the form of dysarthria, right-sided upper hemiparesis, right-sided hemihypoesthesia. Cryptogenic temporal lobe epilepsy with rare simple paroxysmal seizures. Meningioma of the left frontal lobe.
Acute oral poisoning with barbiturates of moderate severity from 01/19/2014.
Coronary artery disease. Stable angina pectoris 11I functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and post-infarction (1995) cardiosclerosis with rhythm disturbance as a paroxysmal form of atrial fibrillation (without exacerbation).
Hypertensive disease of the third stage (AH - 1, risk 4) Chronic heart failure stage 11a, 111 functional class
Secondary nephropathy of mixed genesis (atherosclerotic, hypertensive) genesis. Chronic pyelonephritis, remission. Cysts of the left kidney. Chronic kidney disease C2Ax stage. Acute urinary tract infection (urinary catheter 20-21.01.2014).
operated thyroid gland. Total strumectomy (1996, 2010) for recurrent follicular tumor of the thyroid gland Clinical hypothyroidism.
Sensorimotor hearing loss. Chronic atrophic pharyngitis. Absence of the gallbladder (2002).
Chronic viral hepatitis C with a minimal degree of activity.
Consolidated fracture of the right femoral neck, osteosynthesis (2010)
Widespread osteochondrosis of the spine.
Primary age-related cataract, AMD, dry form.
A disability certificate was not issued. Total radiation dose 0 mSv
Clinical outcome (underline): recovery, improvement,
Outcome: discharged on improvement, discharged on recovery.
On admission:
Complaints of weakness, nausea, vomiting, dizziness, local pain in the left side of the chest.
The real worsening of the state of health came on the afternoon of 10/19/2014, when, while taking nitrospray for pain in the left side of the chest, the patient lost consciousness (the duration of the syncope is unknown). The patient refused the hospitalization offered by the emergency medical service team. Regularly takes phenobarbital for epilepsy (dose in the last day is unknown). On the morning of January 20, 2014 there was nausea, vomiting. Social transport delivered to the hospital therapy clinic VMedA. In the course of the survey, no convincing data were obtained for acute coronary syndrome (chest pain the day before and taking nitrospray for this reason) (chest pain was regarded as thoracalgia of non-cardiac origin). Loss of consciousness the day before, most likely due to orthostatic hypotension while taking nitrospray. Attention is drawn to the pronounced cerebral symptoms. The main severity of the condition at the time of hospitalization on 20.01.2014. caused cerebral symptoms, within which a differential diagnostic search was carried out between acute cerebrovascular accident in the vertebrobasilar basin and poisoning (overdose) of antiepileptic drugs (phenobarbital). Taking into account the obtained MRI data (according to sito), the results of a toxicological blood test for barbiturates, the patient had toxic encephalopathy due to an overdose of barbiturates. In order to conduct detoxification therapy, the patient was urgently transferred, in agreement with the leadership of the department of military field therapy, to a specialized toxicological department of resuscitation and intensive care of the VPT clinic, where complex detoxification therapy was carried out. According to the stabilization of the state on 21.01.2014. at 18:30 she was again admitted to the hospital therapy clinic by transfer from the ICU. In the course of the examination, it was found that diseases of the internal organs are of a compensated nature and do not require additional correction of the therapy. Dominant in the picture of the disease is the pathology of the central nervous system, which does not require urgent medical intervention and the patient can undergo further treatment on an outpatient basis. that diseases of the internal organs are compensated and do not require additional correction of the therapy. Dominant in the picture of the disease is the pathology of the central nervous system, which does not require urgent medical intervention and the patient can undergo further treatment on an outpatient basis. that diseases of the internal organs are compensated and do not require additional correction of the therapy. Dominant in the picture of the disease is the pathology of the central nervous system, which does not require urgent medical intervention and the patient can undergo further treatment on an outpatient basis.
Epidemiological history: tuberculosis, syphilis denies, sexually transmitted diseases. Contact with infectious and febrile patients denies. Hepatitis C since 2010 (according to the patient).
Insurance history: Pensioner. Does not work. There is no need to apply for a disability certificate.
Laboratory results:
General clinical blood test (attached): Hb
date
, units.
Er., *1012/l
Leuc., *109/l
Rt,
‰
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
20.01
132
4.34
5.1
28
301
6
29
7
8
50
22.01
133
4.44
3.9
16.2
31
274
2
1
27
7
7
58
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol /l
Salts
Mucus
Acetone
M / o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
22.01
clear
1030
yellow
5.0
0.3
no
no
2
traces
3
2-5
no
up to 100
1-2
Biochemical blood test on January 22, 2013: glucose, urea, creatinine, total protein, potassium, sodium, chlorine are normal.
Biochemical blood test and test for cardiospecific enzymes (myoglobin, troponin T, CPK-MB) dated January 20 and 22, 2014. - are negative.
Blood test for barbiturates 20.01.2014 12:20 - positive.
The results of instrumental studies:
On the ECG dated 01/20/2014. recorded sinus rhythm with a heart rate of 56 in 1 minute, indirect signs of left ventricular hypertrophy, diffuse repolarization disorders. 22.01.2014 - without dynamics
ECHO-KG from 01/22/2014: the walls of the aorta and the leaflets of the aortic valve are sealed. Concentric left ventricular myocardial hypertrophy (IVH=ZS=11.2 mm, LVMI 113g/m2). The cavities of the heart are not dilated, free. The LV systolic function is reduced (EF35%, LV 44.3/32.3 mm). Hypokinesia of the middle and basal segments of the lower wall. Diastolic dysfunction of the rigid type. Minimal mitral and tricuspid regurgitation. Slight increase in pulmonary pressure. Pericardium without features.
MRI - from 01/20/2014. on hands.
Recommended:
1. Observation of a therapist, a neurologist at the place of residence.
2. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
3. Limit the consumption of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium.
4. Monitor the level of TSH and fT4 in the blood, followed by a consultation with an endocrinologist.
5. Routine Consultations
a. neurosurgeon (MRI - meningioma of the frontal lobes),
b. epileptologist (selection of antiepileptic therapy)
c. endocrinologist (total strumectomy - selection of therapy)
6. Continue taking:
a. Tab. Prestans 10/5 mg 1 tablet 1 time per day continuously.
b. Tab. Bisoprolol 5 mg - 1/4 tablet in the morning constantly.
c. Tab. Thrombo ACC 0.05 1 tablet in the morning constantly.
d. Tab. Veroshpiron 25 mg 1 tablet 2 times a day continuously.
e. Tab. Kanefron 1 tablet 3 times a day for 1 month
f. Tab. Norfloxacin 0.4 - 1 tablet 2 times a day for 10 days
g. Tab. Phenobarbital 0.1 - 1 tablet 3 times a day (Dose adjustment after consultation with an epileptologist)
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. (812) 577-11-35
Discharge summary No.
born in 1973 (36 years old),
was examined and treated in the clinic of hospital therapy
with a diagnosis of
Hypertensive disease of the first stage (AH-2, the risk of CVE is moderate). NK-0
Obesity of the third degree, alimentary-constitutional genesis, stable phase. Fatty hepatosis without impaired liver function. Chronic recurrent pancreatitis with impaired exocrine function in the phase of incomplete remission. Autoimmune thyroiditis, euthyroidism. Osteochondrosis of the lumbar without exacerbation. Initial signs of deforming arthrosis of both knee joints. Toxicoderma.
She was admitted to the clinic in a planned manner with complaints of a severe dull aching headache without a clear localization, an increase in blood pressure to 165/100 mm Hg, a rash on the body, pain in the knee joints during prolonged walking.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht, %
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
06.07.
155
5.22
6.3
47.3
8
318
6
1
30
5
1
57
22.07
153
4.8
5.8
5
1
37
8
1
53
General analysis of urine and feces from 22.07.10 without pathological changes.
Safety factors (anti-HCV, HBsAg, F-50, RW) from 07/19/2010 - negative
Biochemical blood test:
Name
Unit rev.
Norm
06.07
Creatinine
mmol/l
53-124
70
urea
mmol/l
2.5-6.4
4.1
sodium
mmol/l
136-145
142.7
chlorine
mmol/l
98-107
108.7
Potassium
mmol/l.
3.5-5.1
4.22
Sa
mmol/l
2.1-2.55
2.29
glucose
mmol/l
3.9-6.2
5.95
total protein
mmol/l
64-83
78.1
T3
nmol/l
1.3-3.1
1.59
Т4
nmol/l
66-181
95.02
TSH
uIU/l
0.27-4.2
3.43
cortisol
nmol/l
221-690
403.6
ALT
U/L
8.4-53.5
60.2
AST
U/L
7-39.7
25.5
GGTP
U/ L
7-63
28.9
CS
mmol/l
3.7-7
7.9
TG
mmol/l
0-2.37
2.34 Vol
. bilirubin
µmol/l
6.8-26
7.9
amylase
U/L
28-100
45.2
C-reactive protein
mg/l
3-10
2.5
B-lipoproteins
units
350-650
1400
Results of instrumental studies:
ECG in dynamics from 05.072.2010, sinus rhythm with a heart rate of 68/min, horizontal EOS. 07/16/2010 - without negative dynamics.
Ultrasound examination of the abdominal cavity and thyroid gland from 07/12/2010. in the left lobe of the thyroid gland, a hypoechoic node with a diameter of 5 mm is located; revealed signs of fatty hepatosis, chronic pancreatitis.
Ultrasound examination of the pelvic organs dated 07/13/2010 - no pathological changes were detected.
EchoCG from 14.07.2010. Aorta 30 mm, aortic ring 24 mm, asc. aorta 29 mm, opening of the aortic valve 19.4 mm, LA 40 mm, CRLV 29 mm, CRLV 43 mm, fr. reproach. 32%, fr. select 61%, AP 10 mm IVS 10 mm, E/A=1.7, PP 38mm, RV 24mm; the myocardium of the left ventricle is not thickened, the cavities are not expanded. The aorta is not changed. The valves are intact, laminar blood flow, valvular regurgitation on PC. The pericardium is unchanged, there is no pericardial effusion.
X-ray of the chest organs dated 07/08/2010. In the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is horizontal. The aorta is not changed.
On spondylograms of the lumbar spine from 08.07.2010. - physiological lordosis is straightened, the height of the discs is not reduced. Small exophytes are determined in the anterior-lateral sections of L4-L5 outside the plane of the disks - the initial manifestations of spondylosis.
On radiographs of the knee joints standing from 23.07.2010. - there is sclerosis of the articular areas in the medial condyles of both tibias. The height of the menisci in these lower extremities is symmetrically reduced (compared to the lateral menisci).
Consulted by a dermatologist - toxicodermia, recommendations were given
. Treatment was carried out: regimen, diet, enalapril, ACC thrombosis, desensitizing, sedative, polyenzymatic therapy.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
1. Observation of a general practitioner at a polyclinic at the place of residence.
2. Continue the course of treatment in a day hospital
3. Optimization of the regime of work, rest, nutrition.
4. Control ultrasound of the abdominal organs of the thyroid gland after 2 months
5. Continue taking:
• Enalapril 0.01 ½ tab.2 r/d. constantly
• Thrombo ASS 0.1 1 tab. 1 r / d after breakfast
• Mildronate 0.25 ½ capsules 2 r / d (after breakfast and lunch) - 2 weeks
• Omeprazole 0.02 1 capsule at night for 2 weeks.
• Motilium 0.01 1 capsule 3 times a day - 2 weeks.
• Suprastin 0.025 - 1 tablet at night for 1 week
Form 12_Uni.VmedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1991
He was on inpatient treatment (in the day hospital mode)
in the hospital therapy clinic
Total days of treatment were 7
The final diagnosis was established ICD code
Diagnosis: HEALTHY.
A disability certificate was not issued.
Ability to work restored
Total exposure dose 0.52 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, established _____ disability group, degree of disability _______________________________, other _____________________________________________
Outcome: discharged on improvement, discharged on recovery, transferred to another medical institution (what) ____________________, transferred to rehabilitation treatment (where) _______________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a
medical
examination
.
Anamnesis of the disease: During a planned medical examination during ECG recording, an incomplete blockade of the right bundle branch block was noted, which was the reason for performing an ECHO-KG (developmental anomaly - an additional chord in the cavity of the left ventricle) and daily ECG monitoring (27 episodes of supraventricular tachycardia were detected). Episodes of SVT were the basis for this hospitalization. The patient himself feels healthy, interruptions in the work of the heart, palpitations, episodes of loss of consciousness denies.
Objective status: Height 169 cm, body weight at admission 75 kg. BMI=25.6kg/m2. The general condition is satisfactory. The position is active. The physique is correct, corresponds to age and sex. Normosthenic constitution. Satisfactory nutrition. Peripheral lymph nodes are not enlarged. The pulse is synchronous, the same on both hands, rhythmic, with a frequency of 65 beats. per minute, satisfactory filling, uniform, tense, the vascular wall is palpated outside the pulse wave. Blood pressure: on the right shoulder - 120/80, on the left shoulder - 120/85 mm Hg. Art. The boundaries of relative cardiac dullness were not changed. The width of the vascular bundle does not extend beyond the edges of the sternum. The number of heartbeats corresponds to the pulse. Heart sounds are clear, pure, their ratio is not changed, there are no noises. The respiratory rate is 14 per minute, the respiratory movements are rhythmic, both halves of the chest evenly participate in the act of breathing. On auscultation over the lungs, breathing is vesicular, rales are not heard. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch.
Treatment: regimen, diet
Results of instrumental studies:
ECG No. 234 dated April 15, 2013: sinus rhythm with a frequency of 55 per 1 minute, horizontal EOS. Syndrome of early repolarization of the ventricles, Incomplete blockade of the right leg of the bundle of His.
ECHO-KG from 27.03.13: MZHP-8mm, ZS-7mm, KDRLV-49mm, KSRLZh-33mm, Vlzh=114/43 ml, EF-62%, FU-34%, UO-71 ml, LP- 29×51m, PP-46mm, RV-32mm, E/A=2.03 Myocardium is not thickened. The kinetics is not broken. The cavities are not dilated, free in visible areas. Aorta, valves, pericardium are not changed. False notochord in the cavity of the left ventricle. Systolic and diastolic functions are not disturbed. Regurgitation attached to the TC. Pulmonary blood flow is not changed. The pericardium is intact.
PE-EPI No. 7/8 dated April 15, 2013: initially, a stable sinus rhythm with a heart rate of 60/min is recorded. VSAP 60 ms, VVFSU 1233 ms, KVVFSU 301 ms, TV 190/min, ERPav 400 ms. After the introduction of atropine (0.02 mg / kg), ERPav 320 ms (FRP 375 ms), TB 190 / min. With a speeding, programmed ECS, single, paired and three extrastimuli failed to start a paroxysm of tachyarrhythmia.
VEM2 dated April 18, 2013: The test is negative. A submaximal heart rate was achieved, no ischemic changes were detected. Tolerance is high. The reaction of blood pressure to the load according to the normotonic type. The recovery period is adequate.
Plain radiograph of the chest No. 1354 dated April 18, 2013: in the lungs without focal and infiltrative changes. The heart is not enlarged.
Results of laboratory researches:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
Rt,
‰
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
16.04
143
4.93
7.4
12
7
339
4
26
9
1
60
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M / o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
16.04
clear
1025
yellow
5.5
no
no
no
no
no
no
2-4
no
0-2
no
_ – without features
Biochemical analysis of blood:
Name
Unit. rev.
Norm
16.04
Creatinine
mmol/l
53-124
100
urea
mmol/l
2.5-6.4
8.4
Potassium
mmol/l.
3.5-5.1
4.27
glucose
mmol/l
3.9-6.3
5.68
fibrinogen
g/l
2.0-4.0
1.82
C-reactive protein
unit
0-6
0
KFK
units
15-150
180
KFK-MB
units
0-55
24
cholesterol
mmol/l
3.5-5.5
3.25
ALT
U/L
8.4-53.5
15
AST
U/L
7-39.7
19
The goals of hospitalization have been achieved - organic pathology of the cardiovascular system has been excluded. The existing morphological and functional changes (additional chord in the cavity of the left ventricle, signs of autonomic dysfunction of atrioventricular conduction, incomplete blockade of the right bundle branch block) do not affect the functional state of the patient and are considered within the framework of the physiological norm.
Discharged in a satisfactory condition.
MILITARY MEDICAL ACADEMY Form 12_Uni.VMedA-2011
Discharge Epicrisis CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic 1933 b.
Was on inpatient treatment in the clinic of hospital therapy
Total days of treatment 8
The final diagnosis was established ICD code _I 20.0
DIAGNOSIS:
Primary disease: Ischemic heart disease. Angina pectoris of the third functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis with rhythm disturbance as a permanent form of atrial fibrillation, tachysystolic variant. Hypertensive disease of the second stage (arterial hypertension of the second degree, the risk of CVE is very high)
Complications of the underlying disease: Chronic heart failure of the second B stage, the third functional class.
Concomitant diseases: Dyscirculatory encephalopathy of the second stage, mixed genesis. Chronic non-calculous cholecystitis in remission. Chronic biliary-dependent pancreatitis in remission. Steatohepatosis. Chronic gastritis in remission. Urolithiasis disease. Chronic bilateral pyelonephritis in remission. Chronic renal failure 0. Primary gout, metabolic type. Chronic gouty arthritis of the I-IV metatarsophalangeal joints of both feet in remission. Functional insufficiency of the joints of the first degree. Chronic catarrhal non-obstructive bronchitis in remission. Emphysema, diffuse pneumofibrosis. Respiratory failure of the first degree. Obesity of the third degree. Degenerative-dystrophic disease of the spine. Chronic vertebrogenic cervical sciatica,
Certificate of incapacity for work: not issued
Total exposure dose _____0.6 mSv ____
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, _____ disability group, degree of limitation
Outcome: discharged due to improvement
Complaints: compressive pain behind the sternum during exercise of moderate intensity, passing at rest after 5-15 minutes from the moment of termination of the load, inspiratory dyspnea during exercise of low intensity, decreased tolerance to previously tolerated physical activity, weakness, swelling of the feet and legs; episodes of palpitations; on recurrent diffuse headache, general weakness with an increase in blood pressure to 165/110 mm Hg. Art., aching pain on the back of the neck when turning the head.
As a result of the treatment: regimen, diet N10, T. Bisoprolol 2.5 mg/day, T. Digoxin 0.125 mg/day, T. Veroshpiron 25 mg/day, T. Allopuroinol 100 mg/day, T. Furosemide 20 mg/day, T. Thrombo ASS 100 mg/day, there is a positive trend: blood pressure is stabilized and meets the target values. The pain syndrome did not recur. Hemodynamic parameters are stable. He notes an increase in working capacity, an increase in tolerance to physical activity. Discharged in a satisfactory condition under the supervision of medical specialists of the clinic. Therapy for the outpatient stage of treatment was selected, recommendations were given.
Results of instrumental studies:
ECG dated April 16, 2013: atrial fibrillation rhythm, normosystolic form. A sharp deviation of the electrical axis of the heart. Dlocade of the anterior branch of the left bundle of His bundle.
FLG UGP dated April 18, 2013: pulmonary fields are moderately emphysematous. The pulmonary pattern is reinforced and deformed due to diffuse pneumofibrosis. The roots of the lungs are structurally heavy. The sinuses are free. The heart is dilated in both directions. The aorta is compacted, elongated, deployed.
X-ray of the cervical, thoracic, lumbar spine dated April 17, 2013: signs of osteochondrosis C4-5, C5-6, C6-7 motor segments with posterior osteophytes at the C5-C6 level. Arthrosis of the intervertebral joints C5-6, C6-7..
Ultrasound of the OBP dated April 18, 2013: the liver is enlarged, the right lobe is 17.6 cm, the left lobe is 9.6 cm, the contours are even, the structure is homogeneous, the echogenicity is increased, the vascular pattern is depleted, the vessels are not dilated, the portal vein is normal, intrahepatic bile moves are not expanded. The gallbladder is of the correct form, dimensions 5.8x2.8 cm, the contours are even, the walls are 4 mm, there are no calculi. The pancreas is located not clearly 17.3x13.0x12.0 mm, the structure is heterogeneous, the echogenicity is increased, the Wirsung duct is 2 mm. Kidneys: typical right location, normal mobility, smooth contours, dimensions 12.1x5 cm, heterogeneous parenchyma 18.0 mm. CHLS is not expanded, microliths. The left one is typically located, the mobility is normal, the contours are even, the dimensions are 12.9x5.7 cm, the parenchyma is heterogeneous 14 (mm). CHLS is not expanded, microliths. No pathological formations were found in the projection of the adrenal glands. The spleen is not enlarged 11.2x4.7, the structure is homogeneous. Conclusion: diffuse changes in the liver according to the type of fatty hepatosis, diffuse changes in the pancreas. Thinning of the parenchyma of the left kidney. Microliths..
Echocardiography dated 21.04.2013:
Result, mm
Norm, mm
Aorta
At the level of AC
23
22-36
Valve opening
18.2
15-26
Left atrium
Anteroposterior size
58.7
25-40
Left ventricle
DFR
49.5
≤ 36
KDR
60, 6
≤ 55
Posterior wall thickness (diast.)
12.6
Interventricular septal thickness (l)
12.6
Right ventricle
EVA
≤ 30
Anterior wall
6.5
≤ 5
Right atrium
Transverse dimension
47.8
29-46
Longitudinal dimension
62.1
34-49
Pulmonary artery
At the valve
37.3
12-23
Indicator
Result
Norm
FU, %
18
28-41
EF, %
37
≥55
Ve/
Va
1.0-2.2 leaflets of the mitral and aortic valves of a degenerative-dystrophic nature. Concentric hypertrophy of the left ventricle. Severe dilatation of all chambers of the heart. The cavities of the heart are free. Mitral and tricuspid regurgitation of the 2nd degree, pulmonary regurgitation of the 1st degree. The systolic function of the left ventricle is reduced (total myocardial hypokinesia). Pulmonary hypertension 1 degree. Pericardium without features.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Tr. *109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
17.04
149
4.93
5.5
217
30.2
35
3
-
25
3
6
63
Urinalysis (automatic processing):
Date
U.weight
Reak
Protein
Sah
Ket.
Lei
Er.neiz
Urobil
17.04
1015
5.5
-
-
-
0-2
-
3.2
Biochemical analysis of blood:
Name
Unit of measure.
Norm
17.04
O. protein
g/l
64-83
74
Glucose
mmol/l
4.2-6.4
5.94
Creatinine
mmol/l
0.05-0.12
0.13
Potassium
mmol/l
3.4-4.5
5.22
Calcium
mmol/l
2.1-2.55
Sodium
mmol/l
130-150
142.5
Cholesterol
mmol/l
3.7-6.0
5.59
Total bilirubin
µmol/l
6.3-26
19.2
Direct bilirubin
µmol/l
6.2
Urea
mmol/l
1.9-2.5
6.4
AST
U/l
11-50
22
ALT
U/ l
11-50
13
GGTP
U/l
CPK
LDL
Triglycerides
0-2.37
1.59
HDL
T4 vol.
Nmol/l
0.89-1.76
CRP
up to 5.5
18.1
glycated Hv
%
6.94
PSA
Ng/ml
Up to 4
1.89
Coagulogram dated April 17, 2013: prothrombin 88%, fibrinogen 4.23 g/l, INR 1.07;
Analysis for HBsAg, anti-HCV, RW, F-50 04/19/2013: negative.
Coprogram dated April 17, 2013: normal consistency, neutral mucus reaction - 0, blood - 0, digested muscle fibers 2, undigested longitudinal striation 2, transverse striation 1, vegetable fiber: digested 0, undigested 2, starch grains: intracellular 0 , extracellular 1, iodophilic flora 2, neutral fat 0, fatty acids 2, soaps 1; leukocytes 0; Erythrocytes 0. I/g were not found.
Discharged in a satisfactory condition under the supervision of specialists of the clinic.
Recommended:
1. Observation of a therapist, endocrinologist, neurologist, cardiologist, rheumatologist, gastroenterologist.
2. MRI of the head and neck, followed by a consultation with a neurologist.
3. Control of b / x blood after 3 months (AST, ALT, o. bilirubin, o. cholesterol, lipidogram, glycated hemoglobin) followed by a consultation with a therapist.
4. Normalization of the regime of work and rest. Exclude the use of animal fats, easily digestible carbohydrates, alcohol, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet. exercise therapy.
5. Observe the water regime (fluid balance), daily monitoring of blood pressure and heart rate.
6. Continue taking:
1. T. Bisoprolol 5 mg 1/2 tab. 1 time after lunch
2. T. Digoxin 0.25 mg 1/2 tab. 1 time per day after breakfast except Saturday and Sunday
3. T. Veroshpiron 25 mg 1 tab. 1 time per day before breakfast.
4. T. Thrombo ACC 100 mg 1 tab. 1 time per day after lunch.
5. T. Allopurinol 100 mg 1 tab. 1 time per day after lunch.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1973
Was on inpatient treatment (in the day hospital mode)
in the clinic of hospital therapy
Total number of days of treatment 24
The final diagnosis was established ICD Code I 13.9
Diagnosis:
Hypertension stage II (low blood pressure arterial hypertension 2, the risk of cardiovascular complications is "very high").
Coronary artery disease. Stable angina 1 functional class. Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis.
Chronic heart failure stage 1 1 functional class.
Primary gout is a mixed variant. Acute gouty arthritis with damage to the I metatarsophalangeal joint of the left foot in the phase of fading exacerbation. FTS I.
Android obesity II degree (BMI 36.2 kg/m2), essential, stable phase. Fatty hepatosis with a slight violation of liver function. Dysfunction of the sphincter of Oddi with a spastic component.
Diabetes mellitus of the second type, moderate severity, subcompensation.
Small-nodular hyperplasia of the left adrenal gland.
Secondary nephropathy of mixed (atherosclerotic, hypertensive, diabetic) genesis. Urolithiasis disease. Stone of the right kidney. Chronic latent pyelonephritis without exacerbation. Chronic kidney disease stage II (GFR 73 ml / min / 1.73 m2 according to the MDRD formula), microalbuminuria.
Initial manifestations of cerebrovascular insufficiency in the form of scattered neurological symptoms, astheno-neurotic syndrome.
Degenerative-dystrophic disease of the spine. Osteochondrosis, spondylosis of the lumbar. Chronic discogenic lumbar sciatica with L4-L5 radicular syndrome on the left in remission.
A disability certificate was not issued.
Ability to work restored
Total exposure dose 2.66 mSv
Clinical outcome: improvement
Outcome: discharged due to improvement
Conclusion VVK (VLK): discharged to the unit without medical examination.
On admission:
Complaints: increased blood pressure up to 180/140 mm. rt. Art., accompanied by a dull headache without a clear localization; memory loss; violation
History of present illness. Episodic headaches against the background of an increase in blood pressure have been a concern since 2000. In 2002, he was diagnosed with hypertension. Repeatedly passed inpatient treatment in the clinics of the Academy (VPT, Nervous diseases). Due to the ineffectiveness of the therapy, the appearance of edema and pain in the left foot, in 2007 he was examined inpatiently at the Clinic of Faculty Therapy of the Military Medical Academy, where he was diagnosed with an advanced metabolic syndrome ("Primary gout mixed variant. Acute gouty arthritis with damage to the first metatarsophalangeal joint of the left foot. Secondary osteoarthritis of the shoulder and knee joints FNS I. Hypertension stage II (AH 2, CVC risk 4) Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis without signs of heart failure. Type 2 diabetes mellitus, a sporadic variant, first identified. Obesity II degree, essential, stable phase. Diffuse non-toxic goiter of the 2nd degree, clinical euthyroidism. Fatty hepatosis 1 degree. Chronicdiscogenic radiculopathy with L4-L5 radicular syndrome on the left, with pain and muscular-tonic syndrome in remission). Since the same time, pronounced diffuse repolarization disorders have been detected on the ECG. In the future, against the background of constant neuropsychic overstrain, he noted an increase in the level of blood pressure, mainly diastolic, the appearance of edema of the legs and feet. In order to stabilize the condition, various combinations of medicines were used on an outpatient basis: Tarka, Prestarium, Arifon-retard, Amlodipine, Kordaflex ... However, all combinations were effective only for a short time after their administration, later there was a repeated increase in the level of diastolic blood pressure. He regularly took allopurinol 1-2 times a year for prophylactic purposes. Over the past year, against the background of constant neuropsychic overwork, he began to fall asleep with difficulty, independently used Morozov's drops, gradually increasing their dose to 5-10 ml before bedtime. With an increase in the level of diastolic blood pressure over 130 mm Hg. (during the first days of January 2012) began to notice pronounced pressing pains behind the sternum, independently took nitroglycerin with a positive effect.
Follows a strict hypoglycemic diet. Currently regularly taking Rasilez 300 mg 1 time / day (against this background, the level of blood pressure = 140/110 mm Hg), Thrombo ACC 0.1 / day, Glibomet 400 / 2.5 1 time per day (glucose level blood against this background with self-control 7.0-7.6 mmol/l); and in view of the exacerbation of gouty arthritis of the first metatarsophalangeal joint of the left foot since January 28 - allopurinol 100 mg/day, meloxicam 15 mg/day.
He was admitted to the clinic of hospital therapy as planned to correct the therapy and diagnose the cause of the increase in blood pressure and the genesis of thoracalgia.
Objectively Height 176 cm, body weight at admission 112 kg. BMI=36.2kg/m2. The general condition of moderate severity, stable, is due to the detailed picture of subcompensated metabolic syndrome. Hypersthenic constitution. Increased nutrition. Pastosity of the feet and legs to the middle third. The thyroid gland is not visually determined, the isthmus and the upper poles of the lobes are palpable, mobile when swallowing, not soldered to the surrounding tissues. On palpation of the radial arteries, the pulse is asynchronous, the same on both hands, arrhythmic, with a frequency of 62 beats. per minute, increased filling, uniform, tense, the vascular wall is palpated outside the pulse wave. Blood pressure: on the right shoulder - 160/110, on the left shoulder - 160/110 mm Hg. Art. The boundaries of relative cardiac dullness are extended to the left. Heart sounds are muffled short systolic murmur at the apex, accent of the second tone on the aorta. The respiratory rate is 18 per minute, the respiratory movements are rhythmic, both halves of the chest are evenly involved in the act of breathing. On auscultation of the lungs, there are no vesicular rales. Tongue wet, pink. The abdomen is enlarged in size due to the subcutaneous fat layer, the correct shape, symmetrical, evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*8*7 cm. The spleen is not palpable. Ragosa's symptom is negative. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. both halves of the chest evenly participate in the act of breathing. On auscultation of the lungs, there are no vesicular rales. Tongue wet, pink. The abdomen is enlarged in size due to the subcutaneous fat layer, the correct shape, symmetrical, evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*8*7 cm. The spleen is not palpable. Ragosa's symptom is negative. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. both halves of the chest evenly participate in the act of breathing. On auscultation of the lungs, there are no vesicular rales. Tongue wet, pink. The abdomen is enlarged in size due to the subcutaneous fat layer, the correct shape, symmetrical, evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*8*7 cm. The spleen is not palpable. Ragosa's symptom is negative. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*8*7 cm. The spleen is not palpable. Ragosa's symptom is negative. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*8*7 cm. The spleen is not palpable. Ragosa's symptom is negative. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless.
As a result of the treatment: regimen, diet No. 9, Metabolic therapy (polarizing mixture: Sol. NaCl 0.9% -200.0, Sol.KCl 5% -30.0, Sol.MgSO4 25% -10.0 -N2), Solution Diclofenac 3 ml / day / m No. 2, Solution. Sibazon 0.5%-2ml, solution Movalis 1%-5 ml / day No. 2, T. Glibomet 400/25 mg / day, T. Aspirin 125 mg / day, T. Atorvastatin 20 mg / day, T. Allopurinol 100 mg / day, T. Losartan 50 mg / day → Losartan 100 mg / day → T. Lorista 150 mg / day, Caps. Phosphogliv 4 caps/day, T. Cordipin 60 mg/day → T. Amlodipine 10 mg/day, T. Indapamide 1.5 mg/day, health improved, blood pressure stabilized at the level of "mild" hypertension (140-145/90-105 mm .rt.st.).
After assessing the level of ACTH, plasma renin activity, aldosterone (with a test: infusion of 1200 ml / 4 hours of 0.9% NaCl solution), daily excretion of cortisol: Amlodipine 5 mg in the morning, Veroshpiron 25 mg 3 times a day, the blood pressure level stabilized at 140 /90 mmHg
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
01.02.12
153
5.16
6.7
50
3
209
1
45
10
8
36
15.02.12
173
5.23
8.3
53
5
226
37
9
4
50
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epithelium Profit center in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
02/01/12
clear
1030
yellow
5.5
0.3
no
urates
1
no
no
1-2
no
0-2
1-5
microalbumin in urine 50.5 mg/l (norm: up to 25 mg/l)
17.02.12
clear
1025
yellow.
6.0
no
no
no
0
no
no
0-2
-
0-2
-
15.02.12
Zimnitsky's test - daily diuresis 1280 ml (750/530 ml), specific weight 1024-1027
Biochemical blood test:
Name
Unit of measure.
Norm
02/02/2012
02/07/12
02/15/12 02/20/12
Creatinine
µmol
/l
53-124
80
80
urea
mmol/l
2.5-6.4
5.6
4.7
Potassium
mmol/l.
3.5-5.1
3.81
4.34
glucose
mmol/l
3.9-6.3
5.64
total protein
g/l
63-87
64
Cholesterol
mmol/l
3.7-6.0
6.4
4.95
AST
U/l
11.0-50.0
81
ALT
U/l
11.0-50.0
70
GGTP
U/l
8-63
271
26
CPK
U/l
10-160
442
258
67
CPK-MB
U /l
0-25
22.4
HDL
U/l
120-216
228
amylase
U/l
30-118
50
TSH
μIU/ml
0.23-3.4
2.6
T4
nmol/l
53-158
103
alkaline phosphatase
U/l
45-129
59
bilirubin
mmol/l
6 .8-26
17.7
uric acid
µmol/l
15-420
393
Prothrombin
%
70-130
104
Fibrinogen
g/l
2.0-4.0
3.92
ACTH
pg/ml
<46
8.3
Aldosterone (9:00 )
pg/ml
10-105
172.9
Aldosterone (13:00)
(after infusion of 1200 ml/4h 0.9% NaCl)
pg/ml
10-105
63.6
Cortisol (9:00)
nmol/l
138-690
301
Cortisol ( 21:00)
nmol/l
70-345
39.2
Renin (direct)
μIU/ml
2.8-39.9 (lying down)
11.4
Angiotensin I (9:00)
ng/ml/hour
0.5-1 ,9
0.44
Analysis of daily fluctuations in blood glucose levels February 3, 2012: February 15,
2012:
08:00 – 6.6 mmol/l, 08:00 – 7.3 mmol/l,
10:00 – 8.9 mmol / l, 10:00 - 9.8 mmol / l
12:00 - 5.1 mmol / l. 12:00 - 10.7 mmol / l.
Safety factors [Anti-HCV (Core-n NS3-p NS4-n; Core-n NS4-p NS5-n), AT-HIV 1 and 2; Microreaction with cardiolipin antigen (RW)] from 02.02.12. - negative. HBsAg detected (31.01.12) Control HBsAg (07.02.12) - negative, PCR in hepatitis B virus (07.02.12) - negative
Lipidogram 01.02.2012: α 14.20% (13.00-44.00), β 41.71% (6.9-42.20); β 44.09% (30.30-62.70).
Results of instrumental studies:
X-ray of the chest, lumbar spine, knee and shoulder joints, feet (D=2.24 mSv) No. 482 dated 02/01/2012:
➢ On the chest radiograph in the lungs without focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is expanded in diameter to the left, the aorta is sealed.
➢ On the spondylograms of the lumbar spine in 2 projections, physiological lordosis is smoothed out, scalariform retrolisthesis with displacement of the vertebral bodies L2, L3, L4 posteriorly by 0.4 cm, 0.5 cm, 0.7 cm, respectively. Osteochondrosis of the L4-L5 motor segment with an uneven decrease in the height of the disc, compaction of the end plates and a marginal exophyte of 0.1 cm in the anterior section of the L5 in the projection of the disc.
➢ On radiographs of the knee joint in 2 projections and both shoulder joints, no bone changes were found.
➢ No bony changes were found on radiographs of the feet.
Computed tomography of the abdomen dated February 6, 2012: hepatomegaly, diffuse decrease in liver density. Small-scale hyperplasia of the left adrenal gland. Radiopaque calculus of the right kidney. Lymphoadeonopathy of intra-abdominal lymph nodes.
Magnetic resonance imaging of the lumbosacral spine, MR myelography dated February 6, 2012. MR picture of degenerative-dystrophic changes in the lumbosacral spine (osteochondrosis, spondylosis) with impaired statics. Herniated discs L4-L5, L5-S1 up to 4 mm.
Magnetic resonance imaging of the head with a targeted study of the chiasmal-sellar region dated February 17, 2012: MRI data for the presence of volumetric pathological formations of the pituitary gland were not obtained. MR picture of moderately severe dyscirculatory encephalopathy.
Ultrasound of the abdominal organs No. 298 dated February 1, 2011: the liver is enlarged, the right lobe: 16 cm; left 8.7 cm, smooth contours, homogeneous structure, increased echogenicity; the vascular pattern is depleted, the intrahepatic vessels are not dilated; portal vein 10 mm, hepatic veins 8 mm (up to 10 mm). Intrahepatic bile ducts are not dilated. The gallbladder of the correct form, 5.7 × 2.4 cm, the contours are even, the walls are 4-6 mm, unevenly thickened, calculi and polyps are not visualized, the common bile duct is 0.3 cm. The pancreas is clearly located, the head is 20.0 cm , the body is 18.3 cm, the contours are clear, even, the structure is heterogeneous, the echogenicity is moderately increased; Wirsung's duct is not dilated. Kidneys of normal size (right 10 × 6.0 cm, left 10.6 × 6.0 cm), normal location, with smooth contours, homogeneous parenchyma 16-18 mm thick, cavity systems are not expanded. The spleen is 9.3×4.7 cm in size, not enlarged. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: diffuse changes in the liver according to the type of fatty hepatosis.
DUHG 02/27/2012: Sphincter of Oddi dysfunction with spastic component
Ultrasound of the thyroid gland 02/01/2012: the gland is located typically, symmetrical, not enlarged. Right lobe 14.0×15.2×51.0 mm. Left lobe 16.0×13.3×47.0 mm. Isthmus 4 mm. The total volume is 11.1 ml. The contours are fuzzy, uneven, the structure is heterogeneous, increased echogenicity. Volumetric formations are not located, the blood flow is slightly increased. Regional lymph nodes are not changed. Conclusion: diffuse changes in the thyroid gland.
EchoCG on February 1, 2012: aorta 36 mm, aortic valve dilatation 18 mm, LA 49x50x50 mm, mitral valve S>4 cm2, leaflets sealed, CRLV 38 mm, CRLV 60 mm, EF 60%, FU 33%, PSLV 11 mm , MZHP 11 mm, LA 24 mm, PP 52x52 mm, KDRPZH 25 mm, E/A=1.28. Dilatation of the atrial cavities, left ventricle. No zones of local disturbance of kinetics were revealed. Moderate fibrosis of the IVS. The aorta, fibrous rings of the aortic and mitral valves are sealed. The valves have not been changed. The blood flow is laminar. Diastolic dysfunction 2 (pseudo-normal) type. Applied regurgitation of the mitral and tricuspid valves. The pericardium is not changed, there is no effusion.
ECG No. 425 dated February 15, 2012: atrial rhythm with a heart rate of 62/min, EOS is normal. Partial violation of intraventricular conduction. Left ventricular hypertrophy. Violation of repolarization in the anterior-lateral region
of the left ventricle Consulted by a neurologist on 02.02.2012, the diagnosis was made: Initial manifestations of cerebrovascular insufficiency in the form of scattered neurological symptoms, astheno-neurotic syndrome, chronic discogenic lumbar sciatica with L4-L5 radicular syndrome on the left, remission.
The goals of hospitalization have been achieved - the "target level" of blood pressure has been reached, the ability to work has been restored.
Discharged in a satisfactory condition.
Recommended:
16. Observation of the doctor of the unit according to DM-1 with the involvement of a cardiologist, neurologist, endocrinologist.
17. Control dynamic ultrasonic cholecystography after 1 month
18. Control of AST, ALT, CPK, GGTP, lipidograms after 1 month
19. Keep drinking regimen 1-1.5 l/day; restriction of the use of table salt (no more than 3 g per day).
20. Limit the use of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes).
21. Continue regular medication:
a. Tab. Eplerenone 50 mg 1 tablet daily in the morning.
b. Tab. Amlodipine 5 mg - 1 tablet daily in the morning.
c. Tab. Losartan 100 mg - 1 tablet daily in the morning.
d. Tab. Glibomet 400/2.5 mg - 1 tablet daily in the morning.
e. Tab. Atorvastatin 10 mg - 1 tablet in the evening continuously.
22. Continue course medication:
a. Tab. Duspatalin (Odeston) 0.4 1 tablet 15 minutes before breakfast and dinner 10 days
b. Caps. Urdoksa 0.25 - 2 capsules 2 times a
day
for
1
month (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1986
He was treated in the clinic of hospital therapy in day hospital mode
Total days of treatment 6
The final diagnosis was established by ICD Code K 26.7
Diagnosis:
Duodenal ulcer, often relapsing course, phase of unstable remission, cicatricial deformity of the duodenal bulb without impaired evacuation function. Chronic gastroduodenitis, exacerbation.
Alimentary-constitutional obesity of the 1st degree, android type, stable stage. Complex astigmatism of the right eye.
A disability certificate was not issued.
Ability to work restored
Total radiation dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no change, chronicity
, disability, established _____ disability group, degree of disability _______________________________, other _______________________________________ where)_____________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a medical
examination
.
Complaints of episodic pain in the epigastric region of a aching nature, decreasing after eating, aggravated on an empty stomach (hungry pain) and at night, heartburn, nausea, general weakness.
Anamnesis of the present disease (Anamnesis morbi):
Periodic aching pain in the epigastric region and heartburn after an error in nutrition has been noted since 2006, he did not seek medical help. FEGDS in 2007 verified chronic gastritis in the acute stage, was treated on an outpatient basis, took antacids with temporary improvement. In the future, abdominal pain syndrome recurred after errors in nutrition with a frequency of 2-3 times a year. He treated himself, took almagel with a good effect. Over the past year, abdominal pain has intensified and become more frequent.
On October 11, 2011, FEGDS revealed multiple (two) ulcers of the duodenal bulb. He was treated permanently in the clinic of faculty therapy for newly diagnosed peptic ulcer. On the background of the therapy, scarring of ulcerative defects was achieved. In the future, he took antacid drugs for relapses of abdominal pain syndrome with temporary improvement. Deterioration of well-being a month after discharge, when, after a nutritional error, aching pains in the epigastric region, heartburn, "night" pains recurred, he took Almagel, Omez with little effect. On November 16, 2011, FEGDS revealed an ulcer of the duodenal bulb. In this connection, he underwent inpatient treatment at the FT clinic from 22.11 to 12.12.2011.
Within a month after discharge, he felt satisfactorily, however, with a slight error in the diet, he noted the appearance of heartburn, sour eructation, which forced him to increase the dose of antacids taken on his own, and had a negative effect on the performance of official duties. He was hospitalized in a planned manner for a day hospital in order to diagnose the state of the gastrointestinal tract and correct the therapy.
Objective status:
The general condition is relatively satisfactory. Consciousness is clear. The position is active. Emotionally calm, there are no gross focal symptoms. No sensory disturbances were found. Correct physique, increased nutrition. There are no developmental defects or visible bodily injuries. Skin and mucous membranes of normal color, without rashes. Peripheral lymph nodes are not enlarged. The pulse on the radial arteries is 76 per minute, the same on both arms, satisfactory filling, not tense. The vascular wall outside the pulse wave is not palpable. BP - 130/90 mm Hg. The limits of relative cardiac dullness were within the normal range. Auscultation of the heart tones are clear, rhythmic. The pulse on the arteries of both feet is the same, satisfactory filling. The superficial veins of the lower extremities are not visible. The chest is correct, there are no deformations, evenly participates in the act of breathing Respiratory rate - 16 / min. With percussion of the lungs, a clear pulmonary sound is determined, which is the same at symmetrical points of the chest. The borders of the lungs are within the normal range. On auscultation, vesicular breathing is carried out evenly over the entire surface. There are no wheezes. The mucous membrane of the mouth is pink. The tongue is coated with white. Zev is not hyperemic. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. With percussion of the lungs, a clear pulmonary sound is determined, which is the same at symmetrical points of the chest. The borders of the lungs are within the normal range. On auscultation, vesicular breathing is carried out evenly over the entire surface. There are no wheezes. The mucous membrane of the mouth is pink. The tongue is coated with white. Zev is not hyperemic. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. With percussion of the lungs, a clear pulmonary sound is determined, which is the same at symmetrical points of the chest. The borders of the lungs are within the normal range. On auscultation, vesicular breathing is carried out evenly over the entire surface. There are no wheezes. The mucous membrane of the mouth is pink. The tongue is coated with white. Zev is not hyperemic. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. The borders of the lungs are within the normal range. On auscultation, vesicular breathing is carried out evenly over the entire surface. There are no wheezes. The mucous membrane of the mouth is pink. The tongue is coated with white. Zev is not hyperemic. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. The borders of the lungs are within the normal range. On auscultation, vesicular breathing is carried out evenly over the entire surface. There are no wheezes. The mucous membrane of the mouth is pink. The tongue is coated with white. Zev is not hyperemic. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged.
As a result of the treatment: regimen, diet No. 1, de-nol, omeprazole, almagel, the state of health improved.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., 109/l
MSN
ESR, mm/h
Lf, %
M, %
E, %
P/I, %
S/I, %
19.01
154
5.75
9.6
26.7
8
25
9
58
6
Общеклинический анализ мочи:
Дата
Прозрачность
Относительная плотность
Цвет
рН
Белок, г/л
Сахар, ммоль/л
Соли
Слизь
Ацетон
М/о
Эпителий МВП в п.з.
Цилиндры
в п.з.
Лейкоциты
в п.з.
Эритроциты в п.з.
19.01
прозр
1030
желт.
5,5
нет
нет
нет
2
нет
нет
2-4
нет
1-2
0-2
Биохимический анализ крови:
Наименование
Ед.изм.
Norm
19.01.2012
Cholesterol
Mmol/l
3.7-6.0
2.49
Total protein
G/l
63.0-87.0
77
AST
U/l
11.0-50.0
28
total bilirubin
mmol/l
6.8-26
13.2
glucose
mmol/l
3.9-6.2
5.49
C- RP
mg/l
3-10
9.42
Sialic acids
mol/l
1.9-2, 5
2.1
fibrinogen
g/l
2.0-4.0
4.13
PTI
%
70-110
105
alkaline phosphatase
U/l
36-129
109
GGTP
U/l
11-63
103
Results of instrumental studies:
ECG dated 17.01.2012 g.: sinus rhythm with a frequency of 76 per 1 minute, EOS is normal.
Ultrasound of the abdominal organs from 01/23/2012: the liver is not enlarged, the right lobe: 11.8 cm; left 6.5 cm, smooth contours, homogeneous structure, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein 8 mm, hepatic veins 7 mm (up to 10 mm). Intrahepatic bile ducts are not dilated. The gallbladder of the correct form, 5.6×1.3 cm, the walls are even 2 mm, stones are not visualized. The pancreas is located indistinctly, not enlarged, the contours are indistinct, even, the structure is homogeneous, echogenicity is average; Wirsung's duct is not dilated (2mm). Kidneys of normal size (right 11.2×4.7 cm, left 11.3×4.3 cm), normal location, with even contours, homogeneous parenchyma 15-19 mm thick, cavitary systems are not expanded. The spleen is 9.8×4.9 cm, not enlarged. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: moderate flatulence.
Plain radiograph of the chest No. 389 dated January 23, 2012: in the lungs without focal and infiltrative changes. The heart is not enlarged.
FGDS on 01/19/2012: The esophagus is passable, 42 cm from the upper incisors. Z-line at the level of the abdominal region is indistinct. The erosions were completely epithelialized. The mucosa in the distal section is somewhat hyperemic, edematous. The socket of the cardia does not close completely, there is a reflux of the contents of the stomach into the esophagus. In the stomach, folds of the usual caliber straighten out during insufflation. The mucosa is moderately hyperemic in the area of the body, in the antrum there are multiple, millet-like bulges (whitish). The pylorus does not close completely. The duodenal bulb is deformed due to a strengthened red linear scar. There is a whitish linear scar on the posterior-lateral wall. Conclusion: healed ulcer of the duodenal bulb. Moderately expressed cicatricial and ulcerative deformity of the duodenal bulb. Chronic gastritis with focal atrophy of the antrum (follicular-nodular antrum-gastritis). Distal catarrhal reflux esophagitis.
Recommended:
7. Doctor's supervision according to DM-1
8. Limit the consumption of animal fats, fried and spicy foods, increase the amount of vegetable fiber, vegetable fats, products in the diet.
9. Continue taking:
a. Caps. Omeprazole 0.02 1 capsule in the evening for 2 weeks.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1949
She was hospitalized at the hospital therapy clinic
In total, 10 days of treatment were carried out
. ICD Code M 17.9 MES 381020
Diagnosis:
Secondary nephropathy of mixed (atherosclerotic, hypertensive, nephritic) genesis. Chronic bilateral pyelonephritis, exacerbation phase. Cysts of the right kidney. Chronic kidney disease stage 4 (GFR 24 ml/h). Proteinuria. Chronic renal failure stage 1a. Neoplasm of both adrenal glands.
Arterial hypertension of mixed (essential, renoparenchymal) genesis of III degree → drug normotension, the risk of CVE is "very high".
Coronary artery disease. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis complicated by paroxysmal atrial fibrillation (without exacerbation).
Heart failure II functional class 2a stage.
Bronchial asthma of mixed genesis (infection-dependent, primary altered bronchial reactivity) of moderate course, remission without respiratory failure.
Fixed hiatal hernia. Chronic atrophic gastritis, erosive bulbitis, exacerbation.
Alimentary-constitutional obesity of the 2nd degree (BMI-37.6 kg/m2), stable course.
Certificate of incapacity for work: not issued
Total radiation dose 1.4 mSv
Clinical outcome: improvement.
Outcome: discharged.
Upon enrolment:
Complaints: frequent bouts of palpitations, increased blood pressure up to 190/150 mm Hg, episodic attacks of suffocation accompanied by wheezing, coughing with white bloody discharge, pain in the right hypochondrium and epigastric region with errors in diet.
History of present illness. She suffered from chronic bronchitis for a long time. in 2011, the disease acquired a protracted course with frequent attacks of dyspnea, which prevented active seeking medical help. Bronchial asthma was verified on a stationary basis, adequate therapy was selected for outpatient admission (Seretide-multidisc 50/250 1 dose 1 time per day and berodual 2 doses 2 times a day). In the same year, she was operated on for urolithiasis on both sides, the stones were removed. In the postoperative period, she began to notice a significant increase in blood pressure, mainly due to diastolic blood pressure, palpitations, weakness, and her weight began to progressively increase (over the past 2 years, body weight has been stable). Takes diltiazem without visible effect.
As a result of the treatment: regimen, diet No. 7, Seretide-multidisc, Berodual, Acecardol, Amlodipine, Omeprazole, Furosemide, Ciprofloxacin, the state of health improved.
The patient was consulted by Professor Barsukov A.V. It has been determined that at present the course of concomitant diseases is of the maximum possible compensated character. The severity of the condition and the prognosis determine the functional state of the excretory function of the kidneys and the existing neoplasms of the adrenal glands, which make a significant contribution to the maintenance of arterial hypertension, cardiac arrhythmias, and lesions of the upper gastrointestinal tract. Despite the convincing effect of the prescribed therapy, it is recommended that the patient undergo an additional examination on an outpatient basis in order to determine the functional state of the adrenal glands, perform a blood test for catecholamines, plasma renin activity, aldosterone levels (after discontinuation of drugs that affect the RAAS system for 14 days) followed by a consultation nephrologist.
Results of instrumental studies:
ECG on September 18, 2013: heart rate 83 per minute. Sinus rhythm. Horizontal position of the electrical axis of the heart. Left ventricular hypertrophy. Violation of repolarization processes in the area of the anterior wall and apex.
Echocardiography 23.09.2013: NORMAL
PARAMETERS
NORMAL
PARAMETERS
Diameter
of the aortic root
-
20-37 mm
ERD of the left ventricle
37.7
38-56 mm
Opening of the leaflets of the aortic valve
21.1
more than 15 mm EFR of the
left ventricle
27.4
22-38 mm
Antero-posterior size of the left atrium
25
39.2 -40 mm
Anterior wall thickness of the right ventricle
6.0
less than 5 mm
Transverse left atrium
39.8
25-45 mm
Left ventricular ejection fraction
55
more than 55%
Longitudinal dimension of the left atrium
51.7
29-53 mm
Longitudinal dimension of the right atrium
46.2
Interventricular septal thickness
13.3
7-11 mm
Transverse dimension of the right atrium
37.1
34-49 mm
Thickness of the posterior wall of the left ventricle
12.6
7-11 mm
ECR of the right ventricle
37.7
Less than 30 mm
Systolic pressure in the pulmonary artery
28
to 30 mm Hg
Pulmonary trunk diameter
-
12-23 mm
LVMI, g/m2
92
Less than 109/124 LVMI
, g
198
Less than 141/183
Echocardiography: Sinus rhythm. The walls of the aorta are sealed. The leaflets of the aortic valve are sealed and calcified. Concentric remodeling of the left ventricle. The cavities of the heart are not dilated, free. The systolic function of the left ventricle is preserved. Restrictive type diastolic dysfunction of the left ventricle. LV contractility (global and local) is not broken. Mitral regurgitation 1 degree. Pericardium - without features.
Holter blood pressure monitoring on September 24, 2013: mean systolic blood pressure during the day and mean diastolic blood pressure during the daytime were within the normal range, mean diastolic blood pressure at night is characteristic of mild labile hypertension. At night, systolic and diastolic blood pressure decrease insufficiently (nondipper). The variability of systolic and diastolic blood pressure during the day is within the acceptable range. Episodes of hypotension were not registered. There is an increase in the rate of morning rise in systolic blood pressure.
Holter monitoring of the ECG on September 20, 2013: During the observation, sinus rhythm was recorded with a heart rate of 49 to 97 per minute. The decrease in heart rate at night is insufficient. Average heart rate 58/63/53 per minute. Registered single supraventricular extrasystoles (total 123), periodically paired, group. When performing the planned load (staircase test 72 and 96 steps), the heart rate reached 78 and 97 per minute. Ischemic changes in the ST segment were not detected.
Spirometry on September 23, 2013: VC 46%, FVC 48%, FEV1 40%. Violation of FVL according to the mixed type III degree (sharp).
Spirometry (test with salbutamol) on September 23, 2013: VC 61%, FVC 61%, FEV1 49%. ROf expiration 22.55%. The test with salbutamol is positive (the coefficient of bronchodilation was 22.55%).
Ultrasound examination of the abdominal cavity and thyroid gland on September 20, 2013: the liver is not enlarged, the right lobe is 16.0 cm, the left lobe is 9.9 cm, echogenicity is increased, the vascular pattern is depleted, choledochus is 4 mm. The gallbladder is irregular in shape, an inflection in the area of the body. Dimensions: length 5.6cm, diameter 3.1cm, smooth contours, wall 3mm, not changed. The pancreas is located indistinctly, the dimensions are: the head is 19.5 mm, the body is 17.2 mm, the contours are fuzzy, uneven, the structure is heterogeneous with signs of lipomatosis, the Wirsung duct is not dilated, 2 mm. The spleen is not enlarged, dimensions: length 10.0 cm, thickness 5.6 mm, homogeneous structure. Kidneys: irregular contours. Right kidney: length 11.0 cm, width 5.7 cm, homogeneous parenchyma 16.0 mm, PCL moderately dilated, grossly deformed. Hyperechoic inclusions 65 x 45 mm, 26 x 23 are visualized in the upper pole of the kidney. 2 mm with partitions. In the area of the sinus, the calculus is 19.5 mm in diameter. Left kidney: length 10 cm, width 5.0 cm, homogeneous parenchyma 15.5 mm, PCL is sealed. In the area of the adrenal gland, no changes are visualized. The thyroid gland is not enlarged, the contours are fuzzy, uneven, the structure is heterogeneous, the isthmus is 5 mm. Right lobe: width 23.0cm, thickness 22.7cm, length 43.4cm, volume 12.0cm3. Left lobe: width 29.1cm, thickness 33.4cm, length 52.0cm, volume 26.4cm3. Vtot. 138.4. Diffuse mass formations are not visualized. The blood flow is moderately increased. Regional lymph nodes are not changed. Conclusion: Diffuse changes in the liver according to the type of fatty hepatosis. Pancreatic lipomatosis. ICD. Cysts of the right kidney. Hyperplasia of the thyroid gland. CHLS is sealed. In the area of the adrenal gland, no changes are visualized. The thyroid gland is not enlarged, the contours are fuzzy, uneven, the structure is heterogeneous, the isthmus is 5 mm. Right lobe: width 23.0cm, thickness 22.7cm, length 43.4cm, volume 12.0cm3. Left lobe: width 29.1cm, thickness 33.4cm, length 52.0cm, volume 26.4cm3. Vtot. 138.4. Diffuse mass formations are not visualized. The blood flow is moderately increased. Regional lymph nodes are not changed. Conclusion: Diffuse changes in the liver according to the type of fatty hepatosis. Pancreatic lipomatosis. ICD. Cysts of the right kidney. Hyperplasia of the thyroid gland. CHLS is sealed. In the area of the adrenal gland, no changes are visualized. The thyroid gland is not enlarged, the contours are fuzzy, uneven, the structure is heterogeneous, the isthmus is 5 mm. Right lobe: width 23.0cm, thickness 22.7cm, length 43.4cm, volume 12.0cm3. Left lobe: width 29.1cm, thickness 33.4cm, length 52.0cm, volume 26.4cm3. Vtot. 138.4. Diffuse mass formations are not visualized. The blood flow is moderately increased. Regional lymph nodes are not changed. Conclusion: Diffuse changes in the liver according to the type of fatty hepatosis. Pancreatic lipomatosis. ICD. Cysts of the right kidney. Hyperplasia of the thyroid gland. 1cm, thickness 33.4cm, length 52.0cm, volume 26.4cm3. Vtot. 138.4. Diffuse mass formations are not visualized. The blood flow is moderately increased. Regional lymph nodes are not changed. Conclusion: Diffuse changes in the liver according to the type of fatty hepatosis. Pancreatic lipomatosis. ICD. Cysts of the right kidney. Hyperplasia of the thyroid gland. 1cm, thickness 33.4cm, length 52.0cm, volume 26.4cm3. Vtot. 138.4. Diffuse mass formations are not visualized. The blood flow is moderately increased. Regional lymph nodes are not changed. Conclusion: Diffuse changes in the liver according to the type of fatty hepatosis. Pancreatic lipomatosis. ICD. Cysts of the right kidney. Hyperplasia of the thyroid gland.
Fibrogastroduodenoscopy on 09/19/2013: the esophagus is passable, 38 cm from the upper incisors. G line at the level of 35 cm from the upper incisors, a symptom of "two cardias" is noted, a fixed fixed hernia of the pi of the esophageal opening of the diaphragm is not excluded. In the mid/gr and v/gr sections of the esophagus, there are single veins in the form of tubercles of a bluish hue with a diameter of 0.2 to 0.4 cm. In the stomach, folds of the usual caliber are straightened out during insufflation. The mucosa is moderately hypertrophied with areas of atrophy. The pylorus does not close completely, there is a reflux of duodenal contents with prolapse of the mucosa of the pyloric canal. There are multiple petechial erosions in the duodenal bulb. Conclusion: "Ectopic varix" of the upper esophagus. Fixed hiatal hernia. Chronic focal atrophic gastritis. Duodenogastric reflux with hypermotor dyskinesia. Erosive bulbitis.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/L
Leuc., *109/L
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
Tr, 109/L
19.09
128
4.44
4.0
28.9
12
0
-
43
5
1
52
229
General
urine
analysis
(
automatic
processing
)
:
Date
Urobil
Bacteria
19.09
1015
6.5
0.1
No
No
30-35-40
8-10-15
3.2
1
Biochemical blood test:
Name
Unit of measure.
Norm
19.09
27.09
Glucose
mmol/l
4.2-6.4
5.29
Creatinine
mmol/l
0.05-0.12
0.19
0.21
Urea
mmol/l
2.5-6.4
12.0
16.3
Cholesterol
mmol/l
3.7-6.0
5.53
Potassium
mmol/l
3.50-5.10
5.28
4.76
sodium
mmol/l
136-145
145.0
ALT
U/l
11-50
23
AST
U/l
11-50
20
O. protein
g/l
63-87
68
Prothrombin
%
70-120
103
Fibrinogen
g
/
l
2.0-4.0
2.45
Unit.
Norm
20.09
Albumin
%
55.80..65.00
53.25
Alpha1
%
2.20..4.60
4.06
Alpha2
%
8.20..12.50
13.28
Beta
%
7.20..14.20
9.36
Gamma
%
11.50..18.60
20.05
Recommended:
10. Observation by a nephrologist at the place of residence.
11. Diet:
a. Limiting the intake of protein with food to up to 0.8-1 g / kg (up to 50-60 g per day), depending on the severity of renal failure. At the same time, 30 g should be a high-value protein, and only 10 g of protein per day should fall on the share of bread, cereals, potatoes and other vegetables. 30-40 g of complete protein. In general, the patient's menu is compiled within table No. 7. The following products are included in the patient's daily diet: meat (100-120 g), cottage cheese dishes, cereal dishes, semolina, rice, buckwheat, barley porridge. A potato and potato-egg diet is recommended. Particularly suitable due to the low protein content and at the same time high energy value are potato dishes (fritters, meatballs, grandmothers, fried potatoes, mashed potatoes, etc.), salads with sour cream, vinaigrettes with a significant amount (50-100 g) of vegetable oil. Tea or coffee can be acidified with lemon, put 2-3 tablespoons of sugar in a glass, it is recommended to use honey, jam, jam. Thus, the main composition of food is carbohydrates and fats and dosed - proteins. Calculating the daily amount of protein in the diet is a must. It is allowed to replace 1 egg with: cottage cheese - 40 g; meat - 35 g; fish - 50 g; milk - 160 g; cheese - 20 g; beef liver - 40 g.
Approximate diet:
• Breakfast: Soft-boiled egg + Rice porridge 60 g + Honey 50 g
• Lunch: Fresh cabbage soup 300 g + Fried fish with mashed potatoes 150 g + Apples
• Dinner: Mashed potatoes 300 g + Vegetable salad 200 g + Milk 200 d
Correction of water balance disorders: take enough liquid to maintain diuresis within 2-2.5 liters per day.
Correction of electrolyte imbalance: salt intake should be limited to 5-10 g per day
12. Perform in a planned manner:
a. Urinalysis for daily protein loss;
b. blood test for catecholamines, plasma renin activity, aldosterone level
13. Nephrologist's consultation with research results.
14. Continue taking:
• Amlodipine 5 mg - 1 tab. in the morning constantly;
• Allapenin 25 mg - 1 tab. 2 times a day;
• Furosemide 40 mg - ½ tab. in the morning;
• Seretide multidisk 50/250 1 dose 2 times a day
• Berodual - op 1 dose 2 times a day
• Omeprazole 20 mg - 1 capsule in the morning for 14 days.
Limiting the intake of protein with food to up to 0.8-1 g / kg (up to 50-60 g per day), depending on the severity of renal failure. At the same time, 30 g should be a high-value protein, and only 10 g of protein per day should fall on the share of bread, cereals, potatoes and other vegetables. 30-40 g of complete protein. In general, the patient's menu is compiled within table No. 7. The following products are included in the patient's daily diet: meat (100-120 g), cottage cheese dishes, cereal dishes, semolina, rice, buckwheat, barley porridge. A potato and potato-egg diet is recommended. Particularly suitable due to the low protein content and at the same time high energy value are potato dishes (fritters, meatballs, grandmothers, fried potatoes, mashed potatoes, etc.), salads with sour cream, vinaigrettes with a significant amount (50-100 g) of vegetable oil. Tea or coffee can be acidified with lemon, put 2-3 tablespoons of sugar in a glass, it is recommended to use honey, jam, jam. Thus, the main composition of food is carbohydrates and fats and dosed - proteins. Calculating the daily amount of protein in the diet is a must.
An approximate daily set of products (diet No. 7) per 50 g of protein in chronic renal failure
It is allowed to replace 1 egg with: cottage cheese - 40 g; meat - 35 g; fish - 50 g; milk - 160 g; cheese - 20 g; beef liver - 40 g.
Approximate diet:
• Breakfast: Soft-boiled egg + Rice porridge 60 g + Honey 50 g
• Lunch: Fresh cabbage soup 300 g + Fried fish with mashed potatoes 150 g + Apples
• Dinner: Mashed potatoes 300 g + Salad vegetable 200 g + Milk 200 g
Correction of water balance disorders: take enough liquid to maintain diuresis within 2-2.5 liters per day.
Correction of electrolyte imbalance: salt intake should be limited to 5-10 g per day
MILITARY MEDICAL ACADEMY Form 12_Uni.VMedA-2011
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic born in 1990
He was hospitalized at the clinic of hospital therapy
Total days of treatment were 7
The final diagnosis was established ICD code G 90.8
DIAGNOSIS:
Main disease: Neurocirculatory asthenia of the cardiac type with severe cardialgic syndrome without heart failure. Nutritional deficiencies.
Concomitant disease: Gastroesophageal reflux disease. Distal catarrhal reflux esophagitis. Superficial gastroduodenitis.
Certificate of incapacity for work: not issued
Total exposure dose _____0.6 mSv ____
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, disability group established, degree of limitation
Outcome: discharged due to improvement
Complaints: palpitations, pressing, stabbing pain in the heart area, irradiation under the left shoulder blade and into the left shoulder with moderate physical exertion, rise to the second floor), psycho-emotional stress, in the position on the left side, discomfort in the epigastrium when bending forward.
Disease history. Chronic diseases are denied. These symptoms began to bother about 2 weeks ago with a tendency to progression, did not take any medications. During the last 3 days, he notes an increase in shortness of breath, the appearance of pressing pain in the region of the heart, radiating under the left shoulder blade and shoulder, and palpitations. On May 27, 2013, he applied for medical help at the Central Clinical Hospital, was consulted by a cardiologist, hospitalization in the cardiology department was recommended.
For examination and treatment, he was admitted to the clinic of GT VMedA in a planned manner.
As a result of the treatment: regimen, diet N10, caps. Cardionate 1.0 g/day showed positive dynamics: the pain syndrome did not recur, hemodynamic parameters were at the level of normal values. Given the patient's lack of a history of cardiac pathology, episodes of pain syndrome should be considered within the framework of dysfunction of the autonomic nervous system.
Results of instrumental studies:
ECG dated May 28, 2013: Sinus rhythm with heart rate 72. EOS vertical position.
ECG control dated May 30, 2013: no dynamics.
FEGDS from 06/03/2013: distal catarrhal reflux esophagitis. Superficial gastroduodenitis.
FLG UGP dated May 29, 2013: no pathological changes.
VEM dated May 31, 2013: negative test.
24-hour ECG monitoring on May 30, 2013: sinus rhythm was recorded during the observation period. Heart rate from 47 to 118 per minute. The decrease in heart rate at night is adequate. Average heart rate 66/72/57 per minute. The following rhythm and conduction disturbances were registered: single supraventricular (2 in total) and ventricular extrasystoles (49 in total). When performing the planned load, the heart rate reached 118 and 113 per minute. Ischemic changes in the ST segment were not detected.
Echocardiography dated May 29, 2013:
Result, mm
Norm, mm
Aorta
At the level of AK
25.4
22-36
Valve opening
18.8
15-26
Left atrium
Anteroposterior size
28.2
25-40
Left ventricle
DSR
30.8
≤ 36
EC
47.4
≤ 55
Posterior wall thickness (diast.)
7.4
Interventricular septal thickness (l)
7.4
Right ventricle
EC
≤ 30
Anterior wall
4.2
≤ 5
Right atrium
Transverse dimension
34.6
29-46
Longitudinal dimension
34.6
34-49
Pulmonary artery
At the valve
12-23
Indicator
Result
Norm
FU, %
35
28-41
EF, %
64
≥55
Ve/Va
1.3
1.0-2.2
Conclusion: Large vessels of the heart without visible pathology. Normal geometry of the left ventricle. The cavities of the heart are not dilated, free. The systolic function of the left ventricle is preserved. Applied tricuspid regurgitation. Pericardium without features. Dopplerography revealed no pathology.
Laboratory results : Complete
urinalysis (automatic processing):
Date
U.weight
Reak
Protein
Sax
Ket.
Lei
Er.neiz
Urobil
29.05
1025
5.5
-
-
-
0-2
-
0.2 CBC
:
Date
Hb, ед.
Эр., *1012/л
Лейк., *109/л
Тр. *109/л
МСН
СОЭ, мм/ч
Э
%
Б
%
Лф
%
М
%
Пя
%
Ся
%
29.05
141
5,39
3,4
194
26,2
5
-
1
42
6
1
43
31.05
146
5,64
4,8
222
25,8
4
4
-
52
7
1
36
Биохимический анализ крови:
Name
Unit.
Norm
29.05
O. protein
g/l
64-83
69
Glucose
mmol/l
4.2-6.4
4.93
Creatinine
mmol/l
0.05-0.12
0.1
Potassium
mmol/l
3.4-4.5
4.22
Calcium
mmol/l
2.1-2.55
Sodium
mmol/l
130-150
137.7
Cholesterol
mmol/l
3.7-6.0
3.71
Total bilirubin
mmol/l
6.3-26
21.9
Direct bilirubin
mmol/l
Urea
mmol/ l
1.9-2.5
5.5
AST
U/l
11-50
ALT
U/l
11-50
GGTP
U/l
CPK
100.4
CPK MB
AtTPO
less than 37
T3
1.25
T4
T4 St.
Nmol/l
0.89-1.76
TSH
0.35-5.5
2.18
glycated Hv
%
PSA
Ng/ml
Up to 4
0.78
Test for HBsAg, anti-HCV, RW, F-50 04/13/2013: negative.
Coagulogram dated April 13, 2013: fibrinogen 2.39 g/l
Coprogram dated April 13, 2013: mushy consistency, neutral mucus reaction - 0, blood - 0, digested muscle fibers 2, undigested longitudinal striation 2, transverse striation 1, vegetable fiber: digested 0, undigested 2, starch grains: intracellular 0 , extracellular 1, iodophilic flora 2, neutral fat 0, fatty acids 2, soaps 1; leukocytes 0; Erythrocytes 0. I/g were not found.
Discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
7. Observation, therapist, gastroenterologist.
8. Normalization of the regime of work and rest. Exclude the use of animal fats, easily digestible carbohydrates, alcohol, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet. exercise therapy.
9. Observe the water regime (fluid balance), daily monitoring of blood pressure and heart rate.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. d. 63, tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1961
Was on inpatient treatment (in day hospital mode)
in the clinic of hospital therapy
Total days of treatment 15
The final diagnosis was established ICD code I.10
Diagnosis:
Hypertensive disease of the second stage.
Coronary artery disease. Angina pectoris of the second functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis.
Heart failure of the first functional class.
Diabetes mellitus of the second type, moderate severity, compensated.
Intervertebral osteochondrosis, deforming spondylosis of the cervical, thoracic, lumbar, lumbar spondylarthrosis, right-sided first degree scoliosis of the thoracic regions with a slight dysfunction of the spine. Chronic discogenic radiculopathy from the fifth lumbar, first sacral roots on the right, remission, without impaired function of the lower extremities.
Dyscirculatory encephalopathy of the second stage of mixed genesis (post-traumatic (1996), atherosclerotic, hypertensive, dysmetabolic) in the form of external hydrocephalus, multiple vascular foci in both frontal lobes, left-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome.
Curvature of the nasal septum without persistent violation of nasal breathing. Vasomotor rhinosinusopathy.
Partial secondary adentia of the upper and lower jaws.
Alimentary obesity of the second degree, stable stage.
Diffuse-nodular euthyroid goiter of the first degree.
Diffuse pneumosclerosis without respiratory failure.
Secondary nephropathy of mixed origin (atherosclerotic, hypertensive, diabetic) without signs of renal failure
.
Ability to work restored
Total radiation dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity
, disability, established _____ disability group, degree of disability _______________________________, other _____________________________________________ where)_____________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a medical
examination
.
Complaints: headache, dizziness, pain in the region of the heart of a pressing nature during physical and psycho-emotional stress, fatigue, memory impairment, decreased performance, emotional lability, sleep disturbance, pain in the spine during physical exertion and prolonged work in a sitting position, the absence of several teeth upper and lower jaws, dry mouth, thirst, overweight.
Anamnesis of the disease: headache in the occipital region, increased blood pressure to 160/90-170/100 mm Hg. Art. worried since 1996, hospitalized diagnosed with hypertension of the first stage. Subsequently, with an increase in blood pressure, enalapril was occasionally taken. Over the past 10 years, notes a stable increase in blood pressure up to 160/100 mm Hg. Art., repeatedly developed a hypertensive crisis, hospitalized diagnosed with hypertension stage II, for permanent use assigned to ACE inhibitors, diuretics. Pressing pain in the region of the heart during physical and psycho-emotional stress over the past year, "on demand" independently took nitroglycerin, in the hospital diagnosed with coronary artery disease, angina pectoris FC 2.
According to the injury certificate of the commander of military unit 63174 dated October 22, 1996, No. 193, on October 15, 1996, while performing military service duties on the territory of the Chechen Republic, he followed the duty station in a GAZ-66 car, which collided with a ZIL-130 car , who fled the scene of an accident, hit his head on the metal rack of the cab, lost consciousness. He underwent inpatient treatment at military unit 63174 with a diagnosis of CBI, concussion. 11/04/1996 was examined by the military military commander at military unit 63174 with a causal relationship "Military injury". In the future, he began to notice the appearance of headache, dizziness at "working" values of blood pressure. Repeatedly underwent treatment with a diagnosis of "remote consequences of CBI".
Pain in the spine has been bothering me for ten years; in 2010, chronic radiculopathy of the L5 and S1 roots on the right was diagnosed as a hospital.
For 10 years, he has noted an increase in body weight, since 2010, body weight has been stable.
In 2010, ultrasound diagnosed a thyroid nodule without disturbing its function.
In 2010, hyperglycemia was detected, type II diabetes mellitus was diagnosed, normoglycemia is achieved with a constant intake of 500 mg of Siofor.
Repeatedly treated at the dentist, extraction of teeth was performed.
Sent to the VVK to determine the category of fitness for military service upon reaching the age limit for military service.
The present examination revealed a curvature of the nasal septum, diffuse pneumosclerosis.
Objective status: hypersthenic physique, overnutrition (BMI-35.1). Skin and visible mucous membranes of normal color. Absence of 14, 15, 17, 24, 25, 26, 27, 36, 46, 47 teeth. Peripheral lymph nodes and thyroid gland are not enlarged. Pastosity of legs and feet. Natural curves of the spine: flattening of the cervical and lumbar lordosis. On palpation, pain over the paravertebral points in the thoracic spine. The distance between the spinous process of the 7th cervical vertebra and the tubercle of the occipital bone increases by 3 cm when the head is tilted, and when the head is tilted back (extension) it decreases by 6 cm. The distance between the spinous processes of the 7th cervical and 1 sacral vertebrae increases by 7 cm when bending over normal posture and decreases by 4 cm when bending back. Lateral movements (tilts) of the body in the lumbar and thoracic regions are possible up to 200 from the vertical line. Movement in the joints of the limbs in full. Pulse 72 per minute, rhythmic. The right and upper borders of the heart are normal, the left - along the left mid-clavicular line. Heart sounds are muffled. BP 160/100-140/90 mmHg Art. Above the lungs there is a clear pulmonary sound, vesicular breathing. The abdomen is painless. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. The perianal region, with a digital examination - the rectum - without pathology. Psychoneurological status: there is a fixation on a change in one's state of health, the situational insistence is reduced, does not reach the level of depression. Emotional and vegetative reactions are unstable. The face is not symmetrical - the left nasolabial fold is smoothed. Weak convergence on both sides. The pharyngeal reflex is increased on both sides. Deep reflexes D>S (anisoreflexia), pathological carpal signs of Rossolimo, Hoffmann on the left. The muscle tone on the left is lowered, changed according to the cerebellar type. Adiadochokinesis. Hypermetry on the left. In the Romberg position, it deviates to the left. Hypesthesia of the radicular type in the projection of the fifth lumbar, first sacral roots on the right. The phenomenon of oral automatism. Visual acuity: OD=OS=1.0. The fundus of the eye: the arteries are narrowed, the veins are dilated, tortuous, the ratio a:b=1:2. IOP: 20/19 mmHg Art. ENT organs: the nasal septum is slightly curved to the right in the form of a cartilaginous ridge. Rumor: SR 6/6 m. The muscle tone on the left is lowered, changed according to the cerebellar type. Adiadochokinesis. Hypermetry on the left. In the Romberg position, it deviates to the left. Hypesthesia of the radicular type in the projection of the fifth lumbar, first sacral roots on the right. The phenomenon of oral automatism. Visual acuity: OD=OS=1.0. The fundus of the eye: the arteries are narrowed, the veins are dilated, tortuous, the ratio a:b=1:2. IOP: 20/19 mmHg Art. ENT organs: the nasal septum is slightly curved to the right in the form of a cartilaginous ridge. Rumor: SR 6/6 m. The muscle tone on the left is lowered, changed according to the cerebellar type. Adiadochokinesis. Hypermetry on the left. In the Romberg position, it deviates to the left. Hypesthesia of the radicular type in the projection of the fifth lumbar, first sacral roots on the right. The phenomenon of oral automatism. Visual acuity: OD=OS=1.0. The fundus of the eye: the arteries are narrowed, the veins are dilated, tortuous, the ratio a:b=1:2. IOP: 20/19 mmHg Art. ENT organs: the nasal septum is slightly curved to the right in the form of a cartilaginous ridge. Rumor: SR 6/6 m. the nasal septum is slightly curved to the right in the form of a cartilaginous ridge. Rumor: SR 6/6 m. the nasal septum is slightly curved to the right in the form of a cartilaginous ridge. Rumor: SR 6/6 m.
As a result of the treatment: regimen, diet No. 10, Metabolic therapy, diuretics (indapamide - 2.5 mg 1 time per day), ACE inhibitors (Enalapril 5 mg 2 times a day), Aspicor 100 mg in the morning, hypoglycemic agents (Metformin 500 mg 2 times a day), stugeron, celebrex, health improved, symptoms of heart failure stopped, blood pressure stabilized at the target level (130-135/80-90 mm Hg), headaches significantly decreased.
The results of laboratory and instrumental studies:
complete blood and urine analysis on 06/24/2011: ESR 26 mm/h, other indicators are normal.
Biochemical blood test on June 24, 2011: cholesterol 6.25 mmol/l, GGTP 85 U/L, ALT, AST, alkaline phosphatase, CPK, glucose, urea triglycerides, creatinine, amylase, electrolytes, total protein is normal.
Glycolized hemoglobin 06/24/2011: 6.6%.
HBs-Ag, anti-HCV, serological tests for syphilis, F-50 06/10/2011: negative. PSA 06/24/2011: normal.
ECG 06/22/2011: sinus bradycardia with a heart rate of 58 per minute, horizontal EOS, partial violation of intraventricular conduction. The predominance of the potentials of the left ventricle.
Ultrasound of 06/06/2011: the liver is not slightly enlarged, echogenicity is increased. Choledoch, portal vein, gallbladder, pancreas, kidneys, spleen without pathology.
Ultrasound of the small pelvis on June 24, 2011: the bladder is without pathology. The prostate gland (30x40x44 mm), the echostructure is homogeneous. There is no residual urine.
Ultrasound of the thyroid gland on 06/06/2011: the gland is located typically, enlarged. Right lobe 23x28x63 mm, volume 22 ml. Left lobe 20x21x61 mm, volume 13.5 ml. Isthmus 3 mm. The total volume is 35 ml. The contours are clear, even, the structure is heterogeneous, medium echogenicity. In the right lobe, there is an isoechoic nodule 15 mm in diameter, with a cystic central component without signs of increased blood flow.
EchoCG on 06/03/2011: aorta 31 mm, aortic valve dilatation 18 mm, LA 43x46x61 mm, mitral valve S>4 cm2, leaflets sealed, CRLV 35 mm, CRLV 56 mm, EF 58%, FU 29%, PSL 12 mm , MZHP 12 mm, LA 22 mm, PP 49x56 mm, KDRPZH 29 mm, E/A=0.86. Dilatation of the atrial cavities. atherosclerosis of the aorta. Symmetrical LV myocardial hypertrophy. LV diastolic dysfunction.
SM BP and ECG 06/08/2011: in the afternoon: cf. SBP 152 mmHg Art., max. SBP 189 mmHg st., min. SBP 117 mmHg st., cf. DBP 92 mm Hg avg., max. DBP 112 mm Hg st., min. DBP 71 mm Hg. st., at night: cf. SBP 147 mmHg Art., max. SBP 160 mmHg st., min. SBP 128 mmHg st., cf. DBP 87 mm Hg avg., max. DBP 99 mmHg st., min. DBP 69 mm Hg Art. Sinus rhythm was recorded with a heart rate of 51 to 132 per minute. At night, the decrease in heart rate is insufficient. Two supraventricular extrasystoles were registered. When performing the planned load, the heart rate reached 132 and 125 in 1 minute, while palpitations, shortness of breath, horizontal depression of the ST segment according to the ischemic type up to 2 mm were subjectively noted.
Radiography of the UCP on June 2, 2011: in the lungs without focal and infiltrative changes. The pulmonary pattern is reinforced and deformed due to diffuse pneumosclerosis. The roots of the lung structure. The sinuses are free. The heart is dilated to the left. The aorta is condensed and deployed.
Spondylography on 06/02/2011: physiological lordosis is straightened, C2 body is shifted posteriorly by 0.5 cm. The height of the intervertebral discs is reduced at the level of C4-5, C5-6, C6-7, the endplates are compacted, marginal bone growths in the anterior parts of the bodies C5,6,7 in the projection of the intervertebral discs and C4.5 outside the plane of the intervertebral discs in the form of a bracket. Right-sided scoliosis with an angle of deviation from the vertical axis of 70 (according to Chaklin) with the center of the arc at the level of Th3-7, torsion of the bodies Th3,4,5 to the left. The thoracic kyphosis is intensified. The height of the intervertebral discs is reduced at the level of Th5-6, Th6-7, Th7-8, the endplates are compacted, the marginal exophytes in the anterior parts of the bodies are Th5,6,7,8 0.1 cm in the projection of the intervertebral discs. Schmorl's hernia at the level of Th6-7, Th7-8. the height of the intervertebral discs at the level of L3-4, L4-5 is reduced, the endplates are compacted, marginal exophytes are 0,
EPI 06/29/2011: instability, increased exhaustion of attention come to the fore. Memory functions are moderately expressed. Thinking with moderately pronounced signs of a decrease in the level of the generalization process.
The goals of hospitalization were achieved - the "target level" of blood pressure - 120-130 / 70-85 mm Hg was reached, the cephalgic syndrome was reduced, the ability to work was restored.
Certified by VVK. On the basis of articles 43 b, 44 b, 24 b, 25 c, 13 b, 66 c columns III of the schedule of illnesses and TDT (annex to the Regulations on military medical examination, approved by Decree of the Government of the Russian Federation of February 25, 2003 No. 123)
B - limited fit for military service.
Discharged in a satisfactory condition under the supervision of doctors of the Central Committee for Children's Hospital of the Military Medical Academy
Recommended:
23. Observation of a cardiologist, neurologist, endocrinologist, gastroenterologist at a polyclinic at the place of residence;
24. Exercise therapy - constantly, swimming;
25. Spinal massage 10 sessions every 6 months;
26. Observe the drinking regime of 1-1.5 l / day; limiting the use of table salt (no more than 3 g per day), limiting easily digestible carbohydrates;
27. Limit the consumption of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium;
28. Periodic level control:
a. the level of glycemia on an empty stomach and 2 hours after a meal;
b. the level of glycosylated hemoglobin - 1 time in 3 months;
c. levels of TSH, St. T4 - 1 time in 6 months;
d. Ultrasound of the thyroid gland - 1 time in 6 months;
e. Examination by an ophthalmologist once a year.
29. Continue taking:
a. Tab. Lozap-plus 80 mg 1 tablet daily in the morning;
b. Tab. Thrombo ACC 0.05 1 tablet in the morning constantly;
c. Tab. Siofor 500 mg - 1 tablet at 22:00 constantly;
d. Tab. Cytoflavin - 2 tablets in the morning and in the afternoon for 1 month;
e. Tab. Stugeron - 1 tablet 3 times a day for 1 month;
f. Tab. Diacarb - 1 tablet in the morning (Monday, Wednesday, Friday) - 2 weeks.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
EXECUTIVE SUMMARY
CASE HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1972
He was hospitalized (in the day hospital mode)
in the clinic of hospital therapy
in the city.
In total, 20 days of treatment were carried out .
The final diagnosis was established. ICD code M 42.1
Diagnosis:
Uncovertebral arthrosis, intervertebral osteochondrosis of the cervical, thoracic and lumbar, deforming spondylosis of the lumbar, right-sided scoliosis of the first degree thoracic and non-fixed scoliosis of the second degree of the lumbar, with a slight dysfunction of the spine.
Hypertension of the first stage (borderline).
Alimentary-constitutional obesity of the first degree, stable stage.
Partial adentia of the upper and lower jaws
. No disability certificate was issued.
Ability to work restored
Total exposure dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicization, disability, _____ disability group, degree of disability _______________________________, other _____________________________________________
Outcome: discharged on improvement, discharged on recovery, transferred to another medical institution (what) ____________________, transferred to rehabilitation treatment (where) _____________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited military service, temporarily unfit for military service (it is necessary to provide sick leave for ____ days, it is necessary to provide an exemption for ___ days, unfit for military service, unfit for service in a military specialty, discharged to a unit without a medical examination.
Examined by MSEC: yes (no) (____ disability group, degree of disability ______________) _________________________________________________________
At admission:
Complaints about: periodic pain in the thoracic and lumbosacral spine at rest and during exercise, episodic headache, dizziness, overweight.
History of present illness: pain in the lumbosacral spine notes since 1998. On this occasion, he repeatedly underwent outpatient treatment with a temporary positive effect. In 2003, the initial manifestations of osteochondrosis of the thoracic and lumbar spine were diagnosed on an outpatient basis. According to the words, a headache against the background of psycho-emotional overstrain, accompanied by an increase in blood pressure to 150/90 mm Hg. Art. began to notice since 2011. He did not seek medical help, he was treated independently, he took captopril with a positive effect. During the present examination, hypertension of the first stage was diagnosed. He has been gaining weight since 1997. Since 2007, alimentary-constitutional obesity of the first degree has been diagnosed, since 2011, body weight has been stable.
Anamnesis of the patient's life: He grew and developed normally, did not lag behind his peers. Higher military education. Married. Material and living conditions are satisfactory.
Allergological history: intolerance to medicines, household, food, animal allergens was not noted.
Epid. History: Over the past 6 months, he has not traveled outside the city of St. Petersburg, he denies contact with patients with tuberculosis, malaria.
Past diseases, injuries, contusions, operations: acute respiratory infections; childhood infections.
Heredity: the mother has type 2 diabetes mellitus, varicose veins with trophic changes in the legs; father is obese.
Habits: smokes 20 cigarettes a day since 1991, drinks alcohol occasionally moderately.
Insurance history: lieutenant colonel of the Ministry of Defense of the Russian Federation, chief of staff of military unit 49719.
Objective examination data: normosthenic physique, overnutrition (BMI-29.0). Peripheral lymph nodes and thyroid gland are not enlarged. The line of the spinous processes is slightly deviated to the right in the thoracic region. Excessive tension of the paravertebral muscles in the region of the cervical, thoracic and lumbar spine is determined. Paravertebral points are painful in the projection C6-C7, L5-S1. Range of motion in the spine: the distance between the spinous process of the seventh cervical vertebra and the tubercle of the occipital bone increases by 3 cm when the head is tilted, and decreases by 6 cm when the head is tilted back (extension). The distance between the spinous processes of the seventh cervical and first sacral vertebrae increases when the spine is flexed 4 cm compared to normal posture and decreases by 4 cm when bending back, lateral movements (tilts) in the thoracic and lumbar spine are possible within 20 degrees on both sides of the vertical line. Pulse 62 per minute, rhythmic. The borders of the heart are normal. Heart sounds are muffled. BP 130-145/80-90 mmHg Art. NPV 16 min. Above the lungs a clear pulmonary sound. Respiration is vesicular. Absence of 12, 25, 27, 37 teeth. Chewing efficiency according to Agapov 90%. The language is clean. The abdomen is soft and painless. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology. Visual acuity: OD=OS=1.0. ENT organs endoscopically: no pathology. Rumor: SR 6/6 m. The borders of the heart are normal. Heart sounds are muffled. BP 130-145/80-90 mmHg Art. NPV 16 min. Above the lungs a clear pulmonary sound. Respiration is vesicular. Absence of 12, 25, 27, 37 teeth. Chewing efficiency according to Agapov 90%. The language is clean. The abdomen is soft and painless. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology. Visual acuity: OD=OS=1.0. ENT organs endoscopically: no pathology. Rumor: SR 6/6 m. The borders of the heart are normal. Heart sounds are muffled. BP 130-145/80-90 mmHg Art. NPV 16 min. Above the lungs a clear pulmonary sound. Respiration is vesicular. Absence of 12, 25, 27, 37 teeth. Chewing efficiency according to Agapov 90%. The language is clean. The abdomen is soft and painless. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology. Visual acuity: OD=OS=1.0. ENT organs endoscopically: no pathology. Rumor: SR 6/6 m. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology. Visual acuity: OD=OS=1.0. ENT organs endoscopically: no pathology. Rumor: SR 6/6 m. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology. Visual acuity: OD=OS=1.0. ENT organs endoscopically: no pathology. Rumor: SR 6/6 m.
As a result of the treatment: regimen, diet No. 10, ACE inhibitors (Enalapril 5 mg 2 times a day), Mildronate 500 mg 2 times a day, Aspicor 100 mg in the morning, health improved, blood pressure stabilized at the target level.
The results of laboratory and instrumental studies:
General analysis of blood and urine 10.10.2012: normal.
Biochemical blood test on September 18, 2012: total protein, calcium, potassium, sodium are normal.
Biochemical blood test on 03.10.2012: cholesterol 6.73 mmol/l, VLDL 0.4 mmol/l, o. bilirubin 26.5 mmol / l, glucose, creatinine, urea, uric acid, fibrinogen, prothrombin, PSA, LDL, triglycerides - the norm.
Serological tests for syphilis, F-50 19.09.2012 negative.
ECG 09/17/2012: sinus rhythm with a heart rate of 72 per minute. The horizontal position of the EOS.
Echocardiography on September 19, 2012: no pathology, LV CR 51 mm, EF 90%, FU 61%, LVL 8.9 mm, IVS 7.4 mm, LVMI 79 g/m2, LA 34 mm, PP 37 mm, CRPV 28 mm , E/A=1.9.
Ultrasound 04.10.2012: liver, gallbladder, pancreas, kidneys, spleen without pathology.
SM BP (on the background of therapy) 10/25/2012: in the afternoon: max. BP 153/101 mm Hg, mean BP 132/84 mm Hg. Art., at night: max. BP 120/77 mm Hg. Art., mean blood pressure 114/67 mm Hg. Art.
VEM on September 25, 2012: the test was terminated at 11 minutes at a load of 200 W due to the achievement of a submaximal heart rate of 151 per minute. The reaction of blood pressure according to the normotensive type. Ischemic changes were not detected. Tolerance to physical activity is high. the test is negative.
Radiography of the UCP on 09.10.2012: no pathology.
Spondylography 03.10.2012: In the thoracic region, an arcuate curvature of the spinal axis to the right (angle of 50 according to Chaklin) with a peak at the level of Th6, in the lumbar region to the right (angle of 120) with a peak at the level of L3 is determined. Physiological lumbar lordosis is enhanced. Reduced intervertebral disc height at the level of C2-C3, C5-C6, C6-C7, C7-Th1, Th5-Th6, Th6-Th7, Th9-Th10, L3-L4, L4-L5, L5-S1, moderately severe subchondral sclerosis endplates of the thoracic vertebrae, mild subchondral sclerosis of the endplates of the lumbar vertebrae. On the cranial endplate of the Th7 and Th8 vertebrae, there are small limited impressions with a sclerotic rim. Coracoid bone growths up to 1 mm in size, emanating from the anterior and lateral surfaces of L1-L2, L2-L3, L3-L4 vertebral bodies at the attachment sites of the anterior longitudinal and lateral ligaments. The apices of the semilunar processes are somewhat pointed.
MRI of the head on 03.10.2012: no pathology.
MRI of the lumbosacral spine on 03.10.2012: decrease in the intensity of the MR signal on T2-WI from the intervertebral discs of the lumbar spine, marginal bone sharpening along the endplates of the vertebral bodies. The MR signal from the bone marrow of the vertebral bodies is unevenly increased on T1 and T2-WI due to areas of fatty degeneration.
The goals of hospitalization have been achieved - the "target level" of blood pressure has been reached - 120-130 / 70-85 mm Hg.
Discharged in a satisfactory condition under the supervision of a doctor of the unit on
10/17/2012. certified by VVK:
on the basis of article 66 in columns III of the schedule of diseases and TDT (annex to the Regulations on military medical expertise, approved by Decree of the Government of the Russian Federation of February 25, 2003 No. 123)
B - fit for military service with minor restrictions.
Recommended:
30. Observation of the doctor of the unit according to DM-1.
31. Observe the drinking regimen 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
32. Limit the intake of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
33. Continue taking:
a. Tab. Enalapril 10 mg ½ tab. 2 times a day all the time.
MILITARY MEDICAL ACADEMY Form 12_Uni.VMedA-2010 GT
DISCLAIMER EPICRISIS CASE
HISTORY No. ____,
Surname, name, patronymic_
He was hospitalized
in the hospital therapy clinic
Total days of treatment _22__
The final diagnosis was established ICD code_I 50.0_
Diagnosis:
Main: coronary artery disease. Stable angina pectoris III f.k. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (2004) cardiosclerosis. Secondary dilated cardiomyopathy. Congestive right-sided lower lobe pneumonia.
Complications of the underlying disease: Aneurysm of the apex of the left ventricle. Anasarca (edema, ascites, total right-sided hydrothorax). Cardiac asthma from 12/22/2010, stopped with medication on 12/23/2010. NC II B Art. CHF IVf.k. DN 2 tbsp.
Concomitant: Chronic viral hepatitis B, stage of cirrhosis. Hypertension III degree. (AH 1, risk IV). DEP 2 tbsp. mixed (atherosclerotic, hypertensive, dysmetabolic) genesis. Degenerative-dystrophic disease of the spine. Diabetes mellitus of the second type, decompensation. Chronic pyelonephritis, latent course. CKD 3 st (GFR=58 ml/min/1.73m2) CKD-1a st.
Disability certificate is not required
Work ability is not fully restored
Total radiation dose 59 mSv
Clinical outcome (underline): improvement
Outcome: discharged on improvement
Admission:
Complaints: increasing dyspnea of a mixed, mainly inspiratory nature, discomfort in the right side of the chest, paroxysmal cough without discharge, increasing weakness, decreased exercise tolerance.
Disease history. For a long time he suffers from coronary heart disease, hypertension. I have been drinking alcohol for a long time. In 2004, she suffered a massive myocardial infarction. 17.10.10 performed surgical treatment for bleeding (shock 2-3) from a chronic stomach ulcer. During the same hospitalization, decompensated diabetes mellitus was revealed. After discharge, she did not comply with the doctor's recommendations, she began to notice an increase in the volume of the abdomen. On this occasion, she was repeatedly hospitalized in the hospitals of the city, where complex treatment was performed with active diuretic therapy. The last hospitalization in the pulmonology department of City Hospital No. 26. After being discharged from the hospital, her condition deteriorated sharply. She was admitted to the hospital therapy clinic for urgent indications.
Objective status: general condition of moderate severity, edema of both legs to the hips, heart rate 60 per minute, no deficit, rhythmic pulse, auscultatory tones of the heart are muffled, the 1st tone is weakened above the apex of the heart, there is a rough systolic murmur at the apex, the boundaries of the heart are expanded , BP 115/70 mm Hg, hard breathing in the lungs, congestive rales in the lower lobe on the left, breathing is not heard on the right; the abdomen is enlarged due to the accumulation of free fluid, soft, painless on palpation, effleurage in the lumbar region is painless on both sides.
As a result of the treatment: regimen, diet No. 9, metabolic therapy (polarizing mixture: Sol.NaCl 0.9% -200.0, Sol.Asparcami 20 ml), vasodilators (Sol. Euphyllini 2.4% 10ml), inotropic therapy (Korglikon 0.06% 1.0 IV drip, Digoxin 0.00025 0.5 tab. in the morning), antibiotic therapy (Ciprofloxacin 0.5 1 tab. 2 times a day), diuretic therapy (Veroshpiron 0.025 tab. 1 tablet 4 times a day, Furosemide 1% 6.0 IV, Diuver 0.01 to 0.5 tablets 2 times a day, Hypothiazid 0.025 to 2 tablets in the morning), beta-adrenolytics (Betaloc-Zok 0, 05, 0.25 tab. 2 times a day), antithrombotic therapy (Aspicor 0.1, 1 tab. 1 time per day), punctures of the right pleural cavity (December 23, 24, 27, 9, 14 with evacuation of 2200 ml, 2500 ml, 2500 ml, 2550 ml straw-yellow liquid) feeling improved, shortness of breath decreased, cough regressed,edema in the legs and ascites disappeared, right-sided hydrothorax persisted, manifestations of heart failure decreased.
Taking into account the resistance of pathological exudation in the right pleural cavity to diuretic therapy and mechanical removal of fluid during pleural punctures, as well as taking into account the one-sidedness of the effusion (right pleural cavity), in further diagnosis, exclude a neoplasm of the right lung, mediastinum, and abdominal organs.
The results of instrumental studies:
ECG 23.12.2010, heart rate - 100 beats sinus rhythm, EOS to the right. Hypertrophy of the right ventricle. Widespread cicatricial changes in the anterior-septal, apical-lateral section of the left ventricle. Diffuse disorders of repolarization. Complete blockade of the right leg of the bundle of His.
ECG from 01/13/2011: sinus rhythm, heart rate 85 per minute. Violations of the processes of repolarization along the lower wall, rhythm disturbance in the form of frequent ventricular extrasystoles persist.
Ultrasound of the abdominal organs on December 27, 2011: no ascites. Flatulence. Diffuse changes in the echostructure of the liver (according to the type of hepatosis). Ultrasound signs of circulatory failure.
Ultrasound of the abdominal organs on 01/06/2011: compared to 12/27/2010 without dynamics. Hydrothorax on the right.
ECHO-KG from 01/11/2011:
PARAMETERS
Val.
NORMAL
PARAMETERS
Value
NORM
Aortic root diameter
27
20-37 mm
Left ventricular ERD
59
38-56 mm
Opening of the aortic valve leaflets
20
greater than 15 mm LV DFR
49
22-38 mm
Antero-posterior dimension of the left atrium
51
25-40 mm
Thickness of the free wall of the right ventricle
4
less
than 5 mm
Frontal dimension of the left atrium
49
25-45 mm
Ejection fraction of the left ventricle
36
more than 55%
Vertical dimension left atrial dimension
60
29-53 mm
Right atrial dimension
45
30-46
Interventricular septal thickness
10
7-11 mm
Right atrial vertical dimension
56
34-49 mm
Left ventricular posterior wall thickness
10
7-11 mm
ECR of the right ventricle, anteroposterior
45
Less than 30 mm
Systolic pressure in the LA
-
up to 30 mm Hg
Pulmonary trunk diameter
27
12-23 mm
During the study, frequent extrasystoles were observed. The wall of the aorta, the aortic crescents, the aortic valve ring are sealed. The mitral valve ring is calcified. The leaflets of the mitral valve are sealed, with small calcifications. Dilatation of all chambers of the heart. Expanded pulmonary artery. Eccentric myocardial hypertrophy of the left ventricle. The apex of the heart is not visualized. Akinesia of the interventricular septum, lateral wall, middle segment of the anterior wall. Hypokinesia of the rest of the myocardium. Global contractility is reduced. Type 3 diastolic dysfunction (rigid). Mitral tricuspid regurgitation of the 2nd degree. Aortic regurgitation 0-1 degree. Significant pulmonary hypertension (grade 2). Circular divergence of the sheets of the pericardium by 3-4 mm.
X-ray of the chest on December 23, 2010: subtotal hydrothorax of the right.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er
.
,
*
1012
/
l
Leuk
.
,
*
109
/
l
MCH
ESR
,
mm
/
h
_
_
_
_
_
_
_
_
12.01.
145
5.56
11.3
26.0
8
2
-
15
6
5
72
Biochemical blood test: Urinalysis:
Name
Unit of measure.
Norm
23.12
24.12
12.01
Index
24.12
Creatinine
Mkmol
/l
53-124
90
80
Color Yellow Dark
yellow
Cholesterol
Mole/l
3.7-6.0
3.6
Transparency
Clear
Haze
Triglycerides
Mole/l
0-2.37
Specific. Weight
1020
1.020
Total protein
G/l
63.0-87.0
71.6
67
Reaction
Neutr.
Neutr.
Calcium
Mole/L
2.1-2.5
Protein (g/L)
0.3
1.0
Potassium
Mole/L
3.5-5.1
5.08
4.85
Sugar
No
No
Glucose
Mole/L
4.2-6.4
11.54
12.91
10.51
Urobilin
16
33
Prothrombin
%
70-120
60
Leukocytes in p/s
1-3
0-3
Fibrinogen
Mg/dl
200-400
412
Erythr. unchanged in p/s
2-3
CPK
bacteria
U/l
10.0-160.0
56.5
38.5
Erythr. Vyschi. In p/s
Not
in terms of quantity
AST
U/l
11.0-50.0
23.6
31.5
Salts
No
ALT
U/l
11.0-50.0
18.1
20.6
Mucus
1
1
Total bilirubin
Mole/l
6.8-26.0
48.1
19.13
Urea mmol
/l
8.2
6.9
Analysis of the pleural fluid from 12/24/2011: 30 ml of lemon-yellow color, slightly turbid. Revolta test negative. Protein 3.0 g/l. Leukocytes 3.58*109/l, erythrocytes 8.73*109/l, mesothelial cells 4.0*109/l. Mesothelial cells with signs of dystrophic changes (pycnotic nuclei, partial lysis, with multiple cytoplasmic processes and reactive polymorphism (cricoid cells, cells with large nuclei in the form of small layers). Lymphocytes predominate 54%, neutrophils 41%, macrophages and histiocytes 5%
. blood for the presence of markers of viral hepatitis on December 24, 2010:
detected HBs-Ag Anti-HCV was not detected.
Discharged to the clinic at the place of residence. The ability to work was partially restored (significantly pronounced dysfunctions of the cardiovascular system continue to persist), he continues to get sick. Appearance at the clinic 01/15/2011.
Discharged in a satisfactory condition under the supervision of polyclinic doctors
Recommended:
8. Observation of a therapist, cardiologist, endocrinologist, hepatologist at the place of residence
9. Diet, normalization of work and rest. Avoid psycho-emotional stress. Limit salt and liquid intake. Control of blood pressure and heart rate. exercise therapy.
10. Performing computed tomography of the chest and abdomen in a planned manner at the place of residence to exclude a neoplastic process.
11. Consultation of cardiologists in the Federal Center. Almazov, tel. 702-37-06
12. Continue taking:
• Tab. Digoxin 0.00025 ½ tablet in the morning (except Saturday and Sunday)
• Tab. Betaloc-ZOK 0.05 ½ tablet 2 times a day continuously.
• Tab. Enalapril 0.01 ½ tablet 2 times a day continuously.
• Tab. Preductal MB 1 tablet 2 times a day for a month.
• Tab. Maninil 0.0035 1 tablet 2 times a day continuously.
• Tab. Hypothiazid 0.1 1 tablet daily in the morning.
• Tab. Furosemide 0.04 1 tablet on an empty stomach - in the presence of edema.
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
Discharge summary No.
born in 1982 (27 years),
was examined and treated in the clinic of hospital therapy
with a diagnosis
of arterial hypertension of the 2nd degree of unclear etiology (the risk of developing CVC is moderate) without signs of heart failure. Long-term consequences of stroke by hemorrhagic type (09.01.2009) in the form of scattered neurological symptoms, astheno-neurotic syndrome. Hypertensive type retinal
angiopathy On admission, he complained of an episodic increase in blood pressure up to 170/110 mm Hg, accompanied by dizziness, pressing headache without clear localization, and a feeling of discomfort in the left half of the chest.
He was admitted to the clinic for a fee in order to diagnose and select therapy for outpatient treatment.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/L
Leuk., *109/L
Ht, %
ESR, mm/h
Thrombus
*109/L
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
11.08
170
5.06
4.5
51.4
2
169
0
0
26
5
3
66
Biochemical analysis of blood:
Name
Unit. rev.
Norm
11.08
Creatinine
mmol / l
53-124
80
urea
mmol/l
2.5-6.4
2.6
glucose
mmol/l
3.9-6.2
5.14
chlorine
mmol/l
98-107
101.3
potassium
mmol/l
3.5- 5.1
4.26
sodium
mmol/l
136-145
140.5
T3
nmol/l
1.3-3.1
1.79
T4
nmol/l
66-181
75.77
TSH
uIU/l
0.27-4, 2
1.28
Quick prothrombin
%
80-130
112
Fibrinogen
g/l
2.0-4.0
3.47
cholesterol
mmol/l
3.7-7
5.74
triglycerides
mmol/l
0-2.37
0.66
Total protein
g/l
63-87
72.8 Vol
. bilirubin
µmol/l
6.8-26
18.1
ALT
U/L
8.4-53.5
288.1
AST
U/L
7-50.0
152.2
CPK
U/l
36-160
223.8
Creatinine clearance according to the Cockcroft formula- Gault = 129.5 ml/min.
GFR according to MDRD = 104.6 ml / min / 1.73 m2
General analysis of urine and feces from 11.08.2010. without pathological changes.
Results of instrumental studies:
X-ray of the chest organs No. 1635 (D = 0.26 mSv) dated 11.08.2010. In the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. Heart - left ventricular hypertrophy. The aorta is not changed.
Test with a six-minute walk from 08/12/2010. more than 800 m.
ECG No. 1767 dated 08/11/2010: sinus rhythm with a frequency of 64 beats per minute, horizontal EOS, the predominance of left ventricular potentials.
EchoCG from 12.08.2010. Aorta 33 mm, aortic ring 22 mm, asc. aorta 30 mm, opening of the aortic valve 23 mm, LA 34 mm, CRLV 35 mm, CRLV 50 mm, fr. reproach. 29%, fr. select 56%, AP 11 mm IVS 11 mm, E/A=1.38, PP 38mm, RV 24mm; the myocardium is at the upper limit of normal, the kinetics are not disturbed, the cavities are not dilated. Diastolic function is not disturbed. The aorta is not changed. The valves are intact, the blood flow is laminar, regurgitation on the TC 1 degree. The pericardium is unchanged, there is no pericardial effusion.
24-hour ECG monitoring from August 12, 2010: during the observation period, sinus rhythm was recorded with a heart rate of 53 to 138 per minute. The decrease in heart rate at night is adequate. Average heart rate 72/81/61 in 1 minute. Registered single ventricular extrasystole; single supraventricular extrasystoles (3 in total). When performing the planned load, the heart rate reached 138 per 1 minute, noted shortness of breath. Ischemic changes in the ST segment were not detected.
Ambulatory blood pressure monitoring dated August 12, 2010: daytime mean systolic BP is characteristic of mild stable hypertension, mean systolic BP at night and mean daytime diastolic BP are characteristic of moderate stable hypertension. At night, systolic and diastolic blood pressure decrease insufficiently (nondipper). The variability of systolic and diastolic blood pressure during the day is within the acceptable range. Episodes of hypotension were not registered. There is an increase in the magnitude and speed of the morning rise in diastolic blood pressure.
Ultrasound of the abdominal organs No. 951 dated August 11, 2010: no visible pathology.
Ultrasound of the thyroid gland from 11.08.2010: the contours are clear, even, the structure is homogeneous, echogenicity is increased; isthmus 3 mm, right lobe 18x19x60mm = 11cm3, left lobe 17x20x60mm = 10.5cm3 Optometrist's
consultation: retinal angiopathy of hypertensive type.
Neurologist's consultation: long-term consequences of stroke according to the hemorrhagic type (09.01.2009) in the form of scattered neurological symptoms, astheno-neurotic syndrome. In order to make a final conclusion, it needs additional examination.
Treatment: regimen, diet, polarizing mixture, furosemide, metoprolol, fosinopril, sedative therapy.
The goals of hospitalization were partially achieved (patient's refusal to continue treatment).
Discharged in a satisfactory condition under the supervision of a cardiologist of the clinic at the place of residence with recommendations.
A certificate of temporary incapacity for work was not issued.
Recommended:
1. Supervision by a cardiologist at a polyclinic at the place of residence.
2. Optimization of the mode of work, rest, nutrition.
3. Continue the examination on an outpatient basis, to do this:
a. MRI of the brain in normal and vascular mode;
b. Ultrasound of cerebral vessels;
c. Expanded coagulogram;
d. Renin of blood plasma (in the morning, on an empty stomach, after daily abstinence from physical activity);
e. Serum angiotensin-converting enzyme;
4. Repeated consultation of a neurologist and a cardiologist after performing the indicated laboratory and instrumental studies to make a final judgment about the patient's health status and correct the therapy.
5. Continue taking:
• Fosicard 20mg - 1 tablet in the morning constantly
• Thrombo ASS 0.05, 1 tab. 1 r / d after breakfast
• Mildronate 0.25 2 capsules 2 r / d (after breakfast and lunch) - 2 weeks.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1957 (52 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis: Seropositive rheumatoid arthritis (M.05.8), very early stage, III degree of activity, stage I, with systemic manifestations (myocardial dystrophy, mild secondary normoregenerative normoblastic anemia, right-sided exudative pleurisy), anti-CCP (+), FC I, FNS I. Symptomatic arterial hypertension (AH 1, CVE risk 3)
She was admitted to the clinic on a planned basis with complaints of palpitations, fever up to 38.8 ° C, swelling and stiffness of the small joints of the hands and feet, "flying" swelling and pain of the large joints of the legs .
Laboratory results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l
MSN,
pg
Rt,
‰
e, %
b, %
l, %
m, %
p %
s, %
ESR, mm/h
11.11.
98
3.06
10.4
630
32.1
6.9
1
19
7
5
68
70
13.11
101
3.55
8.5
824
28.4
6.6
1
30
5
2
62
70
25.11
122
4.29
13.5
593
28.6
6.2
25
7
1
69
40
Complete urinalysis
Date
Clear
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
11.11
clear
1.020 Yellow
5.5
-
-
-
-
-
-
-
-
-
-
Nechiporenko
test 11.11.09 L=0.75х106/l, E=2.0х106/l
Cal on I/g 11.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11
Total protein
G/l
63.0-87.0
77.5
Cholesterol
Mmol/l
3.7-6.0
5.17
Creatinine
Mmol/l
0.05-0.12
0.06
Glucose
Mmol/l
4.2-6.4
5, 54
Prothrombin
%
80-105
Fibrinogen
g/l
2-4
Potassium
Mmol/l
3.5-5.1
4.38
Calcium
Mmol/l
2.0-2.7
2.07
AST
U/l
11-50
23, 3
ALT
U/l
11-50
25.9
CPK
U/l
10-160
12.3
CEC
U
6-66
567
Beta-lipoproteins
AU 350-650
Serology
for HIV, hepatitis - negative.
* Detailed serology of rheumatoid arthritis (AKA, ACE, ACCP/anti-SSR, RF) 11/17/09.
* Antibodies to cyclic citrulline-containing peptide
- Result options
* <5 U/ml - no antibodies to CCP detected
* 5-50 U/ml - low concentration
* >50 U/ml - high concentration
- Result 56.9 U/ml
* Rheumatoid factor
- normal <1:20 (less than 25 IU/ml), result - 1:80 (100 IU/ml)
* Antikeratin antibodies
- normal <1:10 result <1:10
* Antiperinuclear factor
- normal <1:10 result <1:10
Blood test for antinuclear factor with immunoblot from 11/17/09.
on the hands soft tissue compaction is noted at the level of the metatarsophalangeal and interphalangeal joints, more pronounced on the right.
On the survey radiograph of the chest in the direct and right lateral projection from 11.11.09. No. 2613 (D=0.52 mSv): in the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, not expanded. The right dome of the diaphragm is slightly elevated. Encapsulated fluid in the right pleural cavity at the level of the costophrenic sinus. A small amount of fluid in the interlobar fissures. The heart is not dilated, the aorta is sealed.
On the control radiograph of the chest in the direct and right lateral projection from 11.11.09. No. 329 (D=0.52 mSv): no fluid was found in the right pleural cavity, in the lungs without focal and infiltrative changes.
On the radiograph of the left knee joint No. 2662 dated November 13, 2009. (D=0.02 mSv): no pathological changes were detected in 2 projections.
Ultrasound of the abdominal organs No. 1235 dated 11/16/2009: no pathological changes were detected
On ECG No. 2515 dated 11/10/09: sinus rhythm with a heart rate of 80/min. Normal position of the EOS. Partial violation of intraventricular conduction. Violation of repolarization in the region of the posterior wall, apex.
ECHO-KG No. 762 dated 10.11.09. Ao=30mm, ascending Ao=30mm, opening AC=16mm, LA=30mm, RA=32mm, RV=24mm, LV=47/27mm, IVS=10mm, AP=09mm, EF=74%, FU=43% , SV=75 ml, E/A=0.84 myocardium is not thickened, the kinetics is not disturbed, the cavities of the heart are not expanded, free. The aorta, fibrous rings of the aortic and mitral valves are sealed. The blood flow on the valves is laminar. Diastolic dysfunction of the rigid type. Applied regurgitation on the mitral valve. The pericardium is not changed.
Consulted by the rheumatologist of the clinic. Diagnosis was clarified, therapy was adjusted.
Treatment: regimen, diet, prednisolone, methotrexate, noliprel, calcium-D3-nycomed, cytoflavin, diclofenac, omeprazole, almagel, sedative and restorative therapy.
Against the background of the therapy, the patient's condition improved: He is discharged in a satisfactory condition under the supervision of a rheumatologist at the polyclinic.
Recommended:
83. Outpatient observation of a rheumatologist at the place of residence.
84. In case of resumption of pain syndrome or stiffness of the joints in the morning - a consultation with a rheumatologist with a decision on the correction of the therapy and the need for inpatient treatment.
85. Control of the general blood test after 1 month (then 1 time in 3 months)
86. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
87. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
88. Continue taking:
a. Noliprel - ½ tab 1 time per day (in the morning) constantly
b. Methotrexate 2.5 mg - 1 tablet on Monday evening, Tuesday morning and evening (total 7.5 mg / week) - constantly.
c. Prednisolone 5 mg - daily 4 tab. in the morning, 1 in the afternoon, with food, drinking kissel. In the absence of pain and stiffness in the joints, starting from December 5, reduce by 0.5 tablets every 4 days until a maintenance dose of 7.5 mg (1.5 tablets) is reached, then constantly 1.5 tablets in the morning.
d. Calcium D3-Nycomed - 1 tab. in the evening all the time.
e. Cytoflavin - 1 tab. 3 times a day for 1 month
f. Asparkam - 1 tab. 3 times a day from the 1st to the 10th of each month
XVII. DISCUSSION CASE
HISTORY №, ARCHIVE №_____,
Surname, name, patronymic
Date of birth 37 full years,
She was examined and treated in a day hospital at the clinic of hospital therapy of the Military Medical Academy
Total number of days of treatment
The
final
diagnosis was established by the ICD code []
.
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, ______________ group of disability, degree of disability ________________________________, other _____________________________________________
Outcome
: discharged, died, transferred to (another medical institution) (what) __________________ not formalized.
The total radiation dose during the stay in the hospital was (0)_________ per, mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, ______________ group of disability was established, degree of disability __________________________, other _____________________________________________.
Outcome: Discharged, died, transferred to (another medical institution) (what) ____________________
Examination at admission (including outpatient):
Examinations:
Complete blood count:
Date
Erit.
Hb g/l
Thrombos.
SOE
Lake.
E
P/poison
C/poison
Lymph
Mon
Hematocrit
March 4, 2014
5.08
15.3
210
13
4.8
2
1
62
27
6
45.1
Urinalysis:
Date
Rel. dense
pH
Protein
Acetone
Glucose
Leukocytes
Epithelium
Bacteria
mucus
Bilirubin
Urobilinogen
Erythrocytes
04.03.14g
1030
6.0
0.3
-
5.5
1-2-2
0-1-1
2
2
-
3.2
0-1-1
Biochemical analysis of blood ( glycated hemoglobin)
dated March 12, 2014 - 5.75%
Biochemical blood test (C-reactive protein)
from 05/05/2014 - 3.15
Thyroid hormone (TSH) from 12/16/2013 - 2.9 mIU / l (N- 0.3-4.0)
Blood test on F50, HbsAg, anti-HCV, RW from 12/11/2013: negative.
Biochemical blood test (fibrinogen) dated 03/04/2014 - 2.87 g / l
Fecal analysis No. 5 dated 03/04/2014 - without features
Biochemical blood test 03/04/14.
Indicators
Unit
Cholesterol
4.91
3.7-6.0
mmol.l
Triglycerides
1.72
0-2.37
mmol/l
HDL
1.45
0.78-2.33
mmol/l
LDL
2.67
1.9- 4.4
Rel. U
VLDL
0.79
0.6-1.2
Rel. UI Atherogenic
coefficient
2.39
0-3.0 Rel.
UI
ALT
23.0
11-50
g/l
AST
16.0
11-50
g/l
GGT
41
11-63
g/l
Urea
6.3
2.5-6.4
mmol/l
Glucose
5.70
3.90-6.20
mmol/l
Creatinine
0.11
0.05-0.12
mmol/l
Total protein
69
64-83
g/l
Chlorine
113.2
98.0-107.0
mmol/l
Potassium
4.38
3.50-5.10
mmol/l
Sodium
140.2
136.0-145.0
mmol/l
SK
97
10.0-160.0
g/l
SK
-MB
21.9
0-25
g/
l no evidence of neurological pathology was found at the time of examination.
Ophthalmologist (dated March 13, 2014): Healthy.
Otorhinolaryngologist (dated March 6, 2014):
Dentist (dated March 6, 2014):
Instrumental research methods:
Fluorography of the chest cavity and paranasal sinuses No. 0026 dated (03/06/2014) - Without focal and infiltrative changes. On the fluorography of the paranasal sinuses: their pneumotization is not reduced.
X-ray No. 190 dated March 14, 2014 - On the spondylograms of the cervical spine in 2 projections, the physiological lordosis is straightened, the C5 body is displaced posteriorly by 0.4 cm. Kimmerley anomaly. Osteochondrosis of C4-5, C5-6, C6-7 motor segments with a decrease in the height of the discs, compaction of the end plates and marginal bone growth of 0.1 cm in the posterior C5 and anterior C5-6 parts of the vertebral bodies in the projection of the discs.
No pathological changes were found on spondylograms of the thoracic spine in 2 projections.
The results of ECG Holter monitoring (dated February 20, 2014) - average heart rate during the day 82 bpm, at night 60 bpm. The decrease in heart rate at night is sufficient, the increase in heart rate in response to physical activity is adequate. Circadian index 1.4. Against the background of sinus rhythm with a heart rate of 51 to 140 bpm, registered:
1) ventricular extrasystole, total 1.
2) supraventricular extrasystole, total 401, according to the type in bigemia 37, according to the type of trigemenia 7, running supraventricular tachycardia 28.
Ischemic ST-T changes were not detected.
The results of daily monitoring of blood pressure No. 109 of 03/07/2014:
Daytime hours: cf. GARDEN - 131 mm Hg. Art. Max. GARDEN - 152 min. GARDEN - 108
cf. DBP - 82 mm Hg. Max. DBP - 101 min. DBP - 68
Night hours: cf. SBP - 108 mm Hg max SBP - 114 min. GARDEN - 95
cf. DBP - 65 mm Hg max DBP - 72 min. DAD - 56
Conclusion:
Mean systolic and diastolic blood pressure were within normal limits. At night, systolic blood pressure decreases adequately, diastolic blood pressure, at night, decreases excessively. The variability of systolic and diastolic blood pressure during the day is within the acceptable range. Episodes of hypertension were not registered. There is an increase in the rate of morning rise in systolic and diastolic blood pressure.
ECG dated 03.03.2014 No. 302: Moderate sinus bradycardia. Horizontal position E.O.S. Incomplete blockade of the right leg of the bundle of His. The predominance of the potentials of the left ventricle.
Echocardiography from 03/04/2014: Normal geometry of the left ventricle. The cavities of the heart are not dilated, free. The systolic and diastolic function of the left ventricle is preserved. The heart valves are intact. Pericardium without features.
Aorta and pulmonary artery
Value Norm
Left ventricle
LV EDR, mm 45.5 42-59
LV ECR, mm 26.1 20-36
TMZhP, mm 7.2 6-10
LV VC, mm 7.2 6-10
LP-34.7x31.9x38 .9
PZh-27.4x3.2
PP-36.9x38.4
Report on the test with physical activity (dated March 11, 2014): Functional class-1. The test is negative (submaximal heart rate has been achieved, no ischemic changes in the ST segment have been detected). Tolerance to physical activity is average (7.5 Met). BP response to exercise is normotensive. The recovery period for blood pressure and heart rate is adequate.
Ultrasound of the digestive organs: the liver is not enlarged, the right lobe is 16.0 cm, the left lobe is 7.0 cm. The contours are even, the structure is homogeneous, the echogenicity is moderately increased, the vascular pattern is preserved, the portal vein is 12 mm, the choledochus is 4 mm, the intrahepatic bile ducts are not dilated . Gallbladder: irregular shape, deformation in the body area, dimensions: length-5.5, diameter-2.0 cm, smooth contours, wall -3.0 mm. The pancreas is located clearly. The contours are clear, even. The head is 22.3 mm. body 19.8 mm, tail -17.5 mm. Echogenicity - increased moderately. The structure is homogeneous. Wirsung's duct is not dilated - 2.0 mm. The spleen is not enlarged, dimensions: length-8.8; thickness 5.5, homogeneous structure. Kidneys: typical location, smooth contours, right kidney 10.2x5.3 cm, parenchyma - homogeneous - 27.0 mm; PCS - not expanded, no calculi; left kidney: 10.5x6.0 cm, the parenchyma is homogeneous - 15.0 mm, microliths are not detected. Thyroid gland: not enlarged, clear, even contours, homogeneous structure, perthmus 4 mm, right lobe: width 15.5 cm, thickness 17.2 cm, length 43 cm, volume 6.0 cm3; left lobe: width 15.3 cm, thickness 17.0 cm, length 44.0 cm, volume 6.0 cm 3.
Conclusion: the handwriting is not clear(!).
At discharge: General condition is satisfactory. May be discharged under medical supervision. Recommendations are given.
Recommended:
• Supervision of the physician of the unit.
• Compliance with the regime of work and rest.
• Continue admission:
Form 12_Un.VMEDA-2011
MILITARY MEDICAL ACADEMY
DISCHARGE REPORT CASE
HISTORY No. ARCHIVE No. _________ Last name, first name, patronymic born in 1962.
He was treated in the day hospital mode in the clinic of hospital therapy
Total number of days of treatment was 16
The final diagnosis was established. ICD code _I 42.8
DIAGNOSIS:
Main disease: Arrhythmogenic dysplasia of the right ventricle. Implanted cardioverter-defibrillator (2009) Atherosclerosis of the aorta and coronary arteries. Large-focal myocarditis (1995) and atherosclerotic cardiosclerosis with persistent cardiac arrhythmias of the type of frequent ventricular extrasystole and paroxysmal polytopic ventricular tachycardia. Hypertensive disease of the second stage (arterial hypertension 3, the risk of CVE is very high).
Complications of the underlying disease: Chronic heart failure of the third functional class, stage I.
Background disease: Diabetes mellitus type 2. Diabetic symmetrical distal sensory polyneuropathy. Target HbA1c < 7.0%
Concomitant diseases: Diffuse-nodular goiter, without impaired thyroid function. Dyscirculatory encephalopathy of the second stage of mixed genesis (atherosclerotic, hypertensive, diabetic and vertebrogenic) in the form of scattered neurological symptoms and a pronounced persistent pseudoneurotic syndrome. Chronic gastritis, stage of remission. Fatty hepatosis of the second stage, without dysfunction.
Certificate of incapacity for work: not issued
Total exposure dose 5.6 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, _____ disability group, degree of limitation
Outcome: discharged due to improvement
Complaints: pressing pains behind the sternum that occur during physical exertion, sensations of interruptions in the work of the heart, episodes of palpitations, shortness of breath when climbing to the second floor, walking up to 200 meters, diffuse headache, dizziness with an increase in blood pressure up to 160/110 mm. rt. Art., working 130/80 mm. rt. Art., general weakness, fatigue, irritability, memory loss, sleep disturbance, periodic dry mouth and thirst, heartburn with errors in the diet.
History of present illness. Since childhood, he often suffered from tonsillitis. In 1985, he was diagnosed with chronic tonsillitis, for which he was treated on an outpatient and inpatient basis. In 1995, after a sore throat, an infectious-allergic myocarditis developed, which proceeded with severe disturbances in heart rhythm and conduction. Subsequently, myocardial cardiosclerosis was formed with conduction disturbance in the form of a complete blockade of the right bundle branch of His, blockade of the anterior branch of the left bundle of His bundle. In the future, he was repeatedly treated for this in a hospital. Since 1999, she has been worried about shortness of breath during physical exertion; during a hospital examination, heart failure of the first functional class was verified. Since 2000, he has been worried about interruptions in the work of the heart, and frequent ventricular extrasystoles have been detected. Since 2004, pressing pains behind the sternum during physical exertion began to disturb, coronary heart disease, angina pectoris of the first functional class was diagnosed in a hospital, a constant intake of nitrates, antiplatelet agents was recommended, the patient partially fulfilled these recommendations. In August 2008, there was a hemodynamically significant paroxysm of ventricular tachycardia, stopped by electropulse therapy. In December 2008, coronary angiography was performed, in which angiographic signs of atherosclerotic lesions of the coronary arteries were not detected. In April 2009, when performing an endocardial electrophysiological study of the heart, stable paroxysms of ventricular tachycardia were induced from the outflow tract of the right ventricle. In this regard, on April 15, 2009, a cardioverter-defibrillator was implanted. In the future, the patient continues to be disturbed by pressing pains in the chest and shortness of breath during physical exertion, interruptions in the work of the heart. As a result, he was repeatedly hospitalized. Headache against the background of episodes of increased blood pressure up to 150/100 mm Hg. Art. worried since 1986. Since 1995, he has been observed for neurocirculatory asthenia of the hypertensive type, occasionally taking antihypertensive drugs with a positive effect. Since 2004, an increase in blood pressure to 150/100 mm Hg. Art. takes a persistent character, at a hospital examination, hypertension of the first stage is diagnosed. In 2008, against the background of constant intake of antihypertensive drugs, there were rises in blood pressure up to 160/100 mm Hg. Art., stationary diagnosed with hypertension of the second stage, the initial manifestation of cerebrovascular insufficiency. In September 2011, he suffered a hypertensive crisis, stopped permanently. Since 2000, he has noted the appearance of episodic dry mouth, thirst, was observed due to impaired glucose tolerance. In 2003, during a hospital examination, a diagnosis of type 2 diabetes mellitus, a mild course, was established. Until 2008, compensation was achieved by diet. Since 2008, hypoglycemic drugs have been added to the diet. In 2003, during a hospital examination, a diagnosis of type 2 diabetes mellitus, a mild course, was established. Until 2008, compensation was achieved by diet. Since 2008, hypoglycemic drugs have been added to the diet. In 2003, during a hospital examination, a diagnosis of type 2 diabetes mellitus, a mild course, was established. Until 2008, compensation was achieved by diet. Since 2008, hypoglycemic drugs have been added to the diet.
Currently taking Glibomet. Against this background, diabetes is compensated. In April 2009, a diffusely nodular goiter was detected without functional impairment. About fifteen years worried about heartburn with errors in the diet. Since 2003, chronic gastritis has been detected. In July 2009, the VVK was surveyed (a copy of the document is attached). In the course of this deterioration in health, he was hospitalized at the GT clinic of the Military Medical Academy for further examination and treatment.
As a result of the treatment: regimen, diet N9 Sol. NaCl-200ml Sol. Espalipon 24.0 IV drip N5, T. Carvedilol 37.5 mg/day, T. Preductal 70 mg/day, T. Aspicor 100 mg/day, T. Atoris 20 mg/day, T. Ramipril 2.5 mg/day, T. Glibomet 1600 mg/day, T. Detralex, T. Vazobral, there is a positive trend: the pain syndrome did not recur, blood pressure is stabilized and corresponds to the target values (normotension is maintained). He notes an increase in working capacity, an increase in tolerance to physical activity. Therapy for the outpatient stage of treatment was selected, recommendations were given.
Results of instrumental studies:
ECG from 05/14/2013: sinus rhythm with a heart rate of 70 per minute. A sharp deviation of the EOS. Blockade of the right leg of the bundle of His. Blockade of the anterior-upper branch of the left leg of the bundle of His. Hypertrophy of the left atrium. Left ventricular hypertrophy.
Ultrasound of the abdominal organs and kidneys on May 15, 2013: the liver is enlarged, due to the left lobe - 15.2 cm, the left - 6.6 cm, the contours are even, the structure is homogeneous, the echogenicity is increased, the vascular pattern is preserved, the vessels are not dilated, the portal vein is in normal, intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape, with a bridge, dimensions 8.0x3.2 cm, the contours are even, the walls are 3 mm, there are no calculi. The pancreas is not located, it is blocked by gases. Kidneys: typical right location, normal mobility, smooth contours, dimensions 12.6x6.7 cm, homogeneous parenchyma 23.0 mm. The PCS is not dilated, the left one is typically located, the mobility is normal, the contours are even, the dimensions are 12.5x6.2 cm, the parenchyma is homogeneous 19 (mm). PCS is not expanded. No pathological formations were found in the projection of the adrenal glands. The spleen is enlarged 10.5x4.1, the structure is homogeneous. Conclusion: diffuse changes in the liver according to the type of fatty hepatosis. Diffuse changes in the pancreas.
Radiography of the cervical, thoracic, lumbar spine dated May 16, 2013: cervical and lumbar lordosis is smoothed, osteochondrosis C4-5, Th4-5, Th5-6, L4-5, L3-4 motor segments and marginal bone growths up to 0, 1 cm.
Myocardial SPECT dated May 23, 2013: no pathology.
Echocardiography dated 05/15/2013:
Result, mm
Norm, mm
Aorta
At the level of AC
18
22-36
Valve opening
15-26
Left atrium
Anteroposterior size
38
25-40
Left ventricle
EFR
30
≤ 36
ECR
45
≤ 55
Posterior wall thickness (diast. )
11
Thickness of the interventricular septum (d.)
11
Right ventricle
ECD
48
≤
30
Anterior wall
6
≤ 5
Right atrium
Transverse
dimension
54
29-46
Longitudinal
dimension
50
34-49
Pulmonary
artery
At
the
valve
23
12-23 41
EF, %
60
≥55
Ve/Va
1.19
1.0-2.2
Conclusion: hypertrophy, pronounced dilatation of the right ventricle with a decrease in its contractile function, moderate dilatation of the right atrium. in the right cavities, the shadow of the EKS electrode is located with its fixation on the border of the middle and apical part of the interventricular septum. There are multiple thrombotic deposits on the right ventricular part of the electrode. Concentric LV remodeling. Moderate asynchronism of myocardial contraction. No zones of local disturbance of kinetics were revealed. Slight dilatation of the LP. The aorta and fibrous rings are condensed. Regurgitation of the 2nd degree on the tricuspid valve, 1st degree on the pulmonic valve. The pericardium is not changed.
Daily monitoring of blood pressure on May 16, 2013: mean systolic blood pressure during the day is typical for moderate stable hypertension, mean diastolic blood pressure during the day is typical for severe stable hypertension. At night, systolic and diastolic blood pressure fall adequately (dipper). The variability of systolic blood pressure and diastolic blood pressure during the day is within the acceptable range. Episodes of hypotension were not registered. There is an increase in the rate of morning rise in blood pressure.
24-hour ECG monitoring on May 16, 2013: sinus rhythm was recorded during the observation period. Heart rate from 60 to 119 per minute. The decrease in heart rate at night is insufficient. Average heart rate 73/75/68 per minute. The following rhythm and conduction disturbances were registered: frequent ventricular extrasystoles (total 1754) episodically paired, supraventricular extrasystoles (total 1011). Ischemic changes in the ST segment were not detected.
Consultation of an ophthalmologist dated May 17, 2013: hypertensive angiopathy of the retina in both eyes.
ENT consultation dated May 20, 2013: deviated nasal septum, vasomotor rhinitis.
Consultation of a neurologist dated May 21, 2013: first stage dyscirculatory encephalopathy with diffuse neurological symptoms and pseudoneurotic syndrome. Chronic vertebrogenic cervicalgia, lumbalgia, unstable remission.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Tr. *109/l
MCH
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
15.05
155
5.37
8.3
203
28.8
4
3
-
27
5
5
62
Urinalysis (automatic processing):
Date
U.weight
Reak
Protein
Sax
Ket.
Lei
Er.neiz
Urobil
15.05
1030
5.5
-
-
traces
0-6
-
3.2
Biochemical analysis of blood:
Name
Unit of measure.
Norm
15.05
O. protein
g/l
64-83
71
Glucose
mmol/l
4.2-6.4
7.02
Creatinine
mmol/l
0.05-0.12
0.1
Potassium
mmol/l
3.4-4.5
4.69
Sodium
mmol/l
130-150
143
Cholesterol
mmol/l
3.7-6.0
2.87
Total bilirubin
mmol/l
6.3-26
12.3
Urea
mmol/l
2.5-6 .5
5.6
AST
U/l
11-50
25
ALT
U/l
11-50
31
GGTP
U/l
87.1
Glykirov. HvA%
4-6.5
7.08
Triglycerides
0-2.37
3.28 Coagulation
system on May 15, 2013: prothrombin 91%, fibrinogen 3.11 g/l, INR 1.05;
Employment has been restored. Discharged in a satisfactory condition under the supervision of specialists of the clinic. A certificate of temporary incapacity for work was not issued.
Recommended:
10. Observation, therapist, angiosurgeon, neurologist, cardiologist, gastroenterologist.
11. 24-hour ECG monitoring after 2 months, followed by a consultation with a cardiologist.
12. Control of b / x blood after 3 months (AST, ALT, o. bilirubin, o. cholesterol, lipidogram, coagulogram) followed by a consultation with a therapist.
13. Regular monitoring of glucose levels.
14. Normalization of the regime of work and rest. Exclude the use of animal fats, easily digestible carbohydrates, alcohol, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet. exercise therapy.
15. Observe the water regime (fluid balance), daily monitoring of blood pressure and heart rate.
16. Continue taking:
6. T. Ramipril 2.5 mg, 1 tab. in the morning.
7. T. Preductal 35 mg 1 tab. morning and evening after meals.
8. T. Carvidilol 12.5 mg 1 tab. in the morning and in the evening.
9. T. Metformin 850 mg 1 tab. in the morning and in the evening.
10. T. Pradaxa 110 mg 1 tab. in the morning.
11. T. Detralex 1 tab. in the morning and in the evening.
Main disease: Arrhythmogenic dysplasia of the right ventricle. Implanted cardioverter-defibrillator (2009) Atherosclerosis of the aorta and coronary arteries. Large-focal myocarditis (1995) and atherosclerotic cardiosclerosis with persistent cardiac arrhythmias of the type of frequent ventricular extrasystole and paroxysmal polytopic ventricular tachycardia. Hypertensive disease of the second stage (arterial hypertension 3, the risk of CVE is very high).
Complications of the underlying disease: Chronic heart failure of the third functional class, stage I.
Background disease: Diabetes mellitus type 2. Diabetic symmetrical distal sensory polyneuropathy. Target HbA1c < 7.0%
Concomitant diseases: Diffuse-nodular goiter, without impaired thyroid function. Dyscirculatory encephalopathy of the second stage of mixed genesis (atherosclerotic, hypertensive, diabetic and vertebrogenic) in the form of scattered neurological symptoms and a pronounced persistent pseudoneurotic syndrome. Chronic gastritis, stage of remission. Fatty hepatosis of the second stage, without dysfunction.
Federal State Institution "442 DISTRICT MILITARY CLINICAL HOSPITAL LENVO" Ministry of Defense of the Russian Federation
Discharge summary No.
1967 was on examination and treatment at 15 m / o 442 OVKG during the period with a diagnosis of:
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
Hospitalized in a planned manner with complaints of interruptions in the work of the heart.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/L
Leuc., *109/L
ESR, mm/h
Lf
%
M
%
Granulocytes%
12.05.
136
4.0
6.6
8
35.1
5.3
59.6
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
12.05
clear
1027
yellow
5.0
no
no
no
0
0
0
0
0
1-3
0
Biochemical blood test:
Name
Unit rev.
Norm
12.05
Creatinine
mmol/l
53-124
103.1
INR
U
1.7
Prothrombindex
%
70-120
42.6
ALT
U/L
8.4-53.5
35
AST
U/L
7-39.7
24
LDH
U/L
100-220
105
Glucose
mmol/l
4.2-6.4
6.61
Results of instrumental studies:
ECG from. 05/12/2010: atrial fibrillation with a heart rate of 90 in 1 min. EOS deviated sharply to the left. Blockade of the anterior branch of the left leg of the bundle of His. Left ventricular hypertrophy.
FLG of the chest organs No. 1521 dated May 13, 2010: Conclusion: no focal and infiltrative formations were detected in the lung tissue. The roots are expanded due to the vascular component. On the right, the sinuses are free; on the left, the dome is raised and flattened; the sinuses are obliterated. To the right above the diaphragm there is a linear shadow of the pleural ligament. The shadow of the heart is moderately enlarged, the cardiac arches are smoothed along the left contour.
State of emergency Echo-KG from 15.05.10: atrial cavities, including the area of both atria, the ventricular cavities are free. In the atrial cavities, there is a slightly pronounced phenomenon of pseudoregurgitation. The average velocity of blood flow in the left atrial appendage is 0.33 m/s, there is atrial dilatation, induration of the right coronary crescent. In the interatrial septum in the area of its connection with the aortic ring, there is a slight discharge of blood (a residual defect after suturing an ASD with a diameter of 0.2 cm). There is no effusion in the pericardium.
Treatment: regimen, diet, thrombo ass, cordarone
12.05.2010 performed electrical cardioversion - restored sinus rhythm.
The goals of hospitalization have been achieved. On the background of the therapy, the patient's condition improved. Restored sinus rhythm.
Discharged to the clinic at the place of residence in a satisfactory condition.
Recommended:
89. Outpatient observation of a cardiologist, endocrinologist of a polyclinic.
90. Exclude from the diet animal fats, fried, spicy, salty and spicy foods, foods containing large amounts of carbohydrates.
91. Increase in the diet: dried apricots, prunes, vegetable fats.
92. Dispensary observation:
a. clinical blood test, urinalysis - twice a year;
b. control of blood glucose level, lipidogram - in a week, then according to indications
c. Echocardiography - 1 time per year;
d. ECG - 1 time per quarter
93. Continue taking:
a. Siofor 850mg - 1 time per day (in the morning) constantly
b. Thrombo ACC 0.1 - 1 tablet in the morning constantly
c. Panagin - 1 tablet 3 times a day for 10 days of each month
d. Mildronate 0.5 - 1 capsule in the morning and in the afternoon for 10 days
e. Kordaron 0.2 1 tablet in the morning for a month with a break on Saturday and Sunday
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated
.
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY № ARCHIVE №_________
Surname, name, patronymic: born in 1927
Was on inpatient treatment in the clinic of hospital therapy
In total, 16 days of treatment were carried out.
The final diagnosis was made on January 19, 2014.
ICD code I 48; MES 291180
Diagnosis:
Ischemic heart disease. Angina pectoris III functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis complicated by impaired conduction by the type of blockade of atrioventricular conduction of the first degree, transient complete blockade of the right leg of the bundle of His, rhythm disturbance by the type of supraventricular extrasystole, paroxysmal form of atrial fibrillation. Paroxysm of atrial fibrillation from 18.01.2014. (tachysystolic variant, CHA2DS2VASc 9.8% [6 points], EHRA grade 2, HAS-BLED 2 points), stopped medically on 19.01.2014.
Stage III hypertension (arterial hypertension of the 1st degree, the risk of cardiovascular complications is "very high").
Chronic heart failure II-a stage, 2 functional class.
cerebrovascular disease. Dyscirculatory (stroke stroke from 2000 in the PSMA pool) encephalopathy stage III in the form of moderate (deep in the hand) left-sided hemiparesis, hemihypesthesia, pseudobulbar syndrome, pronounced emotional and volitional disorders.
Secondary nephropathy of mixed (atherosclerotic, hypertensive) genesis. Solitary cyst of the right kidney. Chronic kidney disease C2Ax stage.
Autoimmune thyroiditis, clinically euthyroidism.
Fatty hepatosis I degree.
Chronic cholecystitis, remission. Lipomatosis of the pancreas.
Chronic vertebrogenic lumbosacral sciatica with L5-S1 root syndrome on the left in the phase of unstable remission.
Benign prostatic hyperplasia.
Varicose disease, deep form, subcompensation. Chronic venous insufficiency of the 2nd degree.
Keratoma of the right cheek area.
Mycosis stop.
Artifakia, destruction of the vitreous body, central chorioretinal dystrophy, peripheral chorioretinal dystrophy of both eyes.
Complaints at admission: pain in the region of the heart of a compressive nature against the background of physical (walking around the apartment) and psychoemotional stress, which stops on its own or after the use of nitropreparations; shortness of breath during physical activity (daily household activities), frequent headaches and lability of blood pressure levels (100-150 and 60-90 mm Hg); episodes of interruptions in the work of the heart, palpitations without connection with physical activity; swelling of the lower extremities up to the upper third of the lower leg, mainly the left; limitation of range of motion and violation of skin sensitivity of the left upper and left lower extremities; memory loss; pain in the lumbar region with prolonged static loads; decreased vision; frequent urination at night.
Anamnesis of the disease: Collection of anamnesis is difficult due to severe cognitive impairment. For a long time (more than 10 years) hypertension, coronary disease, noted cardiac arrhythmias. On this occasion, he is observed by a cardiologist at a polyclinic at the place of residence; he has repeatedly been treated and examined in cardiological hospitals. In 2000, he suffered a stroke, which was complicated by left-sided deep hemiparesis, hemihypesthesia (they still persist). The last hospitalization in a therapeutic hospital in August 2013 (clinic of faculty therapy of the Military Medical Academy), was diagnosed with: “CHD. Angina pectoris III FC. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis with arrhythmia according to the type of paroxysmal form of atrial fibrillation, conduction according to the type of AV blockade of the first degree. Hypertension stage III. CHF II-a stage, 2 FC. TsVB. Stage III DEP of mixed (post-stroke (2000), atherosclerotic) genesis in the form of left-sided deep hemiparesis, hemihypersthesia, cognitive impairment ”(copy of the discharge certificate in the medical history). The patient was discharged with improvement, the following therapy was recommended: losartan 12.5 mg/day, veroshpiron 50 mg/day, diuver 5 mg/day, pradaxa 220 mg/day, sotalol 40 mg/day. The regularity of taking drugs is observed (according to the patient). Deterioration of health has been noted since December 2013, shortness of breath has increased, edema of the lower extremities has appeared, lability of blood pressure levels, pains in the heart area, interruptions in the work of the heart, began to notice a decrease in exercise tolerance.
According to the patient, in 2000 he was diagnosed with autoimmune thyroiditis, subclinical hypothyroidism. On this occasion, it is observed by an endocrinologist. August 2013 - subclinical hypothyroidism; dose of L-thyroxine 25 mcg/day. In November 2013, thyroid status was monitored: T3, T4, TSH, and/tPO were normal values (results on the hands), L-thyroxine was canceled by the endocrinologist.
Objectively at the time of admission: the general condition is satisfactory. Consciousness is clear. The skin and visible mucous membranes are clean, dry, turgor is reduced. Limitation of motor activity of the left upper and lower extremities (left-sided hemiparesis due to previous ischemic stroke). The physique is correct, corresponds to age and sex. Normal nutrition: the thickness of the skin fold at the costal arch is 2 cm, near the navel 4 cm. The elasticity of the skin is reduced, slight acrocyanosis of the lips. Diagonal fold of the earlobe, senile arch of the eyes. There are no edema. The pulse is rhythmic, uniform, with a frequency of 80 beats. in min., BP 150 and 100 mm Hg. Heart sounds are muffled, rhythmic, accent II tone over the aorta, there is no pulse deficit. RR 17 per min. On auscultation over the lungs, breathing is vesicular, rales are not heard. The abdomen is soft, painless on palpation. A strengthened scar without signs of inflammation in the right iliac region is determined. The edge of the liver does not protrude from under the edge of the costal arch. The size of the liver according to Kurlov is 10*9*8 cm. The spleen is not palpable. Ragosa's symptom is negative. Tapping on the lumbar region is painless on both sides. There are no dysuric phenomena.
Treatment was carried out: mode 3, diet 10. Parenterally: NaCl, KCl, glucose, cavinton, cordarone. Inside: blocktran, spironolactone, trigrium, pradaxa, sotohexal, sonizim, finasteride, phenazepam, phenibut, propafenone. In the form of ointments mycoseptin, troxevasin.
Against the background of ongoing therapy, hemodynamic parameters are stabilized within the optimal values. The patient notes a moderate improvement in general well-being, increased exercise tolerance.
Repeatedly was on examination and treatment in therapeutic clinics of the Military Medical Academy and city medical institutions, diagnostically clear. Extreme hospitalization in August 2013 to the clinic of faculty therapy (a copy of the discharge summary on hand). Leading in the clinical picture is vascular pathology, represented by the consequences of ischemic stroke in the form of stage III dyscirculatory encephalopathy, left-sided hemiparesis, hemihypesthesia, and cognitive impairment; angina pectoris II-III functional classes, arterial hypertension with moderate symptoms of chronic heart failure, rare paroxysms of atrial fibrillation. The patient receives a full-fledged complex therapy of the underlying disease. Currently hemodynamically stable.
Results of instrumental studies:
ECG on January 20, 2014: sinus bradycardia with a heart rate of 56/min, horizontal EOS. Atrioventricular blockade of the first degree, complete blockade of the right leg of the bundle of His
Holter monitoring of the ECG from 01/21/2014: During the observation period, sinus rhythm was recorded with a heart rate of 50 to 76 per minute. The decrease in heart rate at night is insufficient. Average heart rate 59/59/59 per minute. The following rhythm and conduction disturbances were registered: single polytopic polymorphic ventricular extrasystoles (66 in total), mostly late, periodically paired, group; from 16.20h. until 18-20h. and from 20-20 h. up to 23-20 hours, frequent (up to 234 per hour), the rest of the time single polytopic supraventricular extrasystoles (1016 in total), periodically paired, group; at 1-56 a short run of supraventricular tachycardia (5 complexes); AV block I degree; transient blockade of the right leg of the bundle of His (recorded mainly in the daytime).
Ultrasound of the abdominal organs, thyroid gland from 01/16/2014: the liver is not enlarged, the right lobe is 10.2 cm, the left lobe is 6.0 cm, the contours are even, the echogenicity is increased, the vascular pattern is preserved, the vessels (portal vein, hepatic veins) not expanded. Intrahepatic bile ducts are not dilated. The gallbladder of the correct form, dimensions (length 4.6 cm, diameter 2.3 cm), smooth contours, wall 4 mm, not changed, intracavitary formations - sediment. The pancreas is blocked by intestinal loops. The spleen is not enlarged, dimensions: length 9.7 cm, thickness 5.4 cm, homogeneous structure. The kidneys are located in a typical place, the contours are clear, the right kidney with a large anechoic round formation with clear contours 9 cm in diameter, the left kidney 11 * 6 cm, the parenchyma is homogeneous 24 mm; ChLS of both kidneys is not dilated. The thyroid gland is located in a typical location, symmetrical, not enlarged. The contours are fuzzy, uneven, the structure is heterogeneous due to areas of different echogenicity. Right lobe: width 19.5 cm, thickness 20.6 cm, length 45.0 cm. Left lobe: width 19.7 cm, thickness 20.7 cm, length 43.0 cm. VΣ=17.5 ml. Volumetric formations with clear even contours are visualized in the right lobe 0.8 * 1.2 cm and 0.9 * 1.0 cm, in the left lobe with a diameter of 0.6 cm, 0.5 cm, 0.6 cm, 0.7 see Blood flow is not increased. Regional lymph nodes are not changed. 0.5 cm, 0.6 cm, 0.7 cm. The blood flow is not increased. Regional lymph nodes are not changed. 0.5 cm, 0.6 cm, 0.7 cm. The blood flow is not increased. Regional lymph nodes are not changed.
Ultrasound of the small pelvis: signs of adenoma (V 42.0 ml), chronic prostatitis.
Echo-KG from 17.01.2014:
Index
Value
Norm
Index
Value
Index
Aorta and pulmonary artery
Left atrium
Root, mm
26.4
22-26
Anterior-posterior. size, mm
44.6
30-40
Ascending,
mm
34.6
21-34 size, mm
49.0 29-49
AK
opening, mm
16.1
15-26
Length. size, mm
59.1 29-53
Leg
. artery, mm
16.0
15-21
Left ventricle
Right ventricle LV EDR
, mm
62.4
42-59 LV EDR
, mm
20-28
LV EDR, mm
34.3
20-36 LV EDR
, mm
28.1
27-33
TMZhP (dias), mm
10.0
6-10
CDR (basic-apex), mm
-
71-79
LV TZS (dias), mm
11.0
6-10
RV area (dias.), cm2
-
11-28
LVML, g
342
141
RV area (syst.) , cm2
-
7.5-16
LVMI, g/l2
163
109 Anterior
wall thickness, mm
4.1
< 6
OTS, units
0.34
< 0.42
Right atrium
EF (Teicholz),%
45
>
55 solution , mm
34.1
30-40
IVRT, ms
70-75
Longitudinal solution, mm
48.3
Mitral valve
< 50 years / > 50 years
Tricuspid valve
< 50 years / > 50 years
Peak wave velocity E, m/s
0, 68
0.58-0.68/ 0.48-0.86
0.49
0.34-0.68/0.33-0.49
Peak wave velocity A, m/s
0.57
0.30-0 .50/0.45-0.73
0.20
0.19-0.35/0.25-0.41
U/A
1.2
1.0-1.5
2.5
1.0-1.5
Regurgitation, degree
0-1
0
0
0-1
E wave deceleration time, ms
174
159-199/174-276
200
166-210/175-221
Aortic valve
Pulmonary valve
Peak blood flow velocity, m/s
1.5
1.0-1.7
0.9
0.6 -0.9
Regurgitation, degree
0
0
0
0
Conclusion: The walls of the aorta are indurated. The leaflets of the aortic valve are sealed and calcified. Eccentric LV hypertrophy with dilatation of its cavity. Dilatation of the cavity of the left atrium. Systolic LV function is reduced. Hypokinesia of the basal anterior and basal septal segments. Type II LV diastolic dysfunction. Applied mitral regurgitation. Pericardium without features.
Laboratory results:
Clinical blood test (hardware processing): RBC
date
, *1012/l
Hb
units.
Lake. *109/l
Tr.
109/l
HCT
PCT
ESR, mm/h
E
%
B
%
lim
%
mon
%
p/i
%
s/i
%
15.01.14
4.1
125
8.1
228
367
175
16
1
-
10
11
3
75
Rt,
‰
MCV,
fl
MCH,
pg
MCHC,
g/l
RDW,
%
MPV,
fl
PDW
%
Lf
%
M,
%
Gra,
%
Lf,
109/L
M,
109/L
Gra,
109/L
-
90
30.5
340
14.6
7.6
13.9
14.4
5.3
80.3
1.1
0.4
6.6
Date
RBC, *1012/l
Hb
unit
Lake. *109/l
Tr.
109/l
HCT
PCT
ESR, mm/h
E
%
B
%
lim
%
mon
%
w/w
% w/
w
%
16.01.14
4.26
129
5.0
215
383
171
18
-
-
18
11
3
68
Rt,
‰
MCV,
fl
MCH,
pg
MCHC,
g/l
RDW,
%
MPV,
fl
PDW
%
Lf
%
M ,
%
Gra,
%
Lf,
109/L
M,
109/L
Gra,
109/L
-
90
30.3
337
14.3
8.0
15.4
21.0
7.4
71.6
1.0
0.3
3.7
Biochemical blood test dated January 16, 2014:
Name
Unit of measure.
Norm
16.01
21.01
27.01
Urea
mmol/l
2.5-6.4
9.1
10.4
Glucose
mmol/l
4.2-6.4
5.02
5.15
Creatinine
mmol/l
0.05-0.12
0.09
0, 08
O. protein
g/l
63-87
73
69
Potassium
mmol/l
3.50-5.10
4.69
5.19
Sodium
mmol/l
136-145
134
134
Chlorine
mmol/l
98-107
106
Cholesterol
mmol/l
3.7-6.0
3.62
AST
U/l
11.0-50.0
14
ALT
U/l
11.0-50.0
12
LDH
U /l
120-246
125
CPK –MV
U/l
0.0-25.0
22
19
o.
bilirubin mmol/ l 6.8-26
18.7
ex
. bilirubin
mmol/l
0.0-7.0
4.8
Alkaline phosphatase
U/l
45-120
144
Prothrombin
%
70-130
62
82
Fibrinogen
Mg/dl
200-400
338
362
T3 free
pmol/l
4.0-8.6
5.9
Urinalysis
Date
16.01.14.y
Color
Yellow
Transparency
Transparent
Density
1020
pH
5.5
Protein (g/l)
0 .08
Leukocytes 3-4-4
in p / c
Erythrocytes
up to 100 in p / c
Glucose
4.4 mmol / l
Nechiporenko test: L 1.25x106 / l, E 0.5x106 / l
The goals of hospitalization have been achieved. Discharged in a satisfactory condition under the supervision of a neurologist, urologist, cardiologist, endocrinologist, at the place of residence.
RECOMMENDED:
1. Observation by a neurologist, cardiologist, gastroenterologist, urologist at the place of residence.
2. General measures, including regular, moderate in intensity, physical dynamic loads in the air, sufficient sleep and rest, and, if possible, sanatorium-and-spa treatment in sanatoriums of the local climate.
3. Limit the consumption of animal fats, easily digestible carbohydrates, increase the amount of vegetable fiber, vegetable fats, foods containing an increased amount of potassium (dried apricots, raisins, prunes) in the diet.
4. TSH control 1 time in 3 months.
5. Permanent reception (under the control of the pulse level, blood pressure):
• T. Losartan 25 mg ½ tablet in the morning and evening after meals.
• T. Veroshpiron 25 mg 2 tablets 2 times a day.
• T. Sotalol 80 ½ tablet 2 times a day.
• T. Rocaltrol 0.25 mcg 1 tablet in the morning
• Caps. Cardionat 0.25 1 capsule 2 times a day after meals (for 1 month, courses 3 times a year).
• T. Pradaxa 110 mg 1 tablet 2 times a day
• T. Omnic 1 tablet in the evening
• T. Finasteride 1 tablet in the morning
• T. Seroquel 25 mg at night for a long time
MILITARY MEDICAL ACADEMY Form 12_Un.
DISCHARGE
HISTORY CASE HISTORY No.
Surname, name, patronymic born in 1973
He was hospitalized
at the clinic of hospital therapy
Total days of treatment were 10
The final diagnosis was established ICD code I 40.0
Diagnosis:
Primary: Infectious-toxic (viral-bacterial) myopericarditis, severe.
Complication of the underlying disease: Paroxysmal form of atrial fibrillation, frequent paroxysms of atrial fibrillation, tachysystolic variant. Severe effusion pericarditis, secondary pulmonary hypertension grade 1, heart failure grade 2. Systemic inflammatory response syndrome. DN-2st.
Accompanying: Community-acquired viral-bacterial focal polysegmental confluent pneumonia in the lower lobe of the left lung, severe, left-sided effusion pleurisy. Cholelithiasis, chronic calculous cholecystitis, remission. Obesity I degree, alimentary-constitutional type, stable phase. fatty hepatosis.
A disability certificate was not issued.
Employability has not been restored.
Clinical outcome (underline): improvement
Outcome: discharged due to improvement
Admission:
Complaints: pressing pain in the heart area during exercise; shortness of breath of an inspiratory nature; dry cough without sputum; an increase in body temperature up to 39 degrees; weakness.
Anamnesis of the disease: He considers himself ill since the beginning of March 2011, when these complaints appeared against the background of hypothermia. He did not apply for medical help, periodically took biseptol, amoxicillin. In connection with persistent complaints, he applied for medical help to the clinic on March 17, 2011, the ECG revealed atrial fibrillation, and focal pneumonia on the x-ray. Hospitalized by ambulance to the hospital therapy clinic.
Objective status: general condition is severe, no edema, heart rate 76 per minute, rhythmic, auscultatory heart sounds are muffled, accent of the second tone over the aorta, heart borders are expanded to the left, blood pressure 110/70 mm Hg, hard breathing in the lungs, wheezing No; the abdomen is soft, painless on palpation, tapping on the lumbar region is painless on both sides.
As a result of the treatment: mode III, diet No. 10, antibiotic therapy (Ceftriaxone 1.0 2 r / day), polarizing mixture (glucose 5%, potassium chloride, magnesium sulfate., Vit. C 6 ml - No. 5), metabolic therapy (Mildronate), antisecretory therapy (Omeprazole), anti-inflammatory therapy (Ibuprofen 0.4 3 r / day), GCS therapy (Prednisolone IV 90 mg 3 r / d), antiarrhythmic therapy (Cordaron 0.2 3 r / d) , anticoagulant therapy (Heparin s / c at 2500 4 r / d), the state of health improved in the form of a decrease in shortness of breath, the severity in the heart area, the divergence of the sheets of the pericardium decreased.
Results of instrumental studies:
ECG 22.03.2011 Large-wave atrial fibrillation tachysystolic form. The vertical position of the EOS. Signs of left ventricular hypertrophy. Decreased voltage of ECG waves.
ECG dated April 1, 2011. Atrial fibrillation, tachysystolic form. Normal position of the EOS. The predominance of LV potentials. Violation of the processes of repolarization along the god wall.
ECG from 04.04.2011 Sinus bradycardia with a heart rate of 56 per minute. Left ventricular hypertrophy. Diffuse changes in repolarization processes.
Echocardiography on March 18, 2011: Ascending aorta with a diameter of 28 mm, at the level of the aortic valve 30 mm., Opening of the aortic valve 19 mm. Left atrium: transverse dimension 41 mm, anterior-posterior 43 mm, longitudinal 48 mm. Left ventricle: ECR 35 mm, ECR 50 mm, FU 29%, ejection fraction 55%; UO 64 ml., back wall: diast. 10 mm; interventricular septum: diast. 10 mm. Pulmonary artery: at the valve 23 mm. Right atrium: transverse dimension 37 mm, longitudinal dimension 47 mm. Right ventricle: KDR 28 mm, anterior wall (diast.) 5 mm. The average calculated pressure in the pulmonary artery is 16.7 mm Hg. Conclusion: Sealing of the walls of the aorta, mitral valve leaflets, mitral valve ring. Slight enlargement of the left atrium. The rest of the chambers are not expanded. Two additional false chords are located in the cavity of the left ventricle. Myocardium is not thickened. Violations of local contractility were not revealed. Global contractility is preserved. Mitral regurgitation 0-1 degree. Tricuspid regurgitation grade 1. There is an expansion of the inferior vena cava up to 25 mm (decline on inspiration less than 50%), expansion of the hepatic veins up to 8-10 mm. slight deposition of fibrin. On the control on the visceral sheet is determined by a small deposition of fibrin. On the control on the visceral sheet is determined by a small deposition of fibrin. On the control
EchoCG from 03/21/2011. there is a positive trend in the form of a decrease in the divergence of the sheets of the pericardium: above the apex 5 mm, at the side wall of the left ventricle - up to 16 mm, along the back wall - 16 mm. EchoCG from 03/24/2011. compared with echocardiography of March 21, 2011, there is an increase in the divergence of the pericardial sheets along the lateral wall from 16 to 24 mm, along the apex from 7 to 15 mm. On the back wall, the discrepancy is the same 16-18 mm. In the cavity of the pericardium, a formation measuring 26 * 18 mm (deposition of fibrin) is located. CT of the chest is recommended.
EchoCG from 04/01/2011. against the background of tachysystole (HR 170 per minute), there is a decrease in EF to 23-25%, otherwise without dynamics.
EchoCG from 04.04.11 LV=51/35mm; RV=24mm; MZHP=10mm; LA=23mm; open AC=17mm; EF=56%; FU=29% divergence of pericardial sheets up to 9 mm along the posterior wall. Slight hardening of the walls of the aorta. Cavities are not expanded, free. The myocardium is not thickened, the kinetics is not broken. The valves have not been changed. The blood flow is laminar. Regurgitation applied to the MK and TK. There are two additional transverse chords in the LV cavity. Circular divergence of the sheets of the pericardium (their thickening) up to 9 mm. In the lumen there are single fibrin strands.
Ultrasound of the abdominal organs 03/28/2011: the liver is enlarged, the right lobe is 17.3 cm, the left lobe is 8.5 cm, the contours are even, the structure is homogeneous, echogenicity is average, the vascular pattern is preserved. The vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated; there are no mass formations. the gallbladder is of the correct shape, the dimensions are normal, the contours are even, the wall is 0.2 mm, the contents are bile, the calculus is located 11.4 * 8.1 mm, there are no polyps. The common bile duct is 0.3 cm. The pancreas is located clearly, the contours are clear, even, homogeneous echo density, the Wirsung duct is not dilated. The kidneys are usually located, of a typical shape, not enlarged, the contours are even, the parenchyma is homogeneous with a thickness of up to 20-25 mm; CHLS is not dilated, there is a large number of microliths in the left kidney. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged, homogeneous. Conclusion: Hepatomegaly. ZhKB.
CT angiography on 03/30/2011: the results were handed out.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pya
%
Xia
%
24.03
141
4.5
14.5
31.3
54
0
-
19
3
3
73
31.03
142
4.74
23 ,0
30.1
42
0
-
13
5
4
78
01.04
133
4.39
24.4
30.4
4
1
-
13
5
1
80
03.04
138
4.6
12.1
12
4
3
4
89
_
_
_
Norm
24.03
31.03
Index
23.03
Creatinine
Mkmol/l
53-124
Color
yellow
Cholesterol
Mmol/l
3.7-6.0
Transparency
Clear
Triglycerides
Mmol/l
0-2.37
Specific. weight
1030
Fibrinogen
G/l
200-400
716
Reaction
Acid
Sodium
mmol/l
136.0-145.0
141.3
144.0
Protein (g/l)
No
Potassium
mmol/l
3.5-5.1
4.53
4.17
Sugar
No
Glucose
mmol/ l
4.2-6.4
Urobilin
0.2
Prothrombin
%
70-120
91
Leukocytes in p/ l
no
LDH
U/l
200-400
291
Erythr. unchanged in p/ l
no
CPK
U/l
10.0-160.0
342.1
Erythr. vysch. in p/sp
No
AST
U/l
11.0-50.0
104.9
Salt
no
ALT
U/l
11.0-50.0
126.4
Mucus
No
CPK MB
U/l
10.9
8.2
Consultation with a cardiac surgeon from 01.04.2011 recommended: -
restore sinus rhythm;
- continue therapy with corticosteroids and NSAIDs;
-continue broad-spectrum antibacterial therapy;
-metabolic therapy, electrolytes;
-an. blood for RNG with tuberculin hypertension, Mantoux reaction, consultation of a phthisiatrician.
Recommended:
1. Consultation of a phthisiatrician at the place of residence.
2. Continue treatment in the conditions of the cardiology department.
3. Correction of ongoing therapy ONLY after consulting a cardiologist!
4. Continue taking:
a. Tab. Prednisolone 5 mg - 6 tab. (30 mg) in the morning, crush, drink jelly.
b. Tab. Nurofen 0.4 x 1 t. 1 r / day - 2 weeks;
c. Tab. Kordaron 0.2, 1 t. 2 r / day, after 1 week, 1 t. 1 r / day - during the week;
d. Caps. Omeprazole 0.02 1 caps. 2 times a day - 2 weeks;
e. Caps. Mildronate 0.25 2 caps. 2 r / day - one month.
f. Tab. Metronidazole 0.5 for 1 t. 3 r / day - 2 weeks.
g. Tab. Enalapril 0.005 - ½ tab (2.5 mg) in the evening.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1943
She was on inpatient treatment in the clinic of hospital therapy
Total days of treatment were 14
The final diagnosis was established
ICD Code I 50.0; MES 291110
Diagnosis:
IHD: stable exertional angina 3 FC. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and large-focal post-infarction (of unknown age) cardiosclerosis.
Hypertensive disease of the third stage (arterial hypertension of the 3rd degree, the risk of cardiovascular complications is “very high”)
Chronic heart failure of the 2B stage, IV → III functional class. Recurrent attacks of cardiac asthma. Anasarca (edema, small right-sided hydrothorax). Congestive pneumonia in the lower lobe of the right lung. Cardiac fibrosis of the liver.
Autoimmune thyroiditis, diffuse nodular form, overt hypothyroidism
Mild type 2 diabetes mellitus, HbAc 6.88%, target HbAc<7.5%.
Android obesity 2 degrees, stable phase.
Chronic obstructive pulmonary disease, bronchitis type, moderate course, in the acute stage, DN-1 stage.
Dyscirculatory encephalopathy of the second stage of mixed (hypertensive, post-stroke (CVA according to the ischemic type in the LMMA pool from 12/31/2008), atherosclerotic, dysmetabolic) genesis.
Secondary nephropathy of mixed (atherosclerotic, hypertensive, metabolic) genesis. Chronic kidney disease C4 Ax stage (GFRCKD-EPI 28 ml/min). Chronic renal failure stage 1B. Secondary normochromic anemia of mild severity.
Cholelithiasis stage III. Chronic calculous cholecystitis, remission.
Degenerative-dystrophic disease of the spine.
Post-injection phlebitis of the cubital veins of the left upper limb
Disability certificate: not issued
Total radiation dose 0.78 mSv
Clinical outcome: improvement.
Outcome: discharged.
On admission:
Complaints: increasing dyspnea at rest of a mixed, mostly inspiratory nature, paroxysmal cough without discharge, increasing pronounced general weakness, swelling of the legs to the hips.
History of present illness. For a long time suffers from coronary heart disease, hypertension, obesity, COPD. Since 2010, diabetes. The working figures for blood pressure are 160/100 mm Hg. does not take regular therapy. With an increase in blood pressure, he takes nifedipine. In 2008, she suffered an ischemic stroke in the LCMA pool in the form of right-sided hemiparesis, mild cortical dysarthria, and partial right-sided hemihypesthesia. In 2010, he was diagnosed with large-focal post-infarction cardiosclerosis, chronic renal failure stage 2, CKD stage 3. During the last year, she notes a significant deterioration in the form of increased edema, shortness of breath. From the beginning of September, the edema increased significantly, she independently took veroshpiron, furosemide with a short-term positive effect. Recently, she slept sitting up, with difficulty moving around the house on her own. Outpatient took digoxin 0.5 tab./day, furosemide. Over the past few days, there has been a significant increase in dyspnea at rest. Given the progressive deterioration of her condition, she was hospitalized at the hospital therapy clinic for further diagnosis and treatment.
Objective examination data. Height 157 cm, body weight 93 kg, BMI 37.7 kg/m2. The general condition is severe, due to signs of multiple organ (cardiopulmonary and renal failure, dyscirculatory encephalopathy, disorders of thyroid and carbohydrate metabolism) Hypersthenic physique. Obesity II degree. The skin is earthy-yellow, dry, icterus of the sclera, mucous membranes. Tension swelling of the legs to the level of the waist, trophic changes in the skin of the feet. Peripheral lymph nodes are not enlarged. The thyroid gland on palpation is enlarged, compacted, heterogeneous. Pulse 82 per minute, rhythmic. AD - 150/90 mm. rt. Art. heart sounds are deaf, rhythmic, weakening of the first tone at the apex, systolic murmur at all points of auscultation with a maximum in the projection of the mitral valve. On auscultation of the lungs, breathing is rough, against the background of multiple dry rales scattered over all fields in the lower sections, moist, finely bubbling rales are heard on both sides. Resting respiratory rate 22/min. The abdomen is enlarged in volume due to the subcutaneous fat layer, the correct shape. The edge of the liver +4 cm from under the costal arch. The size of the liver according to Kurlov is 16x14x9 cm.
As a result of the treatment: regimen, diet No. 9, amlodipine, carvedilol, levothyroxine, metabolic therapy, furosemide (with a switch to diuver), berodual, ceftriaxone, lazolvan, heparin, cardionate, the state of health improved. The maximum possible compensation of the functions of internal organs and systems was achieved.
Results of instrumental studies:
ECG dated 10/10/2013: sinus rhythm with a heart rate of 70/min, EOS is indeterminate due to the presence of large-focal cicatricial changes in the area of the lower wall (qII; avF; QIII). Incomplete stem blockade of the left leg of the bundle of His (QRS 0.105 s). Hypertrophy of the left chambers of the heart, diffuse repolarization disorders, diastolic overload of the left ventricle.
ECG No. 825 dated October 18, 2013: sinus rhythm with a heart rate of 60/min, EOS is indeterminate due to the presence of large-focal cicatricial changes in the region of the lower wall (qII; avF; QIII). Incomplete stem blockade of the left leg of the bundle of His. Hypertrophy of the left chambers of the heart, diffuse repolarization disorders, diastolic overload of the left ventricle. In the dynamics, there are positive changes in the form of reversion of the T waves V1-3, approaching the isoline of the ST segment V4-6
ECHO-KG from 10/14/2013: Aorta (root) 33 mm, LV 60/45 mm, MZhVlzh = ZSlzh 12.8 mm, IMMLV 219 g/m2, EF 50%, FVlzh 25%, LA 48 × 58 × 60 mm, PP 54 ×58mm, RV 30 mm, RV free wall 6 mm. Symmetrical eccentric myocardial hypertrophy, hypokinesia of the posterior wall in the basal and middle sections. The atrial and left ventricular cavities are moderately dilated. Aorta, fibrous rings of AK and MK are sealed with the inclusion of calcifications. Calcifications in the structure of the posterior cusp of the MV and the non-coronary crescent of the AV do not limit their opening. The blood flow on the valves is laminar, LV diastolic dysfunction II (pseudo-normal) type. Pulmonary hypertension 1 degree. In the right pleural cavity in the sinus region, free fluid is located up to the level of the 9th rib along the scapular line.
X-ray of the chest organs in direct and lateral projections from 10/15/2013. The pulmonary fields are emphysematous, the pulmonary pattern is strengthened and deformed due to pneumofibrosis and venous congestion. The roots of the lungs are compacted and expanded due to the vessels. Pleural cords in the supradiaphragmatic regions on both sides. The diaphragm is sealed, free fluid in the pleural cavities is not detected. The heart is in a horizontal position, expanded in diameter to the left.
FVD dated 10/18/2013. VC 47%, FEV1 50% moderate-to-severe disorders (St. III) VFL by restrictive type. Bronchodilation coefficient 5.8%.
Ultrasound of the abdominal organs from 10/17/2013.
Liver
Enlarged, the right lobe is 17.5 cm, the left lobe is 10.8 cm, the contours are even, the structure is homogeneous, the echogenicity is significantly increased, the vascular pattern is preserved .
The gallbladder is
5.2 * 3.0 cm, the contours are uneven, the walls are 3 mm, the contents are calculi , common bile duct 0.3 cm
Pancreas
Clearly located, 24.0 * 20.5 * 19.0 mm, echogenicity is significantly increased, Wirsung's duct is not dilated, 2 mm
Kidneys
Right kidney: 9.8 * 5.6 cm, parenchyma homogeneous, 22.0 mm, microliths. Left kidney: 11.0*4.7 mm, homogeneous parenchyma 19.0 mm
Adrenal glands
No pathological formations detected
Spleen
12.5*6.4 cm, homogeneous structure
Conclusion: diffuse changes in the liver, pancreas. JCB. Thinning of the parenchyma of the left kidney. Microliths of the right kidney.
Ultrasound of the thyroid gland from 10/17/2013.
Right lobe
26.2*31.8*48.0 cm. Volume 18.4 cm3.
Left lobe
23.0*27.0*43.0 cm. Volume 14.0 cm3.
Isthmus
7 mm.
The total volume
is 32.3 ml. The structure is heterogeneous, multiple hypo- and hyperechoic areas. In the area of the isthmus, an isoechoic formation with clear, even contours with a diameter of 11.0 mm is located. The blood flow is moderately increased. Regional lymph nodes are not enlarged.
Conclusion: hyperplasia of the thyroid gland. Ultrasound signs of autoimmune thyroiditis.
Results of laboratory tests
Complete blood count
Date
11.10.2013
21.10.2013
Hb, g/l.
106
100
Erythrocytes *1012/l
3.65
3.49
Leukocytes *109/l
8.5
6.7
Myelocytes
1
-
ESR, mm/h
35
50
Eosinophils %
2
-
Basophils %
1
-
Lymphocytes %
16
22
Monocytes %
6
7
Band %
5
7
Segmented %
74
64
Urinalysis
Date
15.10.11.g
Color
Yellow
Transparency
Transparent
Density
1010
pH
5.5
Protein (g/l)
Neg.
Leukocytes
2-3 in p / c
Erythrocytes
None
Glucose
4.4 mmol / l
daily loss of protein
Diuresis 2100 ml, protein was not detected
Nechiporenko test: L 3.25x106 / l, E 0.75x106 / l
Biochemical analysis of blood:
Name
Unit of measure.
Norm
11.10
14.10
22.10
Urea
mmol/l
2.5-6.4
18.4
27.0
24.6
Glucose
mmol/l
4.2-6.4
7.24
5.5
6.08
Creatinine
mmol/l
0.05-0, 12
160
250
230
O. protein
g/l
63-87
71
73.5
71
Albumin
g/l
30-55
41.9
globulins
g/l
17-35
32
Potassium
mmol/l
3.50-5.10
5.29
5.75
5.31
Sodium
mmol/l
136-145
142.2
142.3
Chlorine
mmol/l
98-107
111.7
Triglycerides
mmol/l
0-2.3
1.34
Cholesterol
mmol/l
3.7-6 ,0
3.4
b-lipoproteins (LDL)
ED
350 - 650
400
LDL
mmol/l
1.9-4.4
1.81
VLDL
mmol/l
0.6-1.2
0.61
HDL
mmol/l
0.78- 2.303
0.98
coefficient atherogenicity
units.
0.0-3.0
2.47
AST
U/l
11.0-50.0
10
ALT
U/l
11.0-50.0
24
LDH
U/l
120-246
214
CPK
U/l
10.0-160.0
CPK –MV
U/l
0.0-25.0
o.
bilirubin mmol/ l 6.8-26
6.1
ex
. bilirubin
mmol/l
0.0-7.0
3.4
Amylase
U/l
30-115
Alkaline phosphatase
U/l
45-120
56
GGTP
U/l
8- 63
72
Prothrombin
%
70-130
92
Fibrinogen
Mg/dl
200-400
539
TSH
mIU/ml
0.3-4.0
75.10
TG
ng/ml
0-50
AT to TPO
mIU/ml
up to 30
AT to TG
mIU/ml
up to 100
T4 total
nmol/l
52-155
36
T4 free
pmol/l
10-25
T3 total
nmol/l
1.2-3.0
T3 free
pmol/l
4.0-8.6
Glycated hemoglobin
%
4.0-6.5
6.33
C-reactive protein
mmol/l
0-5.0
101 ,8
HBsAg, anti-HCV, serological tests for syphilis, F-50 10/14/2013. negative.
Capillary blood for glucose from 10/14/2013. 8-00 4.9 mmol/l, 10-00 5.6 mmol/l, 12-00 5.1 mmol/l
The goals of therapy were achieved: manifestations of chronic heart failure, congestive pneumonia were stopped, the maximum possible compensation of the function of internal organs was achieved at this stage. organs and systems, the genesis of pronounced congestion was determined, and therapy was selected for the initial stage of outpatient treatment. In a satisfactory condition, he is discharged to the polyclinic at the place of residence under the supervision of specialist doctors.
Recommended:
15. Lifelong dispensary supervision of a nephrologist, endocrinologist, cardiologist at the place of residence.
16. Control study (at least once every 3 months): ECG, general blood and urine tests, blood tests for cholesterol, triglycerides, LDL, creatinine, potassium, urea, glucose.
17. Determination of blood levels of T3, T4, antibodies to thyroglobulin, cortisol, thyroid-stimulating hormone - 2 times a year, followed by correction based on the results of the dose of levothyroxine
18. Continuous monitoring of body weight !!! with an increase in body weight of more than 1 kg (in comparison with the discharge data), consultation with a cardiologist in order to exclude the worsening of the course of chronic heart failure and correct (if necessary) the therapy.
19. Diet: restriction of protein intake with food to 0.8-1 g / kg (up to 50-60 g per day), depending on the severity of renal failure. At the same time, 30 g should be a high-value protein, and only 10 g of protein per day should fall on the share of bread, cereals, potatoes and other vegetables. 30-40 g of complete protein. In general, the patient's menu is compiled within table No. 7. The following products are included in the patient's daily diet: meat (100-120 g), cottage cheese dishes, cereal dishes, semolina, rice, buckwheat, barley porridge. A potato and potato-egg diet is recommended. Particularly suitable due to their low protein content and at the same time high energy value are potato dishes (pancakes, meatballs, grandmothers, fried potatoes, mashed potatoes, etc.), salads with sour cream, vinaigrettes with a significant amount (50-100 g) of vegetable oil. Tea or coffee can be acidified with lemon, put 2-3 tablespoons of sugar in a glass, it is recommended to use honey, jam, jam. Thus, the main composition of food is carbohydrates and fats and dosed - proteins. Calculating the daily amount of protein in the diet is a must. It is allowed to replace 1 egg with: cottage cheese - 40 g; meat - 35 g; fish - 50 g; milk - 160 g; cheese - 20 g; beef liver - 40 g.
Approximate diet:
• Breakfast: Soft-boiled egg + Rice porridge 60 g + Honey 50 g
• Lunch: Fresh cabbage soup 300 g + Fried fish with mashed potatoes 150 g + Apples
• Dinner: Mashed potatoes 300 g + Vegetable salad 200 g + Milk 200 d
Correction of water balance disorders: take enough liquid to maintain diuresis in the range of 1.5-2.0 liters per day.
Correction of electrolyte imbalance: salt intake should be limited to 5 g per day
20. Continue taking:
• Amlodipine 5 mg - 1 tab. in the morning constantly;
• Carvedilol 12.5 mg - ½ tab. 2 times a day;
• Torasemide (Diuver) 10 mg - 1 tab. in the morning;
• L-thyroxine 50 mcg - 2.5 tab. (125 mcg) in the morning;
• Spiriva - n 1 capsule through an inhaler 1 time per day;
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1978
He was in the day hospital regime
at the hospital therapy clinic Departed from the VMA
Total days of treatment 11
The final diagnosis was established ICD code I 10 (MES 291250)
Diagnosis:
Hypertension stage I (arterial hypertension 2, the risk of CVE is medium). Chronic heart failure I functional class.
Sliding hernia of the esophageal opening of the diaphragm of the second degree. Distal catarrhal reflux esophagitis, hernial gastritis of the proximal stomach.
Peptic ulcer of the duodenum, HP-associated frequently relapsing form, in the acute phase in the form of erosive bulbitis. Cicatricial deformity of the duodenal bulb without disturbing the evacuation function.
Diffuse-nodular goiter of the first degree, euthyroidism.
Certificate of incapacity for work issued no.
Ability to work restored
Total radiation dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity
, disability, established _____ disability group, degree of disability _______________________________, other _____________________________________________ where) _____________________________________________________________________________
Examined by MSEC: yes / no
On admission:
Complaints: headache with an increase in blood pressure to 160/100 mm Hg, palpitations, fatigue, weakness; discomfort in the epigastric region, heartburn.
History of present illness. Over the past 6 years (the patient associates with frequent stressful situations) notes frequent episodes of headache, increased blood pressure to 160/100 mm Hg, constant feeling of rapid heartbeat. He considers the working values of blood pressure to be 130-140 / 80-95 mm Hg. He was not examined, he independently took Andipal on demand (“a pill in his pocket”). Over the past year, arterial hypertension has assumed a permanent stable character, general weakness and fatigue began to increase. October 22, 2013 independently applied to the clinic at the place of residence, from the same day a sheet of temporary disability (outpatient treatment) was opened. Appointed Enalapril 5 mg 2 times a day. Despite ongoing therapy, increasing the dose to 20 mg/day, complaints persisted.
From the age of 21, he notes the appearance of pain in the epigastric region with errors in the diet, spring and autumn. Repeatedly passed inpatient treatment for exacerbations of duodenal ulcer. The development of cicatricial deformity of the bulb against the background of a frequently recurring form of duodenal ulcer was the reason for dismissal from the ranks of the Armed Forces of the Russian Federation in 2004. Over the past 7 years, regularly 2 times a year, conducts courses of antiulcer therapy with a moderate positive effect in the form of reducing the intensity and duration of abdominal pain. FGDS control has not been performed since 2006. The last aggravation, according to the words, was in March 2013.
In December 2004, he suffered from destructive pneumonia with a decay site in the region of the lower lobe of the left. From the proposed lobar pulmonectomy (from the words) refused. Later, an emphysematous transformation of this area was formed, without dynamics in the period from 2005 to 2008. was not observed.
Objectively at admission: Height 177 cm. Body weight 86 kg. BMI=27.5 kg/m2. The general condition is satisfactory. Correct physique. Visible mucous membranes are clean, of normal color. Posture is not broken. The load along the axis of the spine is painless. Movement in all parts of the spine is not limited. The thyroid gland is not visible, palpation is not changed. Heart rate 72 per minute. Blood pressure 150/90 mm Hg. Art. The boundaries of relative cardiac dullness were not changed. Heart sounds are clear and pure. Above the lungs percussion clear pulmonary sound. Breathing is vesicular, no wheezing. The respiratory rate is 16 in 1 minute. The abdomen is soft, painful on palpation in the epigastric zone and the Shofarr point. The liver and spleen are not enlarged. The kidneys are not palpable. Tapping on the lumbar region is painless on both sides.
As a result of the treatment: regimen, diet No. 1, noliprel-forte, metabolic and diuretic therapy, de-nol, omeprazole, almagel, eradication therapy, the state of health improved.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
29.10
147
4.55
9.5
44.3
4
271
3
35
6
1
55
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
29.10
full
1025
light yellow
5.5
no
no
oxalate
no
no
no
0-1
no
0-2
0-1
daily urine: urea 506 mmol/l, creatinine 20 mmol/l, albumin 20.6 units (up to 14 units)
Biochemical analysis of blood:
Name
Unit of measure.
Norm
29.10
Urea
mmol/l
2.5-6.4
4.4
Glucose
mmol/l
4.2-6.4
4.94
Creatinine
mmol/l
0.05-0.12
0.09
O. protein
g/l
63-87
70
Albumin
g/l
30-55
48
globulins
g/l
17-35
28
Potassium
mmol/l
3.50-5.10
4.47
Sodium
mmol/l
136-145
140.7
Chlorine
mmol/l
98-107
106
Triglycerides
mmol/l
0-2.3
1.7
Cholesterol
mmol/l
3.7-6.0
5.81
b-lipoproteins (LDL)
ED
350-650
600
LDL
mmol/l
1.9-4.4
3, 31
VLDL
mmol/l
0.6-1.2
0.78
HDL
mmol/l
0.78-2.303
1.72
coefficient atherogenicity
units.
0.0-3.0
2.38
TSH
mIU/ml
0.3-4.0
1.73
T4 free
mg/dl
4.5-15
7.4
Results of instrumental studies:
FGDS from 10/29/2013: The esophagus is freely passable. Prolapse of the gastric mucosa into the esophagus is noted. The Z-line is above the crura of the diaphragm, clear, in the distal section, the mucosa is edematous, hyperemic, due to reflux. Folds of the stomach of the usual caliber. In the upper third of the stomach, the mucosa is hyperemic and edematous. In other departments pink, in the antrum with focal atrophy. The pylorus does not close completely, there is a reflux of duodenal contents. The bulb of the duodenum is deformed due to cicatricial changes. The mucosa is edematous, inflamed due to single flat-inflammatory and petechial erosions up to 2-3 mm. Conclusion: 2nd degree collapsing hiatal hernia, distal catarrhal reflux esophagitis, hernial proximal gastritis with focal atrophy of the distal segment. Duodeno-gastric reflux. Cicatricial deformity of the duodenal bulb, erosive bulbitis. Urease test strongly positive (+++)
ECHO-KG dated October 30, 2013. IVS=WS=10.5 mm, LV 55/38 mm, EF 56%, FU 28%, VR 80 ml, LA 39 mm, PP 40 mm, aorta 36 mm, aortic dilatation 21 mm, e/a 1.4 The myocardium is not thickened, the kinetics is not disturbed, the cavities are not enlarged, free. Aorta, valves, pericardium are not changed. Systolic and diastolic functions are not disturbed.
Ultrasound of the abdominal organs from 28.10.2013.
The liver
is enlarged, the right lobe is 16.6 cm, the left lobe is 7.8 cm, the contours are even, the structure is homogeneous, the echogenicity is increased, the vascular pattern is depleted .
The gallbladder
is 4.8x3.8 cm, the contours are uneven, the walls are 4 mm, the contents are
homogeneous
. clear, 24.4*18.0*20.0 mm, moderately increased echogenicity, Wirsung's duct is not dilated, 2 mm
Kidneys
Right kidney: 10.2x6.0 cm, homogeneous parenchyma, 18.0 mm. Left kidney: 11.5 * 6.8 mm, homogeneous parenchyma 18.0 mm
Adrenal glands
No pathological formations were detected
Spleen
9.2x4.2 cm, homogeneous structure
Conclusion: diffuse changes in the liver, pancreas.
Ultrasound of the thyroid gland from 28.10.2013.
The right lobe
is 18.0x33.2x51.4 cm. The volume is 16.2 cm3.
Left lobe
16.6x20.3x41.8 cm. Volume 9.1 cm3.
Isthmus
5.5 mm.
The total volume
is 25.3 ml In the right lobe, an isoechogenic formation with clear, even contours is located D1=7.8x11.4mm, D=3.8x4.0mm. In the left lobe isoechoic formation 14.5x7.2 mm. The blood flow is not enhanced. Regional lymph nodes are not enlarged.
Conclusion: hyperplasia of the thyroid gland. thyroid nodules.
No pathological formations were revealed on the chest radiograph dated November 1, 2013.
The goals of hospitalization have been achieved. Employment has been restored. Discharged for work, return to work 09.11.2013. A certificate of incapacity for work was issued from 28.10.2013. to 08.11.2013 for the period of treatment
It is discharged in a satisfactory condition under the supervision of a polyclinic therapist.
Recommended:
21. Dispensary observation of a polyclinic therapist,
22. Control of FGDS after 2 weeks with a test for HP (assessment of the effectiveness of eradication therapy).
23. Consultation with an endocrinologist in a planned manner,
24. Continue taking:
b. Caps. Omeprazole 0.02 1 capsule in the evening for 2 weeks.
c. Caps. Linex 1 capsule 3 times a day for 10 days.
d. Noliprel A biforte 10/1.25 1 tab. in the morning.
25. Limit the consumption of animal fats, fried and spicy foods, increase the amount of vegetable fiber, vegetable fats, products in the diet.
26. Course of antiulcer therapy during autumn-spring exacerbations:
a. Caps. Omeprazole 0.02 1 capsule 2 times a day for 4 weeks.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr., 63 tel. (812) 577-11-35
EXECUTIVE SUMMARY
CASE HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1948
Was on inpatient treatment (in the day hospital mode)
in the hospital therapy clinic
Total days of treatment were 7
The final diagnosis was established ICD code I.48 MES 291180
Diagnosis: Generalized atherosclerosis.
Coronary artery disease. Angina pectoris II functional class. Atherosclerosis of the aorta, coronary and cerebral arteries, atherosclerotic cardiosclerosis with arrhythmias of the type of paroxysmal atrial fibrillation. Paroxysm of atrial fibrillation, tachysystolic variant of 08.10.2013, stopped independently on 10.10.2013. Atherosclerotic aortic valve disease with a predominance of insufficiency (regurgitation of I degree). Mitral valve prolapse with grade I regurgitation.
Hypertensive disease stage II (arterial hypertension 1, the risk of CVE is high).
Chronic heart failure stage I, functional class II.
Chronic non-obstructive bronchitis. Diffuse moderate emphysema. DN-0.
Dyscirculatory encephalopathy stage II of hypertensive, atherosclerotic and vertebrogenic genesis in the form of right-sided pyramidal-cerebellar insufficiency and pseudoneurotic syndrome.
Polysegmental intervertebral osteochondrosis and deforming spondylosis, uncovertebral arthrosis of the cervical and lumbar spine with pain syndrome. Cervical-thoracic sciatica with C6-radicular syndrome on the right. Angiotrophoneurosis of the upper extremities stage I, without impaired circulation and function.
Chronic gastroduodenitis in the phase of unstable remission.
Deviation of the nasal septum. Bilateral sensorineural hearing loss (initial manifestations).
Presbyopia.
Certificate of incapacity for work: 102 207 201 045.
Ability to work restored
Total exposure dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, _____ disability group, degree of disability _______________________________, other _____________________________________________
Outcome: discharged according to a report, discharged on improvement, discharged on recovery, transferred to another medical institution (what) ____________________, transferred to rehabilitation treatment (where) _____________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a medical
examination
.
Complaints: episodes of weakness, palpitations, shortness of breath; for heaviness and headache in the occipital region, severe weakness, fatigue against the background of an increase in blood pressure to 160/100 mm. rt. Art. (normal value of blood pressure 130/80 mm. rdest.) for interruptions in the work of the heart; memory loss, sleep disturbance; to increase urination; weakness in the lower extremities; pain in the thoracic and lumbar spine: pain in the left knee joint.
Anamnesis of the disease: Since 1990, pain in the region of the heart has been disturbing, IHD has been diagnosed on an outpatient basis, angina pectoris I f. class In 1992, a paroxysm of atrial fibrillation developed, which was stopped by the introduction of novocainamide. Subsequently, paroxysms of atrial fibrillation regularly recurred, stopped on their own, took verapamil with panagin, in the absence of effect, an ambulance brigade was called. Headaches with increased blood pressure appear since 1995, took ACE inhibitors. In the future, he was repeatedly treated in a hospital with a diagnosis of coronary artery disease, angina pectoris II f. class, rhythm disturbance by type of paroxysmal atrial fibrillation. Hypertension II stage. NC I Art. For more than 20 years he has been suffering from chronic gastroduodenitis, EGDS - in the spring of 2004. For fifteen years he has been suffering from intervertebral osteochondrosis and deforming spondylosis of the cervical and lumbar spine, and has been treated on an outpatient basis and in sanatoriums. After a business trip to Antarctica, numbness and blanching of the fingers in the cold are disturbing. Angiosurgeon diagnosed angiotrophoneurosis of the upper extremities, was treated on an outpatient basis, took courses of vascular drugs. For 7 years, she has noted a significant deterioration in memory, sleep disturbance, increased dizziness, unsteady gait, a neurologist diagnosed dyscirculatory encephalopathy, and takes nootropic drugs. Diagnosed with hemorrhoids for 25 years, for 5 years - frequent bleeding from hemorrhoids, in October 2004 operated on - excision of hemorrhoids. After surgical treatment, body weight decreased by 10 kg. In the spring of 2004, the FCS was performed, no neoplasms. In 2002, he was examined by the VVK, recognized as partially fit for military service. In 2003 and 2004, a limitation of the ability to work was revealed, certified by MSEK: IHD. Angina pectoris III f. class Atherosclerosis of the aorta, coronary and cerebral arteries, atherosclerotic cardiosclerosis with rhythm disturbances by the type of paroxysmal tachysystolic atrial fibrillation. Atherosclerotic defect of the aortic valve with a predominance of insufficiency (regurgitation of the I degree). Mitral valve prolapse with grade I regurgitation. Hypertension stage II (AH II, risk IV). Dyscirculatory encephalopathy stage II of hypertensive, atherosclerotic and vertebrogenic genesis. CHF II f. class Right-sided pyramidal-cerebellar insufficiency. Slight dysfunction of the spine. Slight dysfunction of the right upper limb. pseudoneurotic syndrome. Chronic non-obstructive bronchitis. Diffuse moderate emphysema. DN-0. Polysegmental intervertebral osteochondrosis and deforming spondylosis, uncovertebral arthrosis of the cervical and lumbar spine with pain syndrome. Cervical-thoracic sciatica with C6-radicular syndrome on the right. Angiotrophoneurosis of the upper extremities stage I, without impaired circulation and function. Chronic gastroduodenitis in remission. Deviated septum of the nose. Bilateral sensorineural hearing loss (initial manifestations). Presbyopia. Later in 2006 and 2007 was treated permanently in the clinic of GT VMedA for paroxysms of atrial fibrillation, successfully stopped. After discharge in 2007, he was prescribed and constantly took Concor 5 mg / day, panangin courses. Against this background, paroxysms did not recur, blood pressure at the level of normotension. Deterioration of condition from 08.10.2013, when, after physical exertion (running after the bus), severe weakness and shortness of breath appeared against the background of “palpitations”. Independently took 3 tab. panangin and 10 mg of concor without a positive effect. On 09.10.2013, he applied to the Central Clinical Laboratory of the Medical Academy of Medicine, ECG registered atrial flutter 2:1, 3:1. He refused hospitalization. On October 10, 2013, he independently applied to the HT VMedA clinic, was hospitalized for urgent indications. On 09.10.2013, he applied to the Central Clinical Laboratory of the Medical Academy of Medicine, ECG registered atrial flutter 2:1, 3:1. He refused hospitalization. On October 10, 2013, he independently applied to the HT VMedA clinic, was hospitalized for urgent indications. On 09.10.2013, he applied to the Central Clinical Laboratory of the Medical Academy of Medicine, ECG registered atrial flutter 2:1, 3:1. He refused hospitalization. On October 10, 2013, he independently applied to the HT VMedA clinic, was hospitalized for urgent indications.
Objective status Condition is satisfactory. The elasticity of the skin is reduced. The physique is correct, corresponds to age and sex. Normosthenic constitution. Subcutaneous tissue of a homogeneous consistency. There are no edema and pastosity. The hairline is developed according to age and sex. Gray hair, dull nails. The shape of the neck is not changed, the contours are even. Thyroid gland: not visually determined. Lymph nodes are not enlarged, painless. The muscular system is developed satisfactorily, muscle tone is preserved, strength in the upper and lower extremities is sufficient. The pulsation of the dorsal arteries of the feet and popliteal arteries is normal. Reticular varicose veins of the lower extremities are determined.
.
Lab Results:
CBC:
Date
Hb, units
Er., *1012/l
Leuk., *109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
11.10.2013
133
5.03
5.3
26.4
11
4
0
28
6
2
60
Biochemical blood test: dated October 11, 2013 Urinalysis dated October 11, 2013
Name
Unit of measure.
Norm
Index
11.10
Creatinine
umol/l
53-124
100
Color
Light Yellow
Cholesterol
Mmol
/l
3.7-6.0
5.50
Transparency
Triglycerides
Mmol/l
0-2.3
2.19
Specific. weight
1020
Total protein
G/l
63.0-87.0
66
Reaction
5.0
Potassium
Mmol/l
3.5-5.1
4.42
Protein (g/l)
No
Sodium
Mmol/l
130-150
140.9
Sugar
No
Glucose
Mmol/l
4.2- 6.4
6.4
Urobilin
3.2
Prothrombin
%
70-130
Leukocytes in p/s
3-4
Fibrinogen
Mg/dl
200-400
258
Erythr. in p/sp
No
AST
U/l
11.0-50.0
17.5
Erythr. vysch. in p/w
No
ALT
U/l
11.0-50.0
16.7
Salts
No
LDH
U/l
200-400
Mucus
2
CPK
U/l
10.0-160.0
72
Urea
Mmol/l
3.0-8, 3
o. bilirubin Mmol
/l
6.8-26
8.5
b-lipoproteins
AU
350 - 650
660
VLDL
Mmol/l
1.00
LDL
Mmol/l
3.50
Albumin
g/l
30.00-55.00
51.45
Amylase
U/l
30-115
115
CPK
U/l
10-160
72
Alkaline phosphatase
U/l
45-120
96
HDL
Mmol/l
0.78-2.30
1.00
CPK –MV
U/l
0.0- 25.0
23.1
Investigation of excrement from 10.11.2013: Macroscopic examination Color brown; Consistency designed; Slime 0; Blood 0; Pus 0. Microscopic examination: Muscle fibers are digestible 1-2; Muscle fibers not digested 0-1; Vegetable fiber digested 0; Vegetable fiber not digested 1; Starch grains intracellular 0; Starch grains extracellular 1-2; Iodophilic flora 0; No helminthic eggs were detected
. Thyroid hormones dated 11/10/2013: T4(b.), TSH, T3(b.), antibodies to TPO and TP are normal
Results of instrumental studies:
ECG from 09.10.2013: atrial fibrillation. Normal position of the heart of the electrical axis of the heart. Violation of repolarization processes in the region of the upper lateral wall. indirect signs of left ventricular hypertrophy.
ECG dated 10/10/2013: Sinus bradycardia with a heart rate of 55 per minute. Normal position of the EOS.
Ultrasound examination of the abdominal organs dated 10/11/2013: the liver is not enlarged, the right lobe is 14.0 cm, the left lobe is 6.1 cm; echogenicity is moderately increased, the vascular pattern is preserved, the vessels are not dilated, the intrahepatic bile ducts are not dilated, there are no mass formations. The gallbladder was of regular shape, dimensions 5.8 x 2.0 cm, smooth contours, walls 4 mm, intracavitary formations were not detected. The pancreas is not clearly located, not enlarged, the head is 21.2 mm, the body is 17.5 mm, the echogenicity is increased, the structure is heterogeneous, with fibrous inclusions, the Wirsung duct is not expanded, 2 mm. The spleen is enlarged 10.3 x 4.7 cm, homogeneous. Kidneys: right - typical location, dimensions 9.1 x 4.1 cm, homogeneous parenchyma 17.1 mm, pyelocaliceal system is not expanded; left - typical location, smooth contours, dimensions 11.2 x 5.5 mm, parenchyma homogeneous 20.6 mm. The thyroid gland is not enlarged, the contours are clear, even, the structure is homogeneous. Isthmus 4 mm. Right lobe: width 20.2mm; thickness 20.4mm.; length 44.0mm; volume 9.5 mm. Left lobe: width 20.0 mm; thickness 14.0 mm; length 44.0 mm; volume 6.2 mm. In the right lobe, an aneochogenic formation is located, d <1 cm, with clear, even contours. The blood flow is not enhanced. Peripheral lymph nodes are not changed. Conclusion: Diffuse changes in the liver, pancreas, Nodules of the right lobe of the thyroid gland. with clear, even contours. The blood flow is not enhanced. Peripheral lymph nodes are not changed. Conclusion: Diffuse changes in the liver, pancreas, Nodules of the right lobe of the thyroid gland. with clear, even contours. The blood flow is not enhanced. Peripheral lymph nodes are not changed. Conclusion: Diffuse changes in the liver, pancreas, Nodules of the right lobe of the thyroid gland.
Ultrasound examination of the pelvic organs 15.10.2013. The bladder is filled with 320 ml. The contours are clear, even, the walls are not thickened. The content is uniform. The prostate gland is located in a typical place, the contours are not clear, not even, the structure is with light hyperechoic and hypoechoic areas. Dimensions: 20.8 x 55.0 x 31.6 mm V = 27.1 ml. The volume of residual urine is 30 ml.
Fluorography of the organs of the chest cavity from 10/15/2013: The organs of the chest cavity within the limits of age-related changes.
Echocardiography on 10/14/2013: Sinus rhythm. The leaflets of the aortic valve are sealed and calcified. Dilatation of the aortic root. Eccentric hypertrophy of the left ventricle with dilatation of its cavity. Dilatation of the cavity of the left atrium. The cavities of the heart are free. The systolic function of the left ventricle is preserved. Diastolic dysfunction of the left ventricle of the rigid type. LV contractility (global and local) is not broken. Applied aortic regurgitation. Pericardium without features
Goals of hospitalization achieved. Discharged in a satisfactory condition under dispensary supervision of a cardiologist of the clinic.
Employment has been restored. Discharged for work, return to work on 10/18/2013. A certificate of incapacity for work was issued 102 207 201 045 from 10.10.2013. to 17.10.2013 for the period of treatment.
Recommended:
34. Observation by a cardiologist.
35. Consultation of a urologist in a planned manner
36. Observe the drinking regimen of 1-1.5 l/day; restriction of the use of table salt (no more than 3 g per day).
37. Limit the consumption of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes), protein (cottage cheese, veal) in the diet.
38. Continue taking:
a. Tab. Sotalol 80 mg 1 tab. 2 times a day.
b. Tab. Prestarium A 5 mg - ½ tab. once a day continuously
c. Tab. Mildronate 500mg - 1 tablet 2 times a day for 2 weeks.
d. Tab. Cardiomagnyl 75 mg - 1 tab. in the morning all the time.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1983
He was in the hospital therapy clinic
He left the VMA
Total days of treatment were 11
The final diagnosis was established “ICD Code F 45.3 KES 511069
Diagnosis:
Neurocirculatory asthenia of hypertensive type without heart failure. Dyslipoproteinemia IIa
Peptic ulcer of the duodenum, rarely relapsing course, remission phase. Cicatricial deformity of the duodenal bulb without disturbing the evacuation function. Alimentary obesity of the first degree (BMI 30.4 kg/m2), android form, stable stage.
A disability certificate was not issued.
Ability to work restored
Total exposure dose 0.26 mSv Clinical outcome (underline): recovery,
improvement
, no changes, chronicity, disability, _____ disability group
was established
Certified by MSEC: yes / no
On admission:
Complaints of headache mainly in the parieto-occipital region, increased blood pressure to 155/100 mm Hg, overweight.
History of present illness. During the last year against the background of increased psycho-emotional stress. He independently measured the level of blood pressure, which began to be labile with episodes of its increase during psycho-emotional stress. He did not apply for medical help, he did not undergo an in-depth medical examination. Peptic ulcer of the duodenum for 5 years. Last update in October 2012. In spring and autumn, on the recommendation of a gastroenterologist, he conducts courses of antiulcer therapy with a positive effect. Increase in body weight within 5 years, during the last 3 years the body weight is stable.
Objectively at admission: hypersthenic physique, overnutrition (BMI-30.4). Peripheral lymph nodes and thyroid gland are not enlarged. Movement in the joints of the limbs and the spine in full. Pulse 62 per minute, rhythmic. The borders of the heart are normal, the tones are clear, there are no murmurs. BP 130/90 mm Hg. Art. Respiration is vesicular. The abdomen is soft and painless. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology.
As a result of the treatment: regimen, diet No. 10, perindopril, idrinol, the state of health improved.
Laboratory results:
Complete blood count, urinalysis 01.10.2013: normal.
Biochemical blood test 01.10.2013: cholesterol 6.02 mmol/l, LDL 950U (norm up to 650U), ALT, glucose, AST, CPK, LDH, urea, uric acid, creatinine, total protein, potassium, sodium, chlorine, fibrinogen, PTI norm.
HBsAg, anti-HCV, serological tests for syphilis, F-50 02.10.2013 negative.
ECG 10/01/2013: sinus bradycardia with a heart rate of 52 per minute. The horizontal position of the EOS. Partial violation of intraventricular conduction. Violation of the repolarization of the lower wall of
the ECHO-KG from 02.10.2013. - the norm
of ultrasound of the OBP on 04.10.2013: liver, pancreas, portal vein, common bile duct, gallbladder, spleen, kidneys without pathology.
FLG 04.10.2013 without pathology.
Daily monitoring of blood pressure from 04.10.2013. mean blood pressure during the day 135/78 mm Hg. (time index 41% SBP and 6% DBP), mean BP at night 117/63 mm Hg. (time index 5%)
The goals of hospitalization have been achieved, the ability to work has been fully restored.
Discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
27. Observation of the doctor of the unit according to DM-1,
28. Normalization of the regime of work and rest. Exclude the use of animal fats, easily digestible carbohydrates, alcohol, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet. exercise therapy.
29. Observe the water regime (fluid balance), daily monitoring of blood pressure and heart rate.
30. Continue taking:
II. T. Prestarium A 5 mg ½ tab. in the morning.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1931
Was on inpatient treatment in the clinic of hospital therapy
Total days of treatment 10
The final diagnosis was established on October 04, 2013
ICD code I 50.1 MES 291110
Diagnosis: Ischemic heart disease. Stable angina pectoris III functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (1998, 2002) cardiosclerosis. Complete blockade of the right leg of the bundle of His. Dyslipoproteinemia type IIb.
Hypertensive disease stage III (drug normotension, the risk of cardiovascular complications is "extremely high").
Chronic heart failure stage II-A, functional class III.
Type 2 diabetes mellitus, HbAc 7.85%, target HbAc<7.5%.
Secondary nephropathy of mixed (atherosclerotic, hypertensive, metabolic) genesis. Chronic kidney disease C3a A1 stage (GFRCKD-EPI 55.4 ml/min).
operated thyroid gland. Right-sided hemistrumectomy (1971). Diffuse-nodular goiter I degree, clinically euthyroidism.
Chronic gastroduodenitis without exacerbation. Fatty hepatosis without impaired liver function.
Chronic pancreatitis without exacerbation.
Varicose disease. Varicose veins of the superficial veins of the legs. CVI 2nd degree
Android obesity of the 1st degree (BMI 32.7 kg/m2), stable course
Chronic anemia of mixed (B12-iron deficiency) genesis, compensated by medication
Disability certificate: not issued
Total radiation dose 1.4 mSv
Clinical outcome: improvement.
Outcome: discharged.
Upon enrolment:
Complaints: episodes of pressing pain behind the sternum that occur against the background of physical (tolerance was difficult to clarify) and psycho-emotional stress, including at rest, stopped by taking nitrosorbide; episodes of palpitations, shortness of breath during physical exertion (climbing one flight of stairs) and episodes of it at rest, significantly aggravated by physical exertion, dizziness, flickering of “flies” before the eyes, general weakness against the background of an increase in blood pressure to 180/100 mm Hg. ; frequent urination at night, the presence of varicose veins of both legs, heaviness in the legs; general weakness, malaise, increased fatigue.
History of present illness. According to him, he considers himself ill for 30 years, when, against the background of psycho-emotional stress, periodic pains in the region of the heart appeared, shortness of breath, aggravated by previously well-tolerated physical activity, general weakness against the background of an increase in blood pressure to 180/100 mm Hg. (working blood pressure 130/70 mm Hg). I saw a therapist in a clinic. No medical documentation provided. In 1998, according to the words, she suffered a myocardial infarction. She was treated on an outpatient basis. In 2003, according to the words, there were pressing pains behind the sternum that were not relieved by taking nitrosorbide, shortness of breath at rest. By ambulance, she was hospitalized in St. George's Hospital with a diagnosis of myocardial infarction. According to the words, against the background of ongoing therapy in the intensive care unit, the patient developed a clinical death with successful resuscitation. In 2005, according to A chest CT scan revealed pulmonary embolism. She was treated permanently in the clinic of the Military Medical Academy. No medical documentation provided. The last hospitalization in 2012 in the clinic of GT VMedA due to: “Ischemic heart disease. Angina pectoris III functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (1998, 2002) cardiosclerosis. Complete blockade of the right leg of the bundle of His. Frequent polytopic polymorphic ventricular and frequent polytopic supraventricular extrasystoles. Hypertensive disease stage III (drug-achieved normotension, the risk of cardiovascular complications is "extremely high"). Chronic heart failure stage II-a, functional class II. Diabetes mellitus type 2, mild severity. Secondary mixed nephropathy (atherosclerotic, hypertensive, metabolic) genesis. Chronic kidney disease stage III (GFRCKD-EPI 55.4 ml/min). Diffuse-nodular goiter I degree. Right-sided hemistrumectomy (1971), clinically euthyroidism. Chronic gastroduodenitis without exacerbation. Fatty hepatosis without impaired liver function. Chronic pancreatitis without exacerbation. mild hypochromic anemia. She is currently taking carvedilol, cardiomagnyl, liptonorm, L-thyroxine. Over the past 3 months, the patient's condition has worsened, in the form of an increase in pressing pain behind the sternum, blood pressure lability with a downward trend. In connection with the deterioration of health, she turned to the Military Medical Academy. Hospitalized for examination and treatment in the clinic in a planned manner. She arrived at the clinic unaccompanied by herself. According to 2008 Diabetes mellitus was revealed during the examination by the therapist in the polyclinic.
As a result of the treatment: regimen, diet No. 9, antihypertensive, metabolic, antianginal, lipid-lowering therapy, the state of health improved.
The results of instrumental studies:
ECG 01.10.2013: sinus rhythm, heart rate 70 per minute. Normal position of the EOS. Complete blockade of the right leg of the bundle of His. Cicatricial (focal) changes in the region of the lower (posterior) wall.
ECG 07.10.2013: sinus rhythm, heart rate 50 per minute. EOS is deflected to the left. Frequent ventricular extrasystole. Complete blockade of the right leg of the bundle of His. Blockade of the anterior branch of the left leg of the bundle of His
Echocardiography on 02.10.2013: left ventricle: VTRV (diastole) 9.6 mm, LV EDD 53.5 mm, LVEC (diastole) 9.6 mm, LV ESR 38.4 mm, LVMM 225 g, mass index LV myocardium 128 g/m2, OTC 0.34 units, fr. overshoot 53%, FU 28%, IVRT 60 ms. Aorta: annulus 24.5 mm, sinuses of Valsalva 31.8 mm, pulmonary artery 26.5 mm. Left atrium: transverse dimension 35.6 mm, anterior-posterior dimension 35.3 mm, longitudinal 39.3 mm. Right atrium: diameter 36.5 mm, longitudinal 42.5 mm. Right ventricle: CDR (middle) 28.9 mm, anterior wall 6.0 mm. Valve apparatus: mitral valve - Vmax E 0.84 m/s, Vmax A 0.47 m/s, E/A 1.8, gradient 2.8 mm Hg. st., regurgitation 1 st, DTe 111 ms; aortic valve - Vmax 1.15 m/s, gradient 5.3 mm Hg. Art., regurgitation 0 Art.; tricuspid valve - Vmax E 0.48 m/s, Vmax A 0.34 m/s, E/A 1.4, gradient 0.9 mm Hg. st., regurgitation 0 st., DTe 167 ms; pulmonary valve - Vmax 0.8 m/s, gradient 2.6 mm Hg. Art., regurgitation - 0 Art. The average systolic blood pressure in the pulmonary artery (AT / ET) 28 mm Hg. Art. Conclusion: the walls of the aorta are sealed. The leaflets of the aortic valve are sealed and calcified. Eccentric hypertrophy of the left ventricle with dilatation of the cavity. Systolic LV function is reduced. Total myocardial hypokinesia. Restrictive LV diastolic dysfunction. Pericardium without features. Doppler examination revealed no pathology. Systolic LV function is reduced. Total myocardial hypokinesia. Restrictive LV diastolic dysfunction. Pericardium without features. Doppler examination revealed no pathology. Systolic LV function is reduced. Total myocardial hypokinesia. Restrictive LV diastolic dysfunction. Pericardium without features. Doppler examination revealed no pathology.
Ultrasound of the abdominal organs on 10/03/2013: the liver is not enlarged, the right lobe is 15.0 cm, the left lobe is 5.5 cm, echogenicity is increased, the vascular pattern is _______. The portal vein is not dilated. Intrahepatic bile ducts are not dilated. Gallbladder: cholecystectomy in 2005. The pancreas is located indistinctly, blocked by bowel loops. The kidneys are located in a typical location, the contours are even, the dimensions of the right kidney are 9.6x4.3 cm, the left kidney is 9.8x4.6 cm, the parenchyma is homogeneous 14.0-14.0 mm, the PCL is not expanded, there are no calculi. The spleen is not enlarged, 8.6x4.6 cm, the structure is homogeneous. Thyroid gland: the right lobe and isthmus are not located. An isoechoic formation is visualized in the left lobe, with clear, even contours in d=14.3 mm x 13.7 mm with hyperechoic inclusions in d=3.2 mm. Conclusion: Condition after cholecystectomy. Diffuse changes in the liver.
X-ray of the chest organs on October 3, 2013: in the lungs without focal and infiltrative changes. Fibrous changes in the lung pattern in the root zone. The roots of the lungs are structural. The sinuses are free. The heart is in a horizontal position. The aorta is compacted, elongated and deployed.
Laboratory results:
Clinical blood test (hardware processing): Hb
date
, units.
Er., *1012/L
Le*109/L
Tr.,
109/L
HCT
PCT
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
02.10
116
4.85
6.0
380
373
273
29
1
0
35
7
1
58
Rt,
‰
MCV,
fl
MCH,
pg
MCHC,
g/l
RDW,
%
MPV,
fl
PDW
%
Lf
%
M,
%
Gra,
%
Lf,
109/l
M,
109/l
Gra,
109/L
---
77
23.9
310
15.4
7.2
14.4
39.4
7.3
53.3
2.3
0.4
3.3
07.10
Hb, units
Er
.
,
*
1012
/
L
Le
*
109
/
L
Tr
.
,
109
/
L
HCT
PCT
ESR
,
mm
/
h
_
_
_
34
10
1
51
Rt,
‰
MCV,
fl
MCH,
pg
MCHC,
g/l
RDW,
%
MPV,
fl
PDW
%
LF
%
M,
%
Gra,
%
Lf,
109/l
M,
109/l
Gra,
109/l
77
24.1
313
13.6
7.7
13.6
33.9
5.5
60.6
2.7
0.4
5.1 Complete
urinalysis (hardware processing):
Date
Sp. weight
Reaction
Protein
Sugar
Cylinders
Ketones
Lake
Er.neiz
Urobil
02.10
1025
5.5
traces
No
No
No
1-1-2
0-1-1
3.2
Biochemical blood test: 02.10.
Name
Unit
Norm
result
Total cholesterol
mmol/l
3.7-6.0
6.63
Triglycerides
u/l
120-246
3.20
Urea
mmol/l
2.5-6.4
4.7
Creatinine
mmol
0.05-0.12
0.10
Total bilirubin
µmol/l
6.8-26.0
11.8
direct bilirubin
µmol/l
0-7.0
2.5
Total protein
G/l
63-87.0
73
albumin
g/l
30-55
45.23
globulin ratio
17-35
28
Glucose
mmol/l
4.2-6.4
5.6-6.3-4.3
Prothrombin
%
70-120
93
Fibrinogen
g/l
2.-4.0
3.14
AST
U
/l
11-50.0
22
ALT
U/l
11-50.0
96
HDL
mmol/l
0.78-2.33
1.76
LDL ratio
1.9-4.4
,
3.4
VLDL
ratio
0.6-1 .2
1.47
KA
ratio 0-3.0
2.77
GGT
U
/L
8-63
27
LDH
U/L
120-246
213
A\G
ration
1.1-2.5
1.6
ALP
U/L
45-129
96
iron
mmol/l
20-250
15.7
Feces for worm eggs 02.10.2013: Not found.
Microreaction with cardiolipin antigen: negative.
AT-HIV ½: not detected.
Capillary blood glucose on September 23, 2013: 8:00-5.6 mmol/l, 10:00-6.3 mmol/l, 12:00-4.3 mmol/l.
Urinalysis according to Nechiporenko: Lei 25 * 109 / l
Recommended:
31. Observation of a therapist, endocrinologist at the place of residence.
32. Diet: increase the diet of beef, fish, liver, kidneys, lungs, eggs, oatmeal, buckwheat, beans, porcini mushrooms, cocoa, chocolate, herbs, vegetables, peas, beans, apples, wheat, peaches, raisins, prunes, herring, hematogen.
33. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
34. Limit the consumption of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium.
35. Urinalysis according to Nechiporenko and blood test for serum iron level after 1 month
36. Continue taking:
a. Tab. Carvedilol 12.5 mg 1/4 tablet 2 times a day continuously.
b. Tab. Diuver 10 mg - 1 tablet daily in the morning.
c. Tab. Thrombo ACC 0.05 1 tablet in the morning constantly.
d. Tab. Akorta 0.01 1 tablet 1 time per day constantly.
e. Tab. Kanefron 1 tablet 3 times a day for 1 month
f. Tab L-thyroxine 25 mcg - ½ tablet in the morning constantly
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCUSSION (TRANSFER) EPICRISIS CASE
HISTORY №, ARCHIVE №_________
Last name, first name, patronymic
Was on inpatient treatment at the hospital therapy clinic
In total, 4 days of treatment were carried out .
The final diagnosis was established. ICD code
Diagnosis:
Main diagnosis: post-injection phlebitis of the superficial veins of the lower extremities. angiogenic sepsis.
Complications of the underlying disease: Primary infective endocarditis with lesions of the tricuspid valve in the active phase. CH-2 Bilateral embolic pneumonia. Right-sided small hydrothorax. DN 2-3 tbsp. Multiple post-injection granulating wounds of the lower extremities. Secondary anemia of moderate degree.
Background disease: chronic opiate addiction (heroin, methadone) severe. Chronic viral hepatitis C. Secondary immunodeficiency.
Certificate of incapacity for work was not
issued
Total exposure dose 0.78 mSv____________________________________________
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, established _____ disability group, degree of disability _______________________________, other __
Outcome: discharged due to improvement, discharged due to recovery, transferred to another medical institution ), transferred to rehabilitation treatment (where) __________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service,
unfit
for
service in the military specialty, discharged to the unit without medical examination. cough, shortness of breath, general weakness, headache.
Anamnesis of the present illness: Considers himself ill for about 10 last days, when, against the background of relative well-being, she felt a pronounced general weakness, noted episodes of a decrease in blood pressure to 90/80 mm Hg. Art. On the second day of illness, she noted an increase in body temperature up to 380C. Independently, on the recommendation of a polyclinic doctor, she made intramuscular injections of an antibacterial drug, the name is difficult to specify. On February 15, 2011, against the background of an increase in cough and shortness of breath, she called an ambulance. She was taken to the Alexander Hospital, which she left on her own the same day. On February 17, 2011, she called the ambulance again, and was hospitalized at the GT VMedA clinic.
Objective status: general condition is severe, due to the underlying disease. Consciousness is clear. The position is active within the bed. The physique is correct, corresponds to age and sex. Skin turgor is slightly reduced. On the skin of the legs, there are multiple post-injection wounds, abrasions, under fibrin, with swelling of the soft tissues around, on the right there is a granulating wound. Along the course of the peripheral veins of the forearms, there are multiple cicatricial changes in the skin. Subcutaneous tissue of a homogeneous consistency. The shape of the neck is normal, its contours are even, there is no swelling of the jugular veins. The thyroid gland is not enlarged, its isthmus is palpable, which has a homogeneous, soft-elastic consistency, painless. Peripheral lymph nodes are not enlarged. The muscular system is developed satisfactorily. Movements in the peripheral joints are possible in full. On palpation of the radial arteries, the pulse is the same on both arms, low filling, rhythmic with a frequency of 98 beats per minute, the vascular wall is not palpable outside the pulse wave. Blood pressure 100/70 mm Hg. Art. The pulsation in the peripheral arteries is preserved, the same on both sides. The borders of the heart are not expanded. On auscultation, the heart sounds are muffled. Accent II tone over the pulmonary artery, systolic murmur in the projection of the tricuspid valve. The chest is of the correct form, symmetrical. The respiratory rate when breathing atmospheric air is 28-30 per minute (SpO2 = 88-90%), when inhaling 100% oxygen through nasal catheters - 22-24 per minute (SpO2 = 100%), respiratory movements are rhythmic, both halves of the chest are even participate in the act of breathing.dullness. The tongue is wet. The abdomen is of the correct form, symmetrical, evenly participates in the act of breathing, is not enlarged in size, soft and painless on palpation. The edge of the liver protrudes from under the edge of the costal arch by 3 cm, moderately painful on palpation. The size of the liver according to Kurlov is 11*10*8 cm. The spleen is palpable in the region of the lower pole. Ragosa's symptom is positive. Kidneys: tapping on the lumbar region is painless on both sides.
As a result of the treatment: regimen, diet No. 15, antibacterial (Avelox 400 mg/day, Invanz 1.0/day, Amoxiclav 1.2x2r/d), anticoagulant (heparin 10,000 IU/day, APTT from 21.02.11 – 44 s), lazolvan, metabolic therapy, the patient's condition is stabilized.
Results of instrumental studies:
ECG 17.02; 02/21/2011: sinus rhythm, normal position of the EOS, heart rate 93 per minute. In the future, there is an increase in heart rate, the appearance of diffuse disorders of repolarization processes.
X-ray of the chest on February 18, 2011: on the chest radiographs in 3 projections in both lungs, there are multiple foci of lung tissue compaction with decay. Fluid in the right pleural cavity at the level of the fifth rib.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Thrombus.
*109/l
MCH
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pya
%
Xia
%
18.02.2011
97
3.66
17.2
155
26.5
70
0
-
3
7
31
56
20.02.2011
78
2.65
17.1
92
-
60
-
-
9
1
10
80
_
_
Unit.
Norm
18.02.11
Indicator
18.02.11
Color
Red-yellow
Glucose
Mmol/l
4.2-6.4
8.7
Transparency
Turbid
Potassium
mmol/l
3.4-4.5
3.91
Specific. weight
1025
Sodium
mmol/l
130-150
134.8
Reaction
5.0
Urea
mmol/l
2.5-6.4
8.2
Protein (mg/dL)
100
Creatinine
µmol/l
53-124
0.10
Sugar
None
Total protein
g/l
64.0-83.0
56.8
Urobilin
No
APTT
26-36
42.8”
Leukocytes in p/p
1-2
Erythr . unchanged in p/p
0-2
Nitrogenous bases
Yes
Ketone bodies (mg/dL)
15
Salts
Oxalates
Echocardiography from 18.02.2011:
Result, mm
Norm, mm
Aorta
At the level of AC
24
22-36
Ascending
23
21-34
Arc
-
24-36
Valve opening
20
15-26
Left atrium
Anterior -posterior dimension
32
25-40
Transverse
38
25-45
Longitudinal
40
29-53
Left ventricle
RV
31
≤ 36
RV
46
≤ 55
Posterior wall thickness (diast.)
9
7-11
Thickness of the interventricular septum (d.)
7
7-11
Right ventricle
ERD
27
≤ 30
Anterior wall
3
≤ 5
Right atrium
Transverse dimension
34
29-46
Longitudinal dimension
41
34-49
Pulmonary artery
At the valve
19
12-23
Indicator
Result
Norm
FU, %
33
28-41
EF, %
61
≥55 SV
, ml
-
70-85
Mean calculated pressure in the pulmonary artery - N
Conclusion: Vegetations on the leaflets of the tricuspid valve. Mitral valve prolapse 1 degree. Mitral regurgitation 0-1 degree. The chambers of the heart are not dilated. Myocardium is not thickened. Violations of local contractility were not revealed. Global contractility and diastolic function are preserved. Tricuspid regurgitation grade 1. The pericardium is unchanged.
Blood tests for safety factors (HIV, hepatitis, RW) are in progress, the results will be given to the husband.
Chest X-rays No. 630 in 3 projections handed out
As a result of the treatment: regimen, diet No. 15, antibacterial (Avelox 400 mg/day, Invanz 1.0/day, Amoxiclav 1.2x2r/d), anticoagulant (heparin 10,000 IU/day, APTT from 21.02.11 – 44 s), lazolvan, metabolic therapy, the patient's condition is stabilized.
By agreement with the Deputy Chief Medical Officer of the Mariinsky Hospital, the patient is transferred to the Department of Cardiovascular Surgery for further surgical treatment.
Transportable, accompanied by a medical team.
Order for transfer No. 1805
Form 12_Un.VmedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr., 63 tel. (812) 577-11-35
EXECUTIVE STATEMENT No.
born 1989 was on inpatient examination and treatment at the hospital therapy clinic of the Military Medical Academy from January 29, 2014 to February 18, 2014 with a diagnosis of
Acute infectious myocarditis with a rhythm disturbance according to the type of frequently recurrent focal high atrial tachycardia, heart failure of the first functional class.
Chronic periodontitis 16, 24, 46 teeth. Chronic odontogenic osteomyelitis of the lower jaw from the 37th tooth, chronic periodontitis of the 16th tooth (extraction of 16th and 37th teeth on 31.01.2014). Retention 28, 48 teeth.
Deviation of the nasal septum. ARVI by type of rhinopharyngitis, residual effects.
The final diagnosis was established ICD Code I 40.0 MES 291030
Clinical outcome: improvement. ICD code K 10.2 MES 331140 Certificate of
incapacity for work: issued from 01/29/2014. to 18.02.2014 Coming to work February 19, 2013 LN No. 124 744 788 005.
Complaints at admission: severe palpitations, dizziness, moderate general weakness, discomfort in the precordial region.
During the last month, against the background of a protracted episode of acute respiratory illness, she began to notice the daily occurrence of palpitations without a visible provocative situation with a clear onset lasting up to an hour, stages of "warming up", "plateau" and "cooling down"; progressive increase in general weakness, fatigue, the appearance of constant discomfort in the precordial region, low-grade fever. Independently consulted a neurologist (healthy), an endocrinologist (thyrotoxicosis excluded). On the night of January 28-29, she noted a progressive increase in severe weakness, dizziness, nausea, and the appearance of signs of pre-syncope. The ambulance team that arrived at the scene was provided with emergency measures, delivered to the admission department of the Military Medical Academy, where about 30 minutes ago,
Treatment was carried out: mode 2, diet 10. Intravenously: glucose 5% -200 ml, ascorbic acid 5% -10 ml, analgin 50% - 2 ml, asparcam 20 ml. No. 5. Solvent. Metronidazole 500 ml (01.02-04.02.2014) Intramuscularly: Dissolv. Dicynon 2 ml intramuscularly 4 times a day (01.02-02.02.2014). Solv. Novocain 0.5-5 ml, por. Ceftriaxoni 1.0 intramuscularly 2 times a day (01.02-04.02.2014). Inside: tab. metoprolol 25 mg 1 tab in the morning and 12.5 mg in the evening, caps arbidol 0.1 1 caps 4 times a day, biomax 1 tab 1 time a day, caps azimycin 0.5 mg 1 tab 1 time a day, caps. Linex 1 caps 3 times a day, caps. mildronat 0.5 1 caps 2 times a day, susp. viferon 500000 units 2 suppositories 2 times a day per rectum.
Results of instrumental studies:
ECG on January 29, 2014: P-0.08 s, QT-0.40 s, PQ 0.12 s, QRS 0.08 s. Heart rate 60 per minute. Sinus rhythm. Vertical position of the electrical axis of the heart.
ECG on January 30, 2014: P-0.12 s, QT-0.34 s, PQ 0.14 s, QRS 0.08 s. Heart rate 93 per minute. Sinus rhythm. Vertical position of the electrical axis of the heart. Violation of intraventricular conduction. WPW cannot be ruled out. Violation of repolarization processes in the region of the lower wall.
ECG on February 11, 2014: P-0.08 s, QT-0.32 s, P 0.08 s, PQ 0.12 s, QRS 0.09 s. Heart rate 96 per minute. Minor sinus tachycardia. Vertical position of the electrical axis of the heart. ECG signs of left ventricular hypertrophy. Violation of repolarization processes in the posterolateral sections. Negative dynamics in the form of T wave inversion in II, III, AVF, V6 and slight depression of the ST segment in II, III, AVF, V5-V6 leads.
Holter monitoring of the ECG on January 30, 2014: During the observation period, sinus rhythm was recorded with a heart rate of 51 to 145 beats per minute. During wakefulness, tachycardia was recorded with an average hourly heart rate of up to 145 per minute. The decrease in heart rate at night is adequate (circadian index 44%). Average heart rate (day/day/night) 76/85/59 per minute. Solitary polymorphic ventricular extrasystoles (total 198), once as an episode of trigeminia, single polytopic supraventricular extrasystoles (total 196), periodically in the form of couplets (total 61), once as an episode of bigeminia, jogging sinus tachycardia with a heart rate of up to 15 per minute ( total 43, maximum 17 complexes). At 7:30 am, with an increase in heart rate to 133 beats per minute, horizontal and obliquely ascending depression of the ST segment up to 1.5 mm lasting 5 minutes was recorded.
Echo-KG dated 07.02.2014
Index
Value
Norm
Index
Value
Index
Aorta and pulmonary artery
Left atrium
Root, mm
19.7
22-26
Anterior-posterior. size, mm
27.8
27-38
Ascending, mm
21.0
21-34
Cross. size, mm
31.6
29-49
AK opening, mm
16.4
15-26
Length. size, mm
33.8
29-53 Lung
artery, mm
13.3
15-21
Area, cm2
Left ventricle
Right ventricle
LV EDR, mm
41.6
39-53 KDR (bas
.), mm
20-28
KSR LV, mm
23.8
20-36
KDR (average), mm
27.2
27-33
TMZhP (dias)
,
mm
7.2 mm
71-79
LV CRT (dias.), mm
7.8
6-10
RV area (dias.), cm2
11-28
LVML, g
100
<141
RV area (syst.), cm2
7.5-16
LVMI, g/l2
64
<109 Anterior
wall thickness, mm
3.0
< 5
IOT, units
0.36
< 0.42
Right atrium
EF (Teicholz),%
74
> 55
Transverse solution, mm
31.3
29-45
FU %
43
27-45
Longitudinal solution, mm
31.7
Mitral valve
< 50 years / > 50 years
Tricuspid. Valve
<
50
years
/
>
50
years waves А, m/s
0.46
0.30-0.50/0.45-0.73
0.33
0.19-0.35/0.25-0.41
Е/А
2.2
1.0-1.5
1.9
1.0-1.5
Maximum gradient, mm Hg Art.
4.2
0.6
Regurgitation, degree
0-1
0
0
0-1
E wave deceleration time, ms
261
159-199/174-276
144
166-210/175-221
Aortic valve
Pulmonary valve
Peak blood flow velocity, m/s
1.20
1.0-1.7
0.75
0.6-0 .9
Maximum gradient, mmHg Art.
5.8
2.2
Regurgitation, grade
0
0
0
0
IVC 1.2 cm (less than 1.7 cm), inspiratory collapse >50% (greater than 50%). The average systolic pressure in the pulmonary artery (AT / ET) 12 mm Hg. Art. (norm 20-30). Conclusion: Normal geometry of the left ventricle. The cavities of the heart are not dilated, free. Systolic and diastolic functions of the left ventricle are preserved. Heart valves are intact. Applied mitral regurgitation. Pericardium without features.
Ultrasound examination of the abdominal organs on 02/03/2014: liver, gallbladder, pancreas, spleen without pathology.
Consultation of the maxillofacial surgeon on January 31, 2014: On the orthopantogram, the bone tissue at the root of the 37th tooth is determined by the type of a deep bone pocket. Granuloma at the roots of 16, 12 teeth. Retention 28, 48 teeth. Examined by a dentist. Diagnosis: Chronic periodontitis 16.24, 46 teeth. Chronic odontogenic osteomyelitis of the lower jaw from the 37th tooth. Retention 28, 48 teeth. Recommended: sanitation of foci of odontogenic infection - removal of 16, 37 teeth, endodontic treatment of 24, 46 teeth; extraction of impacted teeth 28, 48 in a planned manner. Based on objective data, X-ray examination and examination by the head of the Department of Hospital Therapy of the Military Medical Academy, in order to sanitize foci of chronic infection, teeth 16 and 37 were removed under local anesthesia Sol. Ultracaini 1.7 #4. Hole revision. Nasal tests are negative. Hemostasis.
Consultation of the maxillofacial surgeon on 02/03/2013: Wells of extracted teeth under a clot. There are no signs of inflammation. Monitoring is recommended, if necessary, a second consultation.
X-ray of the chest organs on January 28, 2014: no pathological changes were detected.
Radiography of the paranasal sinuses on January 28, 2014: thickening of the mucous membrane of the left maxillary sinus of the parietal nature.
Radiography of the paranasal sinuses on February 12, 2014: the paranasal sinuses were pneumotized.
Consultation of an ENT doctor on February 11, 2014: On examination of the ENT organs: the mucous membrane of the nasal cavity is hyperemic, edematous, there is no pathological discharge in the nasal cavity, the nasal septum is complexly curved. Nasal breathing is moderately difficult. The external auditory canals are wide, free, there is no pathological discharge. ShR 6/6 meters, BP gray, contoured. The mucous membrane of the pharynx is hyperemic, the palatine tonsils are not enlarged, swallowing is free. In other organs of ENT organs without visible pathology. Diagnosis: ARVI by type of rhinopharyngitis, residual effects. Deviated septum of the nose. Recommended: Rg SNP, lavage of the nasal cavity with saline solutions 3 times a day for 7 days.
Ultrasound examination of the pelvic organs on 05.02.2014: the body of the uterus is determined, in the usual position, the dimensions are normal, length 45 mm, width 46 mm, thickness 44 mm, diffusely heterogeneous myometrium, spherical shape. Endometrium thickness of the functional layer is 7 mm (taking into account the day of the cycle is not thickened), the structure is not changed secretory, the contours of the endometrium at the border with the inner muscle layer are clear, the reflection from the endometrium is not deformed, the uterine cavity is not expanded. The cervix is of normal size, length 30 mm, thickness 20 mm, normal shape, the cervical canal is not dilated. The left ovary is determined, of normal size, length 27 mm, thickness 23 mm, the structure is not changed. The right ovary is determined, the dimensions are normal, length 25 mm, thickness 24 mm, the structure is not changed. Conclusion: Echographic signs of adenomyosis.
Gynecologist's consultation on 05.02.2014: Conclusion: Practically healthy. Observation by a gynecologist at the place of residence is recommended.
Laboratory results:
Clinical blood test (hardware processing): RBC
date
, *1012/l
Hb
units.
Lake. *109/l
Tr.
109/l
HCT
PCT
ESR, mm/h
E
%
B
%
lim
%
mon
%
p/i
%
s/i
%
30.01.14
4.68
129
6.5
382
387
278
6
7
-
40
6
1
45
Rt,
‰
MCV,
fl
MCH,
Pg
MCHC,
g/l
RDW,
%
MPV,
Fl
PDW
%
Lf
%
M,
%
Gra,
%
Lf,
109/L
M,
109/L
Gra,
109/L
-
83
27.6
333
14.6
7.3
12.1
40.4
4.4
55.2
2.6
0.2
3.7
Date
RBC, *1012/L
Hb
units
Lake. *109/l
Tr.
109/L
HCT
PCT
ESR, mm/h
E
%
B
%
limf
%
mon
%
p/i
%
s/i
%
05.02.14
5.9
125
5.9
385
371
285
6
8
-
31
6
1
53
Rt,
‰
MCV,
fl
MCH,
Pg
MCHC,
g /l
RDW,
%
MPV,
Fl
PDW
%
Lf
%
M,
%
Gra,
%
Lf,
109/l
M,
109/L
Gra,
109/L
-
82
27.7
336
14.0
7.4
13.1
37.7
5.4
56.9
2.2
0.3
3.4
Urinalysis (hardware processing):
Date
Rel. dense
pH
Protein
Acetone
Glucose
Lake.
Erythrocytes
Epithelium
Bact
Urobil.
Slime
unchanged.
vyschel.
30.01.14 g
1030
5.5
traces Negative
Negative 2-1-1v p/z 0-0-1
U
in
p
/z
2-3
1
3.2
2
Biochemical analysis of blood dated January 30, 2014:
Indicators
Unit of measure
Indicators
Unit of measure
Cholesterol
4.40
3.7-5.0
mmol/l
LDH
202
120-246
U/l
Triglycerides
1.08
0-2,
mmol/l
VLDL
0.49
0.6 -1.2
U
Glucose
4.60
4.2-6.2
mmol/l
HDL
1.62
0.76-2.33
U/l
Urea
4.5
2.4-6.4
mmol/l
LDL
2.28
1.9-4.4
U/l
CPK
238
10-160
U/l
KFK-MB
19.6
0-25
U/l
GGTP
15
8-63
U/l
SRP
2.2
3-10
umol/l
Alkaline phosph.
89
36-129
U/l
Total protein
68
63-87
g/l
Creatinine
70
53-123
umol/l
ALT
20
10-50
U/l
K+
4.45
4-6
mmol/
AST
30
11-50
U/l
Fibrinogen
2.27
0 -4
g/l
Co. atherogenic
1.72
0-3.0
U/l
Blood test for myoglobin, CPK-MB, troponin 01/29/2014: positive.
Blood test for myoglobin, CPK-MB, troponin 15.02.2014:
negative (11-50), CPK 238 U/l (10-160), CPK-MB 19.6 U/l (0-25).
Biochemical blood test 01/31/2014: CRP 0.2, rheumatoid factor 10.
Biochemical blood test 02/05/2014: LDH 211 U/l (120-246), AST 30 U/l (11-50), CPK 350 U/l (10-160), CPK-MB 27.7 U/l (0-25), fibrinogen 2.38 g/l (0-4).
Blood for microflora and determination of sensitivity to antibiotics 01/30/2014: There is no growth of microflora.
Antibodies to the myocardium 1:10 (normal 1:10).
Myocardial antigen 6 mmol/l (norm <1.5).
Microreaction with cardiolipin antigen 31.01.2014: negative.
AT-HIV ½ 02/03/2014: not detected.
HBs, Anti-HCV 02/03/2013: not detected.
Fecal analysis on February 11, 2014: no worm eggs were found.
The goals of hospitalization have been achieved. Employment has been restored. Discharged for work, return to work on February 19, 2014. A certificate of incapacity for work was issued 124 744 788 005 from 01/29/2014. to 18.02.2014 for the period of treatment
RECOMMENDED:
6. Observation by a cardiologist at the place of residence
7. Control performance of daily ECG monitoring after 1 month
8. Normalization of lifestyle.
9. Limit the intake of animal fats, easily digestible carbohydrates, increase the amount of vegetable fiber and vegetable fats in the diet.
10. Continue taking medications:
a. metoprolol 25 mg - ½ tab. 2 times a day for 1 month
b. Mexicor 0.1 - 1 tab. 2 times a day 1 month
Form 12_Un.VmedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1978
Stayed at the hospital therapy clinic
Total days of treatment 9
The final diagnosis was established by “ICD Code K 58.9; MES 311100
Diagnosis:
Irritable bowel syndrome with diarrhea. Chronic gastroduodenitis, exacerbation. Chronic internal hemorrhoids without exacerbation. Fibrocystic mastopathy of the left mammary gland.
Certificate of incapacity for work issued series no.
Ability to work restored
Total exposure dose 0.26 mSv Clinical outcome (underline): recovery,
improvement
, no changes, chronicity, disability, _____ disability group
was established
Certified by MSEC: yes / no
On admission:
Complaints: a feeling of discomfort in the right iliac region, heartburn, a feeling of "bitterness in the mouth", bloating, excessive gas formation, unstable stools (loose stools 2-7 times / day); swelling of the legs; throbbing pain in the right parietal region; node of the inner quadrant of the left breast.
History of present illness. At the age of 6 months, due to the developed complex (thin-thin) ileocolic intussusception, the operation of resection of the ileocecal angle with anastomosis of the small intestine to the side of the large intestine (submersible anastomosis) was performed. In the future, she often noted pain in the abdomen. In 1994, she was hospitalized for chronic gastroduodenitis. During the second pregnancy (5 years ago), she significantly gained body weight (since then her body weight has been stable) up to 94 kg, varicose veins of the lower extremities appeared and she began to notice the appearance of discomfort in the right iliac region, stool instability, bloating, excessive gas formation. In 2007, she independently identified the node of the inner quadrant of the left breast, was consulted by a mammologist at the regional hospital (fibrocystic mastopathy). In June 2013, she was consulted on an outpatient basis by a gastroenterologist (on FGDS there were signs of gastroduodenitis), a course of therapy was recommended, which included platifilin s / c, pariet, duspatalin, drip administration of drugs (analgin, papaverine) with a positive effect. In August 2013, while on vacation (Greece), she began to notice significant swelling of the feet and legs, heartburn, and “bitterness” in her mouth. Taking into account that the state of health does not allow to properly perform official duties, she was routinely hospitalized to the hospital therapy clinic for diagnosis and treatment. while on vacation (Greece), she began to notice significant swelling of the feet and legs, heartburn, and “bitterness” in her mouth. Taking into account that the state of health does not allow to properly perform official duties, she was routinely hospitalized to the hospital therapy clinic for diagnosis and treatment. while on vacation (Greece), she began to notice significant swelling of the feet and legs, heartburn, and “bitterness” in her mouth. Taking into account that the state of health does not allow to properly perform official duties, she was routinely hospitalized to the hospital therapy clinic for diagnosis and treatment.
Objectively at admission: hypersthenic physique, overnutrition (BMI-34.4). Peripheral lymph nodes and thyroid gland are not enlarged. Movement in the joints of the limbs and the spine in full. Pulse 62 per minute, rhythmic. The borders of the heart are normal, the tones are clear, there are no murmurs. BP 130/80 mmHg Art. Respiration is vesicular. The abdomen is soft, moderately painful in the epigastric region. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology.
As a result of the treatment: regimen, diet No. 1, duspatalin, almagel, hilak-forte, probiotics, loperamide, exercise therapy, d'arsonval, the state of health improved.
Results of laboratory researches:
Complete blood count, urinalysis 08.10.2013: normal.
Biochemical blood test 08.10.2013: glucose, ALT, AST, total bilirubin, amylase, urea, creatinine, total protein - normal.
HBsAg, anti-HCV, serological tests for syphilis, F-50 09.10.2013 negative.
The results of a blood test in the reaction of indirect hemagglutination (RIHA) with a complex salmonella antigen, with a group diagnosticum for a typhoid-paratyphoid group dated 08.10.2013 - negative
. Results of instrumental studies:
ECG 09.10.2013: sinus rhythm with a heart rate of 80 per minute. The horizontal position of the EOS.
Fluorography of the organs of the chest cavity No. 5025 dated 10/15/2013. - pathological changes are not determined
Colonoscopy from 10/12/2013. - chronic hemorrhoids without exacerbation, condition after resection of the ileum and caecum due to intussusception of intestinal obstruction. Dyskinesia of the colon by hypertonic type.
Ultrasound of OBP 09.10.2013 diffuse changes in the pancreas, deformation of the gallbladder (kink in the body), microliths of both kidneys
The goals of hospitalization have been achieved. Discharged in a satisfactory condition under the supervision of a gastroenterologist clinic.
Employment has been restored. Discharged for work, return to work on 10/17/2013. A certificate of incapacity for work was issued from 07.10.2013. to October 16, 2013 for the period of treatment.
Recommended:
37. Observation of a gastroenterologist at a polyclinic;
38. Performing routine stool culture for microflora, followed by a consultation with a gastroenterologist in order to resolve the issue of the advisability of prescribing probiotic preparations for the selective normalization of a hypoplastic germ;
39. Normalization of the regime of work and rest;
40. Lifestyle changes: reduction in the frequency of stress, additional intake of sedatives on demand or courses in prolonged stressful situations (afobazole);
41. Change in diet: frequent small meals during the day with an increase in the diet of foods that help to fix the stool (poppy, dogwood, nuts, bananas, baked apples ...) and the exclusion of foods that help loosen the stool and gas formation (legumes, cabbage, kefir, melons , watermelons…);
42. Continue taking:
a. Almagel Neo - 1 scoop an hour after meals and at night - 1 month;
b. Hilak forte - 60 drops 3 times a day for 1 month, then 30 drops 3 times a day for 3 months;
c. Loperamide 4 mg (2 tablets) once in the morning, followed by an assessment of the effect and an additional 2 mg after each bowel movement until the effect is achieved or a daily dose of 16 mg (8 tablets).
Discharge summary No.
Clinic of hospital therapy of the Military Medical Academy named after S.M. Kirov, Suvorovsky pr., 63
39 years old, was examined and treated at the clinic of hospital therapy of the Military Medical Academy with a diagnosis of
Main - community-acquired focal pneumonia in the lower lobe of the left lung of mild severity. DN0 Examination
results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l MSI
,
pg
n, %
e, %
b, %
l, %
m, %
n %
s, %
ESR, mm/h
12.11
139
4.13
5.6
300
33.8
1
1
48
15
2
34
22
16.11
148
4.43
6.3
325
33.5
4
4
29
10
1
52
23
Urinalysis
Date
Transp.
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
12.11
clear
1.025
yellow
7.0
-
-
-
-
-
-
-
-
-
-
Feces per I/g 13.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11.09
Total protein
G/l
63.0-87.0
67.2
Cholesterol
Mmol/l
3.7-6.0
5.32
Triglycerides
Mmol/l
0-2.37
0.94
Glucose
Mmol/l
4.2-6.4
4.86
Prothrombin
%
80-105
98
Fibrinogen
g/ l
2-4
2.9
Sialic acids
Mmol/l
1.9-2.5
2.3
ECG dated 11/11/2009 No. 2528 .: sinus tachycardia, deviation of the electrical axis of the heart to the left. Partial violation of intraventricular conduction. The predominance of the potentials of the left ventricle.
According to the results of Rg-graphy of the organs of the chest cavity on November 12, 2009 in frontal and lateral projections without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The median shadow is not expanded.
According to the results of FVD 13.11.09 - slight violations of bronchial conduction. moderate decrease in
Against the background of therapy (regime, diet, bromhexine) notes an improvement in the condition (normalization of body temperature, a decrease in the frequency and intensity of cough, a decrease in weakness).
Recommended:
1. Observation of the doctor's part;
2. Mode of work and rest, dietary nutrition;
3. Complivit 1 tablet 2 times a day after meals for 2 weeks.
4. Exemption from physical exercises, outfits, work for 15 days.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCUSSION (TRANSFER) EPICRISIS CASE
HISTORY №, ARCHIVE №_________
Last name, first name, patronymic_
Was hospitalized
at the hospital therapy clinic
Total days of treatment 11
The final diagnosis was established ICD Code I 50.0
Diagnosis:
Primary: coronary artery disease: stable angina pectoris 3 functional class. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and postinfarction (2004) cardiosclerosis.
Complications of the underlying disease: Bleeding from the intercostal artery of the 9th intercostal space on the right. Aneurysm of the apex of the left ventricle. Right-sided hydrothorax. Chronic cor pulmonale, decompensation. Secondary pulmonary hypertension. CHF IIB stage, IV functional class. Cardiac asthma from 02.04.2011 DN-2.
Background disease: Hypertensive disease of the third stage, arterial hypertension of the 1st degree, the risk of CVE is extremely high.
Concomitant: Chronic viral hepatitis B, moderate degree of activity. Fibrosis of the liver of mixed (cardiac, dysmetabolic) genesis. Chronic liver failure A according to Child-Pugh, compensation. Dyscirculatory encephalopathy of the second stage of mixed (hypertonic, atherosclerotic, dysmetabolic) genesis. Degenerative-dystrophic disease of the spine. Diabetes mellitus of the second type, moderate severity, decompensation. Chronic pyelonephritis, latent course, remission. Nephorpathy of mixed (atherosclerotic, dysmetabolic, diabetic, hypertensive) genesis. Diffuse nephroangiosclerosis. CKD stage II (GFR=85.9 ml/min/1.73 m2 according to MDRD) CRF-0.
On April 4, a puncture of the pleural cavity was performed - 2200 ml of straw-yellow liquid was evacuated. April 05 - 2700 ml of straw-yellow liquid was evacuated
Total radiation dose 0 mSv
Clinical outcome (underline): recovery, deterioration, improvement, no changes, chronicization, disability, _____ disability group, degree of disability _______________________________, other ____________________________
Outcome: discharged due to improvement, discharged after recovery, transferred to the clinic of thoracic surgery of the Military Medical Academy, transferred to rehabilitation treatment (where) _______________________________
Examined by MSEC: yes (no) (____disability group, degree of disability:
Complaints: increasing shortness of breath of a mixed, predominantly inspiratory nature, discomfort in the right half of the chest at rest, paroxysmal cough without discharge, increasing weakness, decreased exercise tolerance.
History of present illness. For a long time he suffers from coronary heart disease, hypertension. In 2006, she suffered a massive myocardial infarction. On October 17, 2010, surgical treatment was performed for bleeding (shock 2-3) from a chronic stomach ulcer. During the same hospitalization, decompensated diabetes mellitus was revealed. After discharge, she did not comply with the doctor's recommendations, she began to notice an increase in the volume of the abdomen. On this occasion, she was repeatedly hospitalized in the hospitals of the city, where complex treatment was performed with active diuretic therapy. The last hospitalization in the pulmonology department of City Hospital No. 26. After discharge from the hospital on December 14, 2010, she began to notice a sharp increase in dyspnea at rest, the appearance of a cough without discharge, and an increase in general weakness. On December 23, 2010, she was admitted to the hospital therapy clinic. After discharge, he feels well for 2 weeks, but later on there is a progressive increase in the feeling of weakness, shortness of breath, which requires re-hospitalization. In February and early March, for the reasons described above, she underwent inpatient treatment, where punctures of the pleural cavity and evacuation of the contents were performed. After the last discharge, she felt well for 2 weeks, but shortness of breath began to increase again, her stomach increased in volume, in the last 7 days she slept half-sitting, and the last night - sitting.
Given the progressive deterioration of her condition, she called an ambulance team, which was hospitalized for urgent indications in the hospital therapy clinic for further diagnosis and treatment.
During hospitalization, taking into account the hemodynamically significant hydrothorax, the patient was evacuated 2200 ml of straw-yellow liquid on April 04. After a second puncture on April 05 (2700 ml of straw-yellow liquid was evacuated), profuse bleeding appeared from the puncture site. Suspected damage to the intercostal artery with the development of bleeding. The patient was reported to the Deputy Head of the Department of Hospital Surgery for clinical work. In order to stop the developed complication, in agreement with the clinical department, the patient is transferred to the hospital surgery clinic.
Objective status upon admission to the ICU: Height 165 cm Weight 77.3 kg BMI-29.3 kg/m2. The general condition is severe, due to signs of cardiopulmonary insufficiency. Consciousness is clear (SHG=15b). The situation is forced. The physique is correct, corresponds to age and sex. Normosthenic constitution. Earthy yellow skin, icteric sclera. The elasticity of the skin is reduced. Subcutaneous tissue of a homogeneous consistency, swelling of the legs. The hairline is developed in accordance with age and sex. Peripheral lymph nodes are not enlarged. The muscular system is developed satisfactorily. On palpation of the radial arteries, the pulse is rhythmic, with a frequency of 78 beats. per minute, satisfactory filling, uneven, not tense. Sat O2 at rest 90-92%. Arterial pressure - 135/70 mm. rt. Art. The boundaries of relative cardiac dullness are expanded in diameter. The width of the vascular bundle does not extend beyond the edges of the sternum. The number of heartbeats corresponds to the pulse. The heart sounds are muffled, the first tone at the apex is weakened, at the apex of the heart there is a coarse systolic murmur. The chest is symmetrical. The respiratory rate at rest is 24-26 per minute, the respiratory movements are rhythmic, the right half of the chest lags behind in the act of breathing. With percussion of the zones, dullness over the entire right half. On auscultation over the lungs, breathing is hard, breathing is not auscultated on the right. Tongue wet, pink. The abdomen is enlarged due to the accumulation of free fluid, the correct form, symmetrical, soft, peritoneal symptoms are negative. The edge of the liver +4 cm from under the edge of the costal arch, dense texture, bumpy, painless on palpation. The size of the liver according to Kurlov is 16x14x9 cm. The spleen is not palpable. Ragosa's symptom is positive. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless.
Treatment in the ICU: regimen, diet No. 9, metabolic therapy, inotropic therapy (Korglicon 0.06% 1.0 IV 2 times a day), hypoglycemic therapy (Maninil 0.005, 2 tablets per day, Metformin 0.5, 2 tablets tab. 2 times a day), antibacterial therapy (Ceftriaxone 1.0 2 r / d i / m), diuretic therapy (Ffurosemide 80 mg i / v 1 r / d, Hypothiazid 0.025 1 tablet in the morning), Enalapril 2, 5 mg in the morning, humidified oxygen inhalation. On April 4, a puncture of the pleural cavity was performed - 2200 ml of straw-yellow liquid was evacuated. April 05 - 2700 ml of straw-yellow liquid was evacuated.
Results of instrumental studies:
On ECG No. 359 (ICU) of 04/05/2011, sinus rhythm is recorded with a heart rate of 74 per minute. EOS is deflected to the right. Complete blockade of the right leg of the bundle of His. Hypertrophy of the right ventricle. Widespread cicatricial changes in the anterior-septal-apical-lateral LV. Diffuse disorders of repolarization.
ECHO-KG from 03/09/2011:
PARAMETERS
Val.
NORMAL
PARAMETERS
Value
NORM
Aortic root diameter
30
20-37 mm
Left ventricular ERR
40
38-56 mm
Aortic valve leaflet opening
17
more than 15 mm
Left ventricular ERR
36
22-38 mm
Anterior-posterior size of the left atrium
55
25-40 mm
The thickness of the free wall of the right ventricle
7
less than 5 mm
The frontal dimension of the left atrium
42
25-45 mm
The ejection fraction of the left ventricle
20
more than 55% The
vertical dimension of the left atrium
is
29-53 mm
The dimension of the right atrium
47
30-46
The thickness of the interventricular septum
6-10
7-11 mm
Vertical size of the right atrium
57
34-49 mm
Thickness of the posterior wall of the left ventricle
10
7-11 mm
Right ventricular EDR anteroposterior
39
Less than 30 mm
Systolic pressure in LA
60
to 30 mm Hg
Diameter of the pulmonary trunk
26
12-23 mm
Conclusion: hypertrophy and dalatation of the right ventricle. Atrial dilatation. Paradoxical movement of the IVS. Total hypokinesia of the myocardium of the left ventricle, apex dyskinesia in the anterior, lateral and septal segments with parietal thrombi; akinesia of the interventricular septum, lateral wall and anterior stack in the middle section. Fibrosis and rupture of the interventricular septum. Dilatation of the pulmonary artery. Pulmonary hypertension grade 2. Regurgitation on all valves: TP - 3, MP - 2, PR - 1, AR - 0/1. Aorta, fibrous rings AK, MK, TK, PC are compacted. The pericardium is thickened, there is no effusion.
Index
04.04
Color
Yellow
Transparency
is cloudy.
Specific Weight
More than 1015
Reaction
6.0
Protein (g/l)
1.0 g/l
Sugar
No
Urobilin
0.2
Leukocytes in p/s
5-7
Erythr. unchanged in p/s
No
Erythr. Vyschi. In p / sp
No
Epithelium pl in p / sp.
All p/s
Results of laboratory tests:
Clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pya
%
Xia
%
04.03
144
5.49
7.7
26.2
5
1
35
7
2
72
05.03
146
5.09
7.8
28.6
10
2
1
27
8
1
61
07.03 10.41
133
4.63
11, 0
28.8
8
1
1
11
7
4
76
07.03 19.52
121
4.05
10.3
29.9
1
35
7
2
72
07.03 22.45
113
3.82
9.6
29.6
1
35
7
2
72
08.03 08.00
97
3.20
9.0
30.3
1
35
7
2
72
08.03 10.58
96
3.15
11.3
30.5
1
35
7
2
72
08.03 16.37
85
2.81
9.1
30.2
1
35
7
2
72
08.03 21.36
82
2.74
9.3
29.9
1
35
7
2
72
09.03 08.08
89
2 .94
10.0
30.3
1
35
7
2
72
09.03 17.30
87
2.86
9.8
30.4
1
35
7
2
72
10.03
87
2.94
9.7
29.6
1
35
7
2
72
11.03 08.02
88
3.00
9.9
29.2
1
35
7
2
72
11.03 08.56
90
3.06
9.7
29.6
44
5
2
18
3
4
68
Biochemical analysis of blood: Analysis of urine:
Name
Unit of measure.
Norm
06.03
07.03
11.03
Creatinine
Mkmol/l
53-124
100
70
70
Cholesterol
Mol/l
3.7-6.0
3.94
4.00
Triglycerides
Mol/l
0-2.37
Total protein
G/l
63.0-87.0
70
53
58
Calcium
Mol/l
2 ,1-2.5
2.37
2.12
2.09
Potassium
Mole/l
3.5-5.1
5.68
AST
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
U/l
11.0-50.0
56
36
56
Glucose
Mole/l
4.2-6.4
8.22
11.20
7.78
SC-MB
Mole/l
0-25
15.1
11.01
Analysis of the pleural fluid from 04/04/2011: yellow, slightly turbid liquid, 20 ml. Clear after centrifugation. Rivalta's test is negative. Protein 30 g/l. Cytosis 31.0*109/l, erythrocytes 23.5*109/l, leukocytes 4.5*109/l, mesothelium, epithelial cells, macrophages - 3.0*109/l. Microscopy: BC were not found; cocci in small quantities. Against the background of erythrocytosis, leukocytes up to 15-25 in the field of view, of which lymphocytes make up 80%. Mesothelial cells are degeneratively changed. Macrophages 0-3-5 in the field of view.
In view of the suspected damage to the intercostal artery with the development of bleeding, the patient was reported to the Deputy Head of the Department of Hospital Surgery for clinical work.
In order to stop the developed complication, in agreement with the clinical department, the patient is transferred to the hospital surgery clinic
. The patient is transportable by specialized ambulance, accompanied by a doctor.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1970 (39 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy Diagnosis: community-acquired focal pneumonia in the lower lobe of the left lung, mild severity DN-0. Astheno-vegetative syndrome. Right-sided nephroptosis I degree, lipoma of the left kidney, CRF-0.
She was admitted to the clinic for urgent indications with complaints of shortness of breath with moderate physical exertion, general weakness, cough with green discharge, and fever.
Laboratory results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l MSI
,
pg
n, %
e, %
b, %
l, %
m, %
n %
s, %
ESR, mm/h
12.11
139
4.13
5.6
300
33.8
1
1
48
15
2
34
23
16.11
148
4.43
6.3
325
33.5
4
4
29
10
1
52
22
Complete urinalysis
Date
Clear
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
12.11
clear
1.025
Yellow
7.0
-
-
-
-
-
-
-
-
-
-
Feces per I/g 13.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11.09
Total protein
G/l
63.0-87.0
67.2
Cholesterol
Mmol/l
3.7-6.0
5.32
Triglycerides
Mmol/l
0-2.37
0.94
Glucose
Mmol/l
4.2-6.4
4.86
Prothrombin
%
80-105
98
Fibrinogen
g/l
2-4
2.9
Sialic acids
Mmol/ l
1.9-2.5
2.3 Plain
radiograph of the chest in the direct and right lateral projection No. 304 (D=0.52 mSv) dated 11.11.09: in the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, not expanded. The heart is not enlarged.
On the survey radiograph and fluoroscopy of the chest in the direct and right lateral projection No. 317 (D = 0.52 mSv) dated 11/19/09: a stranded pattern is noted in the basal segments of the left lung. Pleural cords in the C8 projection on the left. The roots of the lungs are structural, not expanded. The heart is not enlarged.
ECG No. 2528 dated 11/11/09: sinus rhythm with a heart rate of 80/min. EOS is deflected to the left. Partial violation of intraventricular conduction. The predominance of the potentials of the left ventricle.
ECHO-KG No. 790 dated 11/18/09 Ao=27mm, ascending Ao=23mm, opening AC=19mm, LA=30mm, RA=34mm, RV=22mm, LV=43/30mm, IVS=9mm, AP=8mm, EF=58%, FU=31% , SV=55ml, E/A=1.39 The myocardium is not thickened, the kinetics is not disturbed, the heart cavities are not dilated. The aorta is not changed. The blood flow on the valves is laminar. Systolic and diastolic functions are not disturbed. The free edge of the anterior leaflet of the mitral valve is thickened, loosened. Applied regurgitation on MK and TK. The pericardium is not changed.
Ultrasound of the OBP from 23.11.09. No. 1278: the liver is not enlarged, the right lobe is 10 cm, the left lobe is 3.7x7.6 cm, the contours are even, the structure is homogeneous, echogenicity is average, the vessels are not dilated. The gallbladder is bent in the middle third 4.5x1.6 cm, the contours are even, the walls are 2 mm, it contains bile, calculi and polyps are not detected, the common bile duct is 3 mm. The pancreas is located clearly, the contours are clear, even, the head is 13mm, the body is 10mm, the tail is 11mm, echogenicity is increased, the structure is homogeneous, the Wirsung duct is not dilated. The lower pole of the right kidney to the edge of the liver is 10x3.4 cm, the parenchyma is homogeneous 15 mm, the PCS is not changed; the left kidney is located typically 8.5 x 4.4 cm, the parenchyma is homogeneous 19 mm, the PCS is not changed. In the projection of the adrenal glands, no pathological formations were revealed, the spleen was not changed.
FVD No. 106 dated 11/18/2009 results in hand.
Treatment: regimen, diet, antibacterial, anti-inflammatory, expectorant, sedative and restorative therapy.
Against the background of the therapy, the patient's condition improved: the general intoxication syndrome was stopped, there is no compaction of the lung tissue. However, a cough persists with a slight discharge of a light color, signs of asthenia. Discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
94. Outpatient supervision of a doctor in accordance with DM-1.
95. Control general blood test as of 30.11.2009.
96. Release from performance of official duties for a period of 3 (three) days.
97. Exemption from physical. preparation for 30 days.
98. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
99. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
100. Continue taking:
a. Linex - 1 capsule 3 times a day for 1 month
b. Ascoril - 1 tablespoon in the morning for 7 days
c. Antigrippin – 1 powder 2 times a day for 3 days
d. Eleutherococcus - 1 teaspoon in the morning (dilute in 1/3 cup of water).
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Reference No.
1925 (83 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis:
ischemic heart disease. Progressive angina from 12/17/08, with stabilization at the level of angina pectoris III FC from 12/22/08. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and post-infarction (of unknown duration) cardiosclerosis complicated by paroxysmal form of atrial fibrillation (paroxysm of unknown duration) was stopped on 18.12.08. Hypertension stage III (AH 2st, Risk 4) NK-I, CHF-IV→II FC. Obesity of the first degree, alimentary genesis. Chronic cholecystitis without exacerbation. Chronic pyelonephritis without exacerbation, multiple (two) cysts of the left kidney, CRF-I st. Benign prostatic hyperplasia.
He was admitted to the clinic for urgent indications with complaints of discomfort in the region of the heart during moderate (ascending to the 2nd floor) physical activity, shortness of breath, frequent nighttime urination, memory loss.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
17.12
146
4.87
8.0
47
8
1
1
19
7
72
19.12
144
4.62
6.4
44.7
9
5
27
8
60
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MV epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
11.12
mutn
1014
yellow
sour
0.04
no
no
++
no
no
0-2
no
2-4
12-15 Rehberg's
test
Date
Blood
creatinine Urine creatinine
Diuresis in 1 min
Glomerular filtration
Tubular reabsorption
24.12
0.16
14.53
0.95
86.3
98.9
Biochemical blood test:
Name
Unit. rev.
Norm
17.12
24.12
Name
Unit. rev.
Norm
17.12
24.12
Creatinine
mmol/l
53-124
160
160
CS
mmol/l
3.7-7
6.11
Urea
mol/l
3-8.4
9.0
11.3
TG
mmol/l
0-2.37
Prothrombindex
%
70-120
95
β-LP
u
350-650
Fibrinogen
g/l
200-400
330
HDL
mmol/l
0.78-2.33
Total protein
g/l
63- 87
67.5
72.2
LDL
mmol/l
1.9-4
ALT
U/L
8.4-53.5
12.6
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
16.0
Ig A
g/l
1.25-2.5
AP
U/L
36-92
CPK
U/L
10-160
46.5
LDH
U/L
100-220
Cl
mmol/l
95-108
111.6
GGTP
U/L
11-63
Na
mmol/l
130-150
148.4
148.2
Glucose
mmol/l
4.2-6, 4
5.52
5.77
Ca
mmol/l
2.0-2.7
2.32
2.43
Total bilirubin
µmol/l
6.8-26
25.4
K
mmol/l.
4-6
5.14
5.06
ECHO-KG No. 32 dated 12/15/08: Aorta - 36 mm, AV dilatation - 17 mm, RA - 50 mm, RV EDR - 32 mm, LA - 53 mm, LV ECR - 39 mm, LV EDR - 50 mm, FU - 30%, EF - 60%, IVS=14mm, WS=14mm, LA - 21 mm Hg, Dla - 38 mm Hg e/a = 0.89. Symmetrical concentric hypertrophy of the left ventricular myocardium. Dilatation of the left atrium and right chambers of the heart. The aorta is sealed. Regurgitation on the TC 2 degrees, applied to the mitral valve. Pulmonary hypertension of the first degree. The pericardium is not changed.
Ultrasound of the abdominal organs dated 23.12.08: The liver is not enlarged, the thickness of the right lobe is 13 cm, the contours are even, the structure is homogeneous. The gallbladder is without calculi, the walls are compacted, thickened up to 4 mm. Portal vein - 12 mm., Hepatocholedochus - 5 mm. The pancreas is not enlarged, the contours are even, the structure is hyperechoic, homogeneous. Kidneys: right - 9 × 4 cm, parenchyma up to 12 mm, uneven contours, expansion of individual cups up to 16 mm, PCS deformed; left - 11.5 × 6 cm, parenchyma up to 10 mm, expansion and deformation of the PCS, in the middle third, two cysts 2.6 and 2.2 cm in diameter. The spleen is not enlarged.
ECG No. 156 dated 12/17/08. atrial fibrillation, tachysystole 85-120 per 1 min, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 161/162/177 dated December 18-22, 08: sinus rhythm with a frequency of 60-78 beats per minute, vertical EOS, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 185 dated 12/23/08. sinus rhythm with a frequency of 82 per 1 min., vertical EOS, hypertrophy of both ventricles, more than the right one, in dynamics some worsening of repolarization of the apical-lateral region of the left ventricle
Treatment: regimen, diet, polarizing mixture, vinpocetine, enalapril, cordaflex, siofor, restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
101. Outpatient supervision of a polyclinic therapist.
102. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
103. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
104. Continue taking:
a. Enalapril 0.01 - 1 tab. 2 times a day (morning and evening) continuously
b. Cordaflex (retard) 0.02 - ½ tab. 2 times a day (morning and evening) continuously
c. Verapamil 0.08 - ½ tab in the morning and in the evening constantly
d.
Siofor
500 - 1 tab in the morning and in the evening 15 minutes before
meals (812) 577-11-35
Discharge summary No.
born in 1970 (40 years),
was on examination and treatment in the hospital therapy clinic
from May 26 to June 16, 2010 with a diagnosis of:
Hypertension stage II (Risk of CVE is moderate). Uncomplicated hypertensive crisis from 05/26/2010, stopped by medication on 05/26/2010. IHD: stable exertional angina 1 FC. Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis, complicated by rare ventricular and supraventricular extrasystoles, transient AV block II degree, type 2. NK-1, HSN 1 FK. Peptic ulcer of the duodenum, remission. Cicatricial deformity of the duodenal bulb. Chronic gastroduodenitis, remission. Fatty hepatosis without impaired liver function. Diffuse-nodular goiter of the 1st degree, euthyroidism. Alimentary-constitutional obesity of the second degree, stable phase Initial manifestations of cerebrovascular insufficiency with scattered neurological symptoms.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Rt,
‰
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
27.05
144
4.72
7.8
14.9
6
210
3
17
7
1
72
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
27.05
clear
1020
yellow
5.0
no
no
no
no
no
no
1-2
no
1-2
no
_
_
_ rev.
Norm
28.05
Name
Unit. rev.
Norm
28.05
Creatinine
mmol/l
53-124
100
cholesterol
mmol/l
3.7-7
2.9
Urea
mol/l
3-8.4
K
mmol/l.
3.5-5.1
4.23
Prothrombindex
%
70-120
104
Ab to TPO
nmol/l
0 - 34
19.22
Fibrinogen
g/l
2.00-4.00
3.66
TSH
nmol/l
0, 27-4.2
5.19
Total protein
g/l
63-87
80
T3
nmol/l
66-181
114.8
ALT
U/L
8.4-53.5
35
T4
nmol/l
1.3-3.1
2.03
AST
U/L
7-39.7
22.2
RW
quality
neg.
neg.
Glucose
mmol/l
4.2-6.4
5.2
HBsAg
quality
neg
.
Tot. bilirubin
µmol/l
6.8-26
37.5
AntiHCV
quality
neg
.
Etc. bilirubin
mmol/l
0-7
5.5
Ab to HIV 1/2
quality
neg.
neg.
Results of instrumental studies:
UZDG from 06/04/2010: the blood flow has the features of the main one, without signs of AVM and local stenosis, without pathological overflows. LBF in all located arteries is within acceptable limits, without significant asymmetry. The range of cerebrovascular reactivity was preserved in full.
MRI of the brain dated 04.06.2010: Conclusion: MRI signs of the initial manifestations of dyscirculatory encephalopathy, uneven expansion of the subarachnoid space.
ECG from. 06/03/2010: sinus rhythm with heart rate = 88 in 1 min., horizontal EOS. Incomplete blockade of the right leg of the bundle of His. The predominance of the potentials of the left ventricle.
ECHO-KG dated 06/03/2010: MZHP-12mm, ZS-11mm, KDRLZh-51mm, KSRLZh-34mm, FV-62%, FU-34%, UO-77ml, LP-40×40×50mm, PP-38 ×47mm, RV-25mm, E/A=1.1 IMMlzh-142g/m2 Myocardium is symmetrically thickened. The kinetics is not broken. The cavities are free, not dilated, the valves are not changed, there is valvular regurgitation on the pulmonic valve. The aorta is sealed. The pericardium is intact.
VEM dated 06/01/2010: functional class - 2. The VEM test was carried out against the background of antihypertensive therapy. The test is negative (no signs of coronary circulation disorders were detected). Load tolerance is average. BP response is adequate.
24-hour ECG monitoring from May 31, 2010: during monitoring, sinus rhythm was recorded with a heart rate of 47 to 170 per minute. The decrease in heart rate at night is adequate. Average heart rate 84/85/62 per minute. Registered single ventricular extrasystoles (2); solitary supraventricular, periodically frequent (from 13:00 to 14:00 - 103 extrasystoles; from 15:00 to 17:00 - 101 extrasystoles; in total 263 per day), with episodes of the type of bi- and trigeminia. At 21:25, a single episode of transient 2nd degree type 2 AV blockade (Mobitz 2) was registered with a pause of 2 seconds. When performing the planned load, the heart rate reached 166 and 170 in 1 minute, subjectively noted the heartbeat. Ischemic changes in the ST segment were not detected.
24-hour blood pressure monitoring from May 31, 2010: the study was performed against the background of antihypertensive therapy (amlodipine, enalapril). Mean systolic BP in the daytime is typical for mild labile hypertension, at night the average systolic BP is within the normal range. Mean diastolic BP during the day is typical for mild stable hypertension, at night - for moderate stable hypertension. At night, systolic and diastolic blood pressure fall adequately (dipper). The variability of systolic and diastolic blood pressure during the day is within the acceptable range. There is an increase in the magnitude of the morning rise in diastolic blood pressure, the speed of the morning rise in systolic and diastolic blood pressure. Episodes of hypotension were not registered.
Ultrasound of the abdominal organs from 06/07/2010: the liver is not enlarged, the right lobe: 14cm; left 7×6cm, smooth contours, homogeneous structure, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein 12 mm, hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder of the correct form, dimensions 7×2 cm, smooth contours, walls 2 mm, calculi are not visualized. The pancreas is located clearly 22x10x18mm, homogeneous structure, contours are clear, even, the structure is homogeneous, echogenicity is increased; Wirsung's duct is not dilated. Kidneys of normal size (right 10×5 cm, left 11×6 cm), normal location, with smooth contours, homogeneous parenchyma 16 mm thick on the right, 16 mm on the left; cavity systems are not expanded, there are no calculi. The spleen is not enlarged, 10 × 4.5 cm in size.
X-ray of the chest organs from 27.05.2010. Conclusion: without focal and infiltrative changes. Roots are structural. The heart is dilated to the left. The aorta is sealed.
FGDS from 05/31/201: the esophagus is passable, the cardial rosette does not close completely. In the stomach, the folds are rough, edematous, tortuous, can be traced in the antrum, and are easily straightened during insufflation. The mucosa is moderately hyperemic, "motley" in the antrum. The gatekeeper closes completely. The bulb of the duodenum is somewhat deformed due to cicatricial changes. Mucous edematous, with whitish bulges. In the postbulbar region without features, bile is not passaged. Conclusion: insufficiency of the outlet of the cardia. Chronic gastritis (mixed form, follicular bulbitis). Moderate cicatricial deformity of the duodenal bulb.
Neurologist: initial manifestations of cerebrovascular insufficiency with scattered neurological symptoms.
Ophthalmologist: hypertensive angiopathy of both eyes.
Cardiac surgeon-arrhythmologist: transient AV blockade of the 2nd degree, type 2
Treatment: regimen, diet, polarizing mixture, diuretic therapy, enalapril, ACC thrombosis, metoprolol, Rudotel.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
1. Supervision of the therapist of the part according to DM-1.
2. Release from duty for 5 (five) days
3. Optimization of the regime of work, rest, nutrition.
4. Control HM-ECG after 3 months
5. Continue taking:
• Enalapril 0.01 ½ tab.2 r/d. constantly
• Amlodipine 0.005 1 tab. in the morning
• Thrombo ASS 0.1 1 tab. 1 day after breakfast •
Mildronate
0.25 ½ capsule 2
times a
day (after breakfast and lunch) - 2 weeks .
DIAGNOSIS:
Primary disease: Hypertension II st. (AG-3, R-4). ischemic heart disease. Angina pectoris II f. class, Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis.
Complications of the underlying disease: NK IIA Art. (CHF II f.cl. according to NYXA).
Accompanying illnesses: . Dyscirculatory encephalopathy II st. in the form of right-sided pyramidal-cerebellar insufficiency and persistent moderately pronounced pseudoneurotic syndrome. Intervertebral osteochondrosis of the cervical, thoracic and lumbar regions; deforming spondylosis of the cervical spine, lumbarization of the first sacral vertebra, non-closure of the arch of the second sacral vertebra with a slight dysfunction of the spine. Chronic vertebrogenic lumbosacral sciatica with a predominant lesion of the fifth lumbar first sacral root on the right without impaired function of the lower extremities. Varicose disease of the right lower limb without chronic venous insufficiency. Chronic cholecystitis in remission. Chronic pancreatitis in remission. Chronic gastritis in remission. fatty hepatosis. M KB. CRF 0. Obesity I degree, alimentary-constitutional origin, stable phase. Diffuse-nodular goiter of the first degree without dysfunction. Hand dyshidrosis.
Treatment was carried out: infusion therapy with glucose; metoprolol, enalapril, nifedipine, furosemide, hypothiazide, sibazon.
Against the background of the therapy at the time of discharge, the general condition improved, blood pressure is at working values, pain cardiac syndrome did not recur. There are no edema.
Objectively at the time of discharge: the general condition is satisfactory, the pulse is 78 beats per minute, rhythmic, the boundaries of the heart are not expanded; auscultatory heart sounds are muffled, weakening of the 1st tone over the apex, accent of the 2nd tone over the aorta. BP 140/100 mmHg Art.; Respiratory rate 18 per minute, vesicular breathing, no wheezing; The abdomen is soft and painless. The edge of the liver is not palpated. The spleen is not palpable. Tapping on the lumbar region is painless on both sides.
Physiological functions are normal. The pastosity of the shins is preserved.
Results of instrumental studies:
ECG 20.10.2009: Hypertrophy of the left ventricular myocardium, violations of local intraventricular conduction.
Echocardiography 21.10.2009: IVS 10.4 mm, LV CR 63 mm, PSL 9.6 mm, LV CL 40 mm, EF 65%, FU 36%, SV 132, LA 36 mm, aortic root diameter 40 mm, aortic opening valve 21 mm, MK more than 4 cm2, Pulmonary artery 19 mm, PP 39 mm. MVE/A less than 1.0. Conclusion: Imaging is difficult due to obesity. Dilatation of the left ventricle as a manifestation of hypertension. systolic its function is preserved, diastolic its dysfunction. Consolidation of the aorta. Tricuspid regurgitation. The pericardium is not changed. Pulmonary hypertension 1 tbsp.
24-hour ECG monitoring on October 29, 2009: sinus rhythm, at night the heart rate decreases inadequately (not enough). single ventricular extrasystoles (4), single supraventricular extrasystoles (13), in 20-23 an episode of paired supraventricular extrasystoles was truncated. ectopic activity within the normal range. Significant dynamics of the ST segment was not revealed.
Ultrasound of the abdominal organs 10/29/2009. g.: the liver is enlarged, the right lobe is 16.5 cm, the left lobe is 10 cm, the contours are even, the structure is homogeneous, hyperechogenicity is increased, the hepatic veins and intrahepatic bile ducts are not dilated; portal vein 10 mm, hepatic veins 5 mm. The gallbladder is of the correct form, the contours are even, the dimensions are 9.1x2.9 cm, the contents are bile, no intracavitary formations were detected; the pancreas is located indistinctly, not enlarged, the contours are indistinct, even, the structure is homogeneous, hyperechoic, the Wirsung duct is not dilated; kidneys: normal size, homogeneous parenchyma, homogeneous parenchyma, PCS not dilated, calculi in the left kidney 4x4 mm; the spleen is not enlarged.
Ultrasound of the thyroid gland 02.11.2009: In the right lobe, a 9x6 mm node with a clear, even, apechoic contour of a homogeneous echostructure, without increased blood flow.
ENT consultation on October 30, 2009: no pathology.
Consultation of a physiotherapist 26.10.2009: It is recommended to alternate coniferous baths with oxygen baths. Massage of the lumbosacral and left thigh.
Laboratory results:
Clinical blood test (automatic processing): Hb
date
, units.
Er., *1012/l
Leuk., *109/l
MCHC,
g/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
21.10
146
5.01
6.4
305
14
3
1
33
11
1
51
Giant forms of platelets are present.
Complete urinalysis (automatic processing):
Date
Exp. weight
pH
Protein
Sax
Lay
Ep. class
Blood
Bacteria
21.10
1025
5.5
-
-
-
-
-
-
Biochemical analysis of blood:
Name
Unit of measure.
Norm
21.10
Total protein
G/l
63-87
70.3
Total bil-bin
mmol/l
6.8-26
16.2
Glucose
mmol/l
4.2-6.4
5.55
Triglycerides
mmol/l
0-2.37
0.90
AST
U/ l
11-50
43.1
GGTP
mmol/l
1.9-2.5
39.2
ALT
U/ml
11.0-50.0
66.7 !
Creatinine
mmol/l
0.05-0.12
0.12
Cholesterol
mmol/l
3.7-6.0
4.06
Fibrinogen
Md/dl
2.0-4.0
4.1
Prothrombin
%
70-130
86
Potassium
Mmol/l
3.50-5.10
4.09
B-lipoproteins
ED
350-650
Coprogram 21.10.2009: within normal limits.
Hepatitis markers 10/28/2009: negative.
Discharged in a satisfactory condition under the supervision of specialists of the clinic at the place of residence.
Discharged for work, able-bodied, return to work 04.11.2009 Issued a certificate of incapacity for work series BX No. 5789183.
Recommended:
1. Dynamic observation of a cardiologist, gastroenterologist, neurologist, nephrologist.
2 Normalization of the regime of work and rest. Limit the use of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet. exercise therapy.
2. Continue taking:
• T. Enziks-duo 1 tab. 1 time per day (in the morning) - take a long time;
• T. Coronal 1 tab. 1 time per day (in the morning) - take a long time;
• T. Thrombo Ass 50 mg, 1 tab. 1 time per day (in the evening after meals) - take a long time;
• T. Preductal MB 1 tab. 2 times a day (morning, evening) - 1 month, 4 courses per year;
• T. Panangin 1 tab 3 times a day - the first 10 days of each month;
• Caps. Essentiale forte N 1 caps 3 times a day with meals - take at least 3 months.
3. Control of blood pressure, heart rate daily, ECG 1 time in 1-2 months.
MILITARY MEDICAL ACADEMY
Hospital Therapy Clinic
Discharge summary No.
born in 1964 (43 years old), was examined and treated at the hospital therapy clinic with a diagnosis of:
Hypertension stage II. (AH grade 2, risk 3). ischemic heart disease. Angina pectoris II f.k. Atherosclerosis of the aorta, coronary arteries. Atherosclerotic cardiosclerosis. NC I Art. Dyscirculatory encephalopathy of the second stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders. Chronic toxic steatohepatitis with moderate activity. Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (27.02.02) due to a closed fracture of the surgical neck of the shoulder (15.02.02) and its repeated fracture (18.07.02) with moderate dysfunction of the left upper limb. A consolidating fracture of the neck of the right femur with the presence of a construct (September 25, 2006).
He was admitted to the clinic in a planned manner with complaints of compressive pain in the chest, shortness of breath during exercise, aching headaches with increased blood pressure, dizziness, general weakness, impaired concentration, memory loss, pain in the right shoulder and right thigh.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
22.12
138
4.36
15.0
42.4
33
396
1
10
7
7
75
Biochemical analysis of blood:
Name
Unit. rev.
Norm
22.12
Name
Unit. rev.
Norm
22.12
Creatinine
mmol/l
53-124
70
CS
mmol/l
3.7-6.0
6.31
Urea
mol/l
3-8.4
3.1
TG
Mole/l
0-2.37
1.32
Prothromb. index
%
70-120
102
β-LP
Unit
350-650
540
Fibrinogen
g/l
200-400
320
HDL
mol/l
0.78-2.33
Total protein
g/l
63-87
72.9 Cholesterol
/HDL
Times
3-5
Albumin
%
50-70
49.5
VLDL
mol/l
0.6-1.2
1
%
3 -6
6.2
odds atheros.
Unit
0-3
2
%
9-15
14.5
amylase
U/L
28-100
82.4
%
8-18
16.2
trypsin
u/l
0-0.35
%
15-25
13.6
Ig M
g/l
0.65-1.65
a/ G
1.1-2.5
0.98
Ig G
g/l
7.5-15.5
ALT
U/L
8.4-53.5
72.6
Ig A
g/l
1.25-2.5
AST
U/L
7-39.7
37 .0
CEC
U
6-66
ALP
U/L
36-92
54.6
Fe
Mmol/l
10.5-25
5.76
LDH
U/L
100-220
Na
Mmol/l
130-150
141.4
GGTP
U/L
11-63
77 .8
Ca mmol/
l
2.0-2.7
2.12
Glucose
mmol/l
4.2-6.4
5.49
K
mmol/l.
4-5.5
4.63
Tot. bilirubin
µmol/l
6.8-26
8.1
Sialic
acids mmol/l
1.9-2.5
3.1
Urinary
acid fmol/l
150-420
287
T3
mmol/l
66-181
CPK
units/ l
10-160
148.1
T4
Mmol
/l
1.3-3.1
HBsAg, antiHCV qual negative ref
RW
qual
Results
of
instrumental studies:
X-ray examination and ECG registration was refused due to a "recent study".
Ultrasound examination from 30.03.2007. The liver is enlarged, the right lobe is 17.8 cm, the left lobe is 10.4 cm. The contours are even, the structure is homogeneous, echogenicity is increased, the vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape (curved, partially reduced). The pancreas is located indistinctly, it is not enlarged, the contours are fuzzy, even, the structure is homogeneous, echogenicity is average, the Wirsung duct is not dilated. Kidneys: location and size are normal. Right - the contours are even, the parenchyma is homogeneous 16 mm, the cavity system is not expanded, there are no stones: the left one - the contours are not even, the parenchyma is homogeneous 18 mm, the cavity system is not expanded, there are no stones. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 8.8x3.6 cm, the structure is homogeneous. Flatulence.
EchoCG from 12/25/2008. Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed, calcifications in the AC. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no pericardial effusion.
Treatment was carried out: regimen, diet, olicard, ACC thrombosis, metoprolol, phenazepam.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
1. Observation of a therapist, neuropathologist, traumatologist of the TsKDP VMA.
2. Optimization of the regime of work, rest, nutrition.
2. Continue taking
• Olikard 0.04 1 caps. 1 r / d after breakfast
• Thrombo ACC 0.1 1 tab. 1 r / d after breakfast
• Metoprolol 0.05 ½ tablet 2 r / d (after breakfast and dinner)
• Asparkam 1 tablet 3 r / d the first 10 days of each month.
MILITARY MEDICAL ACADEMY
Hospital Therapy Clinic
Discharge summary No.
born in 1964 (43 years old), was examined and treated at the hospital therapy clinic with a diagnosis of:
ischemic heart disease. Angina pectoris II f.k. Atherosclerosis of the aorta, coronary arteries. Atherosclerotic cardiosclerosis. Hypertension stage II. (AH grade 2, risk 4). NC I Art. Dyscirculatory encephalopathy of the second stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders. Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (02/27/02) due to a closed fracture of the surgical neck of the shoulder (02/15/02) and its repeated fracture (07/18/02) with moderate dysfunction of the left upper limb. A consolidating fracture of the neck of the right femur with a construction (25.09.2006) with a slight dysfunction of the right lower limb.
He was admitted to the clinic in a planned manner with complaints of compressive pain in the chest, shortness of breath during exercise, aching headaches with increased blood pressure, dizziness, general weakness, impaired concentration, memory loss, pain in the right shoulder and right thigh.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
CP
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
21.03
141
4.5
11.0
0.94
24
1
27
3
6
63 Rehberg's
test
Date
Blood
creatinine Urine creatinine
Diuresis in 1 min
Glomerular filtration
Tubular reabsorption
22.03
0.08
18.65
0.83
193.5
99.6
Biochemical blood test:
Name
Unit. rev.
Norm
22.03
Name
Unit. rev.
Norm
11.12
Creatinine
mmol/l
53-124
CS
mmol/l
3.7-7
2.87
Urea
mol/l
3-8.4
6.4
TG
mol/l
0-2.37
0.44
Prothrombindex
%
70-120
β-LP
U
350-650
450
Fibrinogen
g/l
200-400
HDL
mol/l
0.78-2.33
Total protein
g/l
63-87
65
LDL
Mole/l
1.9-4
Albumin
%
50-70 Cholesterol
/HDL
Times
3-5
1
%
3-6
VLDL
Mole/l
0.6-1.2
2
%
9-15
coef. atheros.
Unit
0-3
%
8-18
amylase
U/L
28-100
%
15-25
trypsin
u/l
0-0.35
a/g
1.1-2.5
Ig M
g/l
0.65-1.65
ALT
U/L
8.4-53.5
14.6
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
11.02
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
CEC
U
6-66
LDH
U/L
100-220
Cl
Mole /l
95-108
GGTP
U/L
11-63
11.8
Na
Mole/l
130-150
Glucose
mmol/l
4.2-6.4
4.5
Ca
Mole/L
2.0-2.7
1.85
Total bilirubin
µmol/l
6.8-26
5.6
K
mmol/l.
4-6
ALK pos
U/L
36-92
102.3
T3
Mol/l
66-181
Urinary
acid fmol/l
150-420
T4
Mol/l
1.3-3.1
CPK
u/l
10-160
RW
qual
Results of instrumental studies:
ECG from. 03/21/2007, Sinus rhythm with a heart rate of 58 beats, horizontal EOS. Left ventricular hypertrophy. Syndrome of early repolarization. Local violations of intraventricular conduction, violations of repolarization in the region of the lower wall.
Ultrasound examination from 30.03.2007. The liver is not enlarged, the right lobe is 13.8 cm, the left lobe is 6.4 cm. The contours are even, the structure is homogeneous, the echogenicity is medium, the vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape (curved, partially reduced). The pancreas is located indistinctly, it is not enlarged, the contours are fuzzy, even, the structure is homogeneous echogenicity is average, the Wirsung duct is not dilated. Kidneys: location and size are normal. Right - the contours are even, the parenchyma is homogeneous 16 mm, the cavity system is not expanded, there are no stones: the left one - the contours are not even, the parenchyma is homogeneous 18 mm, the cavity system is not expanded, there are no stones. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 8.8x3.6 cm, the structure is homogeneous. Flatulence.
EchoCG from 03/29/2007. Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed, calcifications in the AC. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no pericardial effusion.
The results of VEM and ECG Holter monitoring are on hand
X-ray of the chest organs dated 30.03.2007. In the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is slightly dilated to the left. The aorta is elongated.
X-ray of the skull from 30.03.2007. On survey craniograms in two projections, the Turkish saddle is normal. There is thinning of the bones of the cranial vault.
Radiography of the right hip joint dated April 2, 2007: on the radiograph of the right hip joint in two projections. Condition after metal osteosynthesis in the area of comminuted fracture of the upper third of the femur. The callus is expressed satisfactorily. The bolt of a metal structure protrudes into the soft tissue by 2.5 cm.
Specialist consultations
Optometrist: VIS OD 1.0; OS 1.0 IOP OD,OS - 18mm Hg
The auxiliary apparatus and the outer parts of the eyeballs are not changed, the optical media are transparent. The fundus of the eye: optic nerve disc of satisfactory nutrition, the contours are clear. The veins are moderately dilated, the arteries are sealed. Focal pathology is not defined.
Neurologist: Dyscirculatory encephalopathy of the 2nd stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders.
ENT: Endoscopic ENT organs without visible pathology. SR 6 m.
Traumatologist: Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (02/27/02) due to a closed fracture of the surgical neck of the shoulder (02/15/02) and its repeated fracture (07/18/02) with moderate dysfunction of the left upper limb . A consolidating fracture of the neck of the right femur with a construction (25.09.2006) with a slight dysfunction of the right lower limb.
Treatment was carried out: regimen, diet, olicard, ACC thrombosis, metoprolol, phenazepam.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
1. Observation of a therapist, neuropathologist, traumatologist of the TsKDP VMA.
2. Optimization of the regime of work, rest, nutrition.
2. Continue taking
• Olikard 0.04 1 caps. 1 r / d after breakfast
• Thrombo ACC 0.1 1 tab. 1 r / d after breakfast
• Metoprolol 0.05 ½ tablet 2 r / d (after breakfast and dinner)
• Asparkam 1 tablet 3 r / d the first 10 days of each month.
MILITARY MEDICAL ACADEMY
Hospital Therapy Clinic
Discharge summary from case history No. 86
was examined and treated at the Military Medical Academy Hospital Therapy Clinic from 24.12.2009 to 12.01.2010.
DIAGNOSIS:
IHD: stable exertional angina 3 FC. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, out of paroxysm.
Hypertension III degree. (AH 2, CVE risk is extremely high). NK 2a st., 3 FC.
Cerebrovascular disease. Acute cerebrovascular accident of the ischemic type in the basin of the right middle cerebral artery from December 2009. Dyscirculatory encephalopathy of the 3rd stage of mixed (atherosclerotic, hypertensive) genesis in the form of scattered neurological symptoms, vestibulopathic and unexpressed psychoorganic syndromes.
Osteochondrosis of the thoracic spine with pain syndrome.
Cholelithiasis. Chronic calculous cholecystitis without exacerbation.
Omission of the right kidney 1 degree.
Varicose disease of the lower extremities, CVI-2st.
Phenomena of initial cataract in both eyes. Severe angiosclerosis of the retina. Initial macular degeneration of both eyes.
Upon admission, she complained of periodic pressing pains in the region of the heart, of varying duration, that occur after climbing to the 2nd floor, stopping on their own after the cessation of physical activity; periodic heartbeats, interruptions in the work of the heart; episodic increase in blood pressure up to 180\90 mm Hg, episodic dull aching headache without clear localization with an increase in blood pressure; pain in the spine, aggravated by physical exertion, unsteady gait, hearing and vision loss during the last month, memory loss, fatigue.
Results of instrumental studies:
X-ray of the chest organs No. 195 dated 12/25/09: on a chest radiograph and on fluoroscopy in the lungs without focal and infiltrative changes. Moderate diffuse emphysema, at the level of the 2nd rib on the left, areas of limited pneumofibrosis 1.5 * 1.0 cm are determined. The roots are structural, not expanded, free fluid in the pleural cavity is not determined. The diaphragm is flattened on the left, the costophrenic sinus is obliterated on the left. The heart is slightly dilated to the left. The aorta is compacted and deployed.
X-ray of the thoracic spine No. 2681 dated 11/17/09. in 2 projections - physiological kyphosis is enhanced (senile round back). Osteochondrosis in the mid-thoracic region with a decrease in the height of the discs, osteochondral sclerosis and marginal exophytes in direct projection up to 0.1 cm.
On ECG No. 176 dated 06.11.09. and 26.12.09. sinus rhythm is recorded with a heart rate of 65 per 1 minute, the EOS is deflected to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His). Left ventricular hypertrophy.
ECHO-KG from 01/08/2010: The cavities are not enlarged, free, the myocardium is not thickened, the kinetics is not disturbed, the aorta is sealed, the walls are thickened, calcification of the aortic crescents. Sealing, calcification of the mitral valve leaflets. Regurgitation of the 1st degree on the TC and MC, valvular on the aortic and pulmonary valves. Pulmonary blood flow is not disturbed. The pericardium is not changed
. Ultrasound of the OBP dated 11.01.2010. Multiple gallbladder calculi with a diameter of up to 10 mm., The right kidney is located 3 cm below its usual location. Visceroptosis.
FVD dated December 27, 2009. conclusion in hand.
CT scan of the head dated December 30, 2009. - conclusion on hand
Results of laboratory tests:
Clinical blood test (automatic processing):
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
MCHC, g/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
26.12.
113
3.62
5.1
326
25
2
1
46
7
1
43
11.01.
116
3.84
5.4
319
30
1
40
6
3
47 Complete
urinalysis (automatic processing):
Date
U.weight
Reak
Protein
Sach
Cylinder
Leu
Er.neiz
Urobil
26.12
1020
6.0
-
-
No
-
-
-
Biochemical blood test:
Name
Unit of measure.
Norm
25.12.2009
11.01.10
AST
U/l
11-50
20
ALT
U/l
11-50
16
CPK
U/l
10-160
68.6
O. bilirubin
mmol/l
6.8-26
8.4
Creatinine
mmol/l
0.05-0.12
0.12
Potassium
mmol/l
3.5-5.1
4.21
4.14
Serum iron
mmol/l
10.5-25
9.47
Total protein
g/l
64-83
70.8
72.7
glucose
mmol/l
3.9-6.2
5.57
F-50, HBsAg, HCV, RW: negative.
Examination of feces on December 26, 2010: no pathology, I/g were not detected.
Consulted by a neurologist. The diagnosis is specified, recommendations are given.
Consulted by an ophthalmologist. The diagnosis is specified, recommendations are given. A prescription for reading glasses has been issued.
Endoscopic examination of the gastrointestinal tract was not performed due to the patient's condition.
Treatment was carried out: regimen, diet, noliprel-forte, cordarone, aspicor, cytoflavin, rudotel, gliatilin, phezam, mildronate.
Discharged home in a satisfactory condition under the supervision of medical specialists of the clinic. A temporary disability sheet was not issued.
Recommended:
1. Supervision by a neurologist, a cardiologist.
2. Continue taking:
• Tab. Noliprel 1 tab. in the morning all the time.
• Tab. Thrombo ASS 0.05 1 tab. in the morning all the time.
• Tab. Preductal MB 1 tab. 2 times a day all the time.
• Tab. Gliatilin 0.4 1 tab. 3 times a day from 11 to 20 January 2010
• Caps. Phezam 2 caps. morning and afternoon from 11 to 20 January 2010.
• Quinax - 2 drops in each eye 4 times a day for 1 month.
• Actovegin 20% - 250ml intravenously 1 time per day for 2 weeks, starting from 20.01.10.
• Tanakan 1 tab 2 times a day from January 20 to February 20, 2010.
3. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
4. Limit the intake of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
5. Repeated hospitalization according to indications.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr., 63 tel. (812) 577-11-35
DISCUSSION REPORT CASE
HISTORY No. 657 ACCORDING TO ARCHIVE No. _________
She was hospitalized (in the day hospital mode)
in the hospital therapy clinic
from September 22, 2014 to September 26, 2014. Departed from VMA "26" 09 2014
Total days of treatment 5
The final diagnosis was established on 25.09.2014. ICD code I 11.9
Hypertension stage II (normotension, the risk of cardiovascular complications is “high”). Aortic atherosclerosis without heart failure.
Polyposis of the large intestine.
A disability certificate was not issued.
The ability to work is not impaired.
Total radiation dose 0.26 mSv
Clinical outcome: discharge.
The results of laboratory studies in dynamics:
General clinical analysis of blood:
Date
Hb, units.
Er., *1012/l
MCH
fl
Leuc., *109/l
Ht
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pi
%
Xia
%
22.09
133
4.91
27.1
6.2
44.5
8
349
5
22.1
10.3
1
60
_
_
_
Norm
22.09
Indicator
22.09
Creatinine
Mkmol/l
53-124
115.2
Color Yellow
Cholesterol
Mmol
/l
3.7-6.0
6.13
Transparency
trans.
Triglycerides
mmol/l
0-2.37
0.87
Specific Weight
1020
PSA
Mmol/l
up to 4
1.34
Protein (g/l)
no
Glucose
mmol/l
4.2-6.4
5.39
Sugar
No
Fibrinogen
g/l
2-4
3.67
Leukocytes in p/s
1-2-3
Potassium
mmol/l
4.0-6.0
4.46
pH
6.0
Urea
mmol/l
3.0-8.4
6.5
Results of instrumental studies:
ECG on September 22, 2014: Sinus rhythm, 74 per min. Normal position of the EOS. Partial violation of intraventricular conduction.
Ultrasound of the abdominal organs on September 22, 2014: Liver: right lobe - 13.2 cm, left - 5.7 cm, echogenicity is not changed, the vessels are not dilated. Portal vein less than 13 mm. The pancreas is located clearly, hyperechoic, the contours are clear, even. The gallbladder of the correct form, not enlarged. The PCL is not dilated; in the right kidney, the sinus is divided by a hypoechoic band. The spleen is not changed. Conclusion: Diffuse changes in the pancreas. Doubling of the right kidney.
ECHO-KG from 23.09.2014: MZHP-9.9mm, ZS-10.5mm, KDR LV-56.1mm, KSR LV-38.8mm, PV-58%, FU-31%, LP-32× 37×46mm, PP-37×46mm, RV-28mm, E/A=1.1 LV myocardial mass 267 g, IMM 136 g/m2. The walls of the aorta are sealed. The myocardium is slightly eccentrically hypertrophied. The cavities of the heart are free, not dilated. Global LV systolic function was preserved. Zones of local violation of contractility were not identified. Type I diastolic dysfunction. The valves are intact. Doppler examination revealed no pathology. Pericardium without features.
24-hour Holter ECG monitoring on September 23, 2014: during the observation period, sinus rhythm was recorded with a heart rate of 63 to 130 per minute, the decrease in heart rate at night was insufficient. Average heart rate 78/82/70 in 1 minute. Single supraventricular extrasystoles were registered (23 in total). When performing the planned load, the heart rate reached 130 and 123 in 1 minute, while the patient noted dizziness. No ischemic changes in the ST segment were detected.
Daily monitoring of blood pressure from 09/23/2014: Mean blood pressure 137/97 mm Hg. Art. during the day and 126/91 mm Hg. Art. at night. Daytime mean systolic BP is characteristic of mild labile hypertension, while nighttime BP is characteristic of mild stable hypertension. At night, systolic and diastolic blood pressure decrease insufficiently (nondipper). Episodes of hypotension were not registered.
X-ray of the chest organs No. 859 dated September 22, 2014: in the lungs without focal and infiltrative changes. The roots of the lungs are fibrously compacted, not expanded. Heart - aortic configuration due to the enlarged left ventricle. The aorta is enlarged and thickened.
Spirometry dated 09/25/2014: VFL within normal limits.
Spirometry (test with bronchodilator) from 09/25/2014: test with salbutamol: bronchodilation coefficient was 1.6%, which corresponds to the physiological variability of the bronchial lumen.
Fibrocolonoscopy dated 09/24/14: perianal skin is not changed. On digital examination, the tone of the rectal sphincter is normal. In the anus area, collapsed hemorrhoids and moderately tense internal hemorrhoids with inflamed mucosa above them are determined. The distal end of the fibrocolonoscope was inserted into the rectum, where 2 hyperplastic polyps on a wide base 0.3-0.4 cm in diameter were detected in the ampulla. At 15 cm in the upper ampullar part, a half-dip on a narrow base with a diameter of 0.5 cm. In the distal part of the sigmoid colon (23-25 cm), a polyp on a long stalk 2.0x2.5 cm (biopsy). In the descending colon - multiple (4) polyps on a narrow and wide base from 2 to 0.5 cm. In the region of the splenic angle, a polyp on a short stalk 1 cm (biopsy). Endoscopic electroexcision of polyps is recommended.
Conclusion: colon polyposis. Exacerbation of internal hemorrhoids.
Biopsy material (FCC dated September 24, 2014): in progress.
Recommended:
1. Observation by a general practitioner, gastroenterologist at a polyclinic at the place of residence.
2. consultation of a surgeon to resolve the issue of surgical intervention for intestinal polyposis.
3. taking the drug: rosuvastatin 10 mg, 1 tab. in the evening for a long time.
4. with an increase in blood pressure above 140/90 mm Hg. Art. taking capoten sublingually 25 mg.
September 26, 2014.
DISTRICT MILITARY CLINICAL HOSPITAL IM. Z.P. SOLOVIEV
Discharge summary No.
born in 1948 (58 years old), was examined and treated in the 23rd cardiological department of the 442th OVKG with a diagnosis of:
Ischemic heart disease, angina pectoris of the third functional class, atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis. Hypertensive disease of the second stage (arterial hypertension-2 Risk-4). Circulatory insufficiency stage IIa. Chronic heart failure of the third functional class. Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of diffuse neurological symptoms. Osteochondrosis of the thoracic, lumbar spine with a slight dysfunction. Chronic vertebrogenic sciatica with L5-S1 with radicular syndrome in remission. Chronic atrophic gastritis in remission. Angioectasia of the stomach. Prostate adenoma. Partial secondary adentia.
He was admitted to the clinic in a planned manner with complaints of dull pressing pain in the left half of the chest and behind the sternum with irradiation to the left hand when climbing to the 2nd floor or walking on a flat area for 100-150m, dull diffuse headache, dizziness, rise in blood pressure to 170/110 mm Hg, shortness of breath, palpitations, nausea.
Laboratory results:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
24.11
132
4.51
6.0
4
248
-
-
30.2
5.3
3
61.5
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
14.11
clear
1030
yellow
sour
no
no
urate
no
no
no
no
no
1-2
1-2
Biochemical blood test:
Name
Unit. rev.
Norm
24.11
CS
mmol/l
3.7-7
5.97
Total protein
g/l
63-87
69
ALT
U/L
8.4-53.5
14
AST
U/L
7-39.7
21
Cl
mmol/l
95-108
106
Na
mmol/ l
130-150
142
K
mmol/l.
4-6
4.8
GGTP
U/L
7-63
24
Glucose
mmol/l
4.2-6.4
5.3 Vol
. bilirubin
µmol/l
6.8-26
22.9
Fibrinogen
g/l
2.0-4.0
2.47
1.12.2006: APTT (1.12.06) =46 sec, INR (1.12.06)=0.88
Results of instrumental studies:
ECG dated 24.11.2006 .: Sinus rhythm with a frequency of 60 bpm, vertical EOS (α=800), increased potentials of the left ventricle.
ECHO-KG from 11/24/2006: MZHP-11.0mm, ZS-11.0mm, KDRLV-48mm, KSRLZh-33mm, EF-45%, E/A=0.6 Myocardium is symmetrically thickened. The cavities are free, not dilated, the valves are not changed, the leaflets of the mitral and aortic valves, the aorta is sealed. The pericardium is intact. The kinetics is not broken. Diastolic dysfunction of the left ventricle.
Ultrasound of the abdominal organs dated 11/15/2006: the liver is not enlarged, the contours are even, the vascular pattern is not clear, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein 13 mm, hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder is of the correct form, the contours are even, calculi and polyps are not visualized. The pancreas is located indistinctly, diffusely heterogeneous structure, the contours are clear, even, echogenicity is increased; Wirsung's duct is not dilated. Kidneys of normal size, normal location, with smooth contours, homogeneous parenchyma. The spleen is not enlarged. In the projection of the location of the adrenal glands, no pathological formations were found. The bladder is full, with a volume of 250 ml, the contours are even, the walls are not thickened (3-4 mm) The prostate gland V = cm3, the contours are fuzzy, the structure is heterogeneous due to compaction areas. Fibrosis in the right lobe. Smoothed interlobar furrow. The middle lobe protrudes slightly into the lumen of the bladder. The volume of residual urine is 30 ml.
Fibrogastroduodenoscopy No. 1156 dated December 8, 2006: in the study of the esophagus, stomach, duodenum, cardiac sphincter insufficiency, chronic gastritis with diffuse atrophy of the mucous membrane of the antrum of the stomach is determined. In the prepyloric and antral regions, two angioectasias are determined along the lesser curvature. The duodenal bulb and postbulbar section are not visually changed.
X-ray of the chest organs dated November 25, 2006: Conclusion: On the survey radiograph of the chest cavity organs in the lungs without fresh infiltrative changes. The roots are structural, the diaphragm is flattened, no free fluid was found in the pleural cavity. The heart is expanded in diameter to the left, the aorta is sealed.
On spondylograms of the thoracic spine in 2 projections from 26.11.06: increased physiological kyphosis due to a decrease in the height of the vertebral bodies in the anterior section Th5-6-7-8 small cartilaginous hernias on the upper and lower areas of the vertebral bodies. Deforming spondylosis Th4-11. X-ray picture of the consequences of osteochondropathy.
Treatment was carried out: regimen, diet, polarizing mixture, asparkam, atenolol, thrombolytic ACC, enalapril, sydnopharm, metabolic therapy.
On the background of the therapy, the patient's condition improved. Does not require sick leave.
Discharged in a satisfactory condition.
Recommended:
105. Outpatient monitoring by a cardiologist.
106. Exclude animal fats, fried, spicy foods from the diet.
107. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
108. Dispensary observation:
a. clinical blood test (with platelet count), urinalysis - 4-6 times a year;
b. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - at least 2 times a year;
c. Echocardiography - 2 times a year;
109. Continue taking:
a. Concor 5mg - 1 tab. in the morning - constantly
b. Sidnopharm - 1 tab. 3 times a day - constantly
c. Thrombo ACC 0.01 - 1 tab. In the morning
d. Ko-renitek - ¼ tab 2 times a day MILITARY MEDICAL
ACADEMY
Form 12_Un
.
Last name, first name, patronymic_
Was on inpatient treatment
at the hospital therapy clinic
Total days of treatment 12
The final diagnosis was established ICD code_I 50.0_
Diagnosis:
Main: coronary artery disease. Stable angina pectoris III f.k. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (2004) cardiosclerosis. Secondary dilated cardiomyopathy.
Complications of the underlying disease: Aneurysm of the apex of the left ventricle. CHSN 2B, IVf.k. Right-sided hydrothorax. Cardiac asthma from 12/22/2010. DN 2 tbsp.
Accompanying: Hypertension III Art. (AH 1, risk IV). Chronic viral hepatitis B, stage of cirrhosis. Dyscirculatory encephalopathy 2 tbsp. mixed (atherosclerotic, hypertensive, dysmetabolic) genesis. Degenerative-dystrophic disease of the spine. Diabetes mellitus of the second type, compensation. Chronic pyelonephritis, latent course.
CKD 3 st (GFR=58 ml/ min
/ 1.73m2) CKD
-
1a
st
. :
Complaints: increasing dyspnea of a mixed, predominantly inspiratory nature, noted at rest, aggravated in a horizontal position; discomfort in the right half of the chest at rest, paroxysmal cough without discharge, increasing weakness, decreased exercise tolerance.
Disease history. For a long time he suffers from coronary heart disease, hypertension. I have been drinking alcohol for a long time. In 2004, she suffered a massive myocardial infarction. 17.10.10 performed surgical treatment for bleeding (shock 2-3) from a chronic stomach ulcer. During the same hospitalization, decompensated diabetes mellitus was diagnosed. After discharge, she did not comply with the doctor's recommendations, she began to notice an increase in the volume of the abdomen. On this occasion, she was repeatedly hospitalized in the hospitals of the city, where complex treatment was performed with active diuretic therapy. After discharge from the pulmonology department of City Hospital No. 26, his condition deteriorated sharply. From December 23, 2010 to January 14, 2011, she was treated at the GT VMedA clinic. In view of the resistance of pathological exudation in the right pleural cavity to diuretic therapy and mechanical removal of fluid during pleural punctures, in the diagnosis, the patient was recommended to perform a CT scan in order to exclude a neoplasm of the right lung, mediastinum, and abdominal organs. When trying to perform tomography, the study turned out to be uninformative, according to the patient, due to the presence of fluid in the pleural cavity. During the last week, she began to notice an increase in dyspnea, its occurrence at rest. In this connection, she was taken by an ambulance to the hospital therapy clinic for urgent indications. When trying to perform tomography, the study turned out to be uninformative, according to the patient, due to the presence of fluid in the pleural cavity. During the last week, she began to notice an increase in dyspnea, its occurrence at rest. In this connection, she was taken by an ambulance to the hospital therapy clinic for urgent indications. When trying to perform tomography, the study turned out to be uninformative, according to the patient, due to the presence of fluid in the pleural cavity. During the last week, she began to notice an increase in dyspnea, its occurrence at rest. In this connection, she was taken by an ambulance to the hospital therapy clinic for urgent indications.
Objective status: general condition of moderate severity, swelling of the feet, legs, heart rate 90 per minute, no deficit, rhythmic pulse, auscultatory tones of the heart are muffled, the 1st tone is weakened above the apex of the heart, there is a rough systolic murmur at the apex, the boundaries of the heart are expanded, BP 110/60 mm Hg in the lungs, hard breathing, single congestive rales in the lower lobe on the left, on the right, breathing is not heard in the zone of dullness from the level of the 5th rib; the abdomen is not enlarged, soft, painless on palpation, the edge of the liver protrudes 4 cm from under the costal arch, effleurage in the lumbar region is painless on both sides.
As a result of the treatment: regimen, diet No. 9, metabolic therapy (polarizing mixture: Sol.NaCl 0.9% -200.0, Sol.Asparcami 20 ml), inotropic therapy (Korglikon 0.06% 1.0 i.v. drip, Digoxin 0.00025, 0.5 tablets in the morning), hypoglycemic therapy (Maninil 0.0035, 2 tablets per day), antibacterial therapy (Augmentin, 1 tablet 2 times a day), diuretic therapy (Diuver 0.01 1 tab per day, Hypothiazid 0.025, 2 tab. in the morning), beta-adrenolytics (Betaloc-Zok 0.05, 0.25 tab. 2 times a day), antithrombotic therapy (Acecardol 0.1, 1 tab. 1 time per day), hepatoprotective therapy (Essentiale 5.0 No. 5 IV), punctures of the right pleural cavity (January 27, 31, February 07 with evacuation of 2700 ml, 1500 ml, 2000 ml of straw-yellow liquid, subsequent administration of 80 mg of gentamicin intrapleurally), the state of health improved, shortness of breath decreased,cough regressed, edema in the legs disappeared, a small amount of fluid remained in the supraphrenic parts of the right lung.
Taking into account the resistance of pathological exudation in the right pleural cavity to diuretic therapy and mechanical removal of fluid during pleural punctures, as well as taking into account the one-sidedness of the effusion (right pleural cavity), further diagnosis should still exclude a neoplasm (pleural mesothelioma?
) it is impractical, since this manipulation requires one-lung ventilation of the lungs - the patient will not tolerate this intervention due to functional disorders.
Data for tuberculosis were not received.
Results of instrumental studies:
ECG 02/27/2011, heart rate - 91 per minute Sinus rhythm, EOS to the right. Cicatricial changes in the anterior-septal, apical-lateral section of the left ventricle. Signs of hypertrophy of both ventricles, left atrium. Diffuse disorders of repolarization. Complete blockade of the right leg of the bundle of His.
ECG from 02/01/2011: Sinus tachycardia. Heart rate 95 per minute. EOS is deflected to the left. Cicatricial changes in the anterior-septal, apical-lateral section of the left ventricle. Complete blockade of the right leg of the bundle of His. Violation of repolarization processes along the posterior and lateral walls. Frequent monotopic monomorphic ventricular extrasystoles.
ECG from 02/07/2011: heart rate 90 per minute. There is a weakly positive dynamics in the form of normalization of repolarization processes, the absence of rhythm disturbances.
X-ray of the chest on 02/07/2011 (control after pleural puncture dated 02/07/2011): after a pleural puncture with the removal of 2 liters of fluid, the lung fills the pleural cavity completely. Fresh focal and infiltrative changes were not found. The roots of the lungs are moderately compacted. In the right pleural cavity, a small amount of fluid is retained in the supradiaphragmatic regions. The heart is considerably enlarged in diameter to the left. The aorta is sealed.
CT scan of the chest, abdomen, small pelvis dated 01/31/2011: condition after drainage of the right pleural cavity. Right-sided hydrothorax. Multiple subsegmental atelectasis of the right lung. Lymphadenopathy of the upper paratracheal group. Enlargement of the heart. Moderate hepatomegaly. Ascites.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er
.
,
*
1012
/
l
Leuc
.
,
*
109
/
l
MCH
ESR
,
mm
/
h
_
_
_
_
_
_
_
_
18.01.
129
5.02
9.6
25.6
9
6
-
27
6
2
59
Biochemical analysis of blood: Analysis of urine:
Name
Unit of measure.
Norm
28.01
Indicator
28.01
01.02.
Creatinine
µmol/l
53-124
110
Color
Yellow
Yellow
Cholesterol
Mole/l
3.7-6.0
Clarity
Light hazy.
Transparency
Triglycerides
Mole/l
0-2.37
Specific. Weight
More than 1030
1.020
Total protein
G/l
63.0-87.0
63
Reaction
5.0
6.5
Calcium
Mole/l
2.1-2.5
2.25
Protein (g/l)
1.0 g/l
1.0
Potassium
Mole/l
3.5-5.1
4.88
Sugar
No
No
Glucose
Mole/l
4.2-6.4
5 .02
Urobilin
3.2
3.2
Prothrombin
%
70-120
113
Leukocytes in s/s
5-7
4-6
Fibrinogen
Mg/dl
200-400
300
Erythr. unchanged in s/s
1-2
0-1
CPK
U /l
10.0-160.0
Erythr. Vyschi. V p/s
No
no
AST
U/l
11.0-50.0
Salts
No
No
ALT
U/l
11.0-50.0
Mucus
1
1
Total bilirubin
Mole/
l
6.8-26.0
Hyal. 1-2
No
Urea mmol
/
l
8.2
11.9
7-10
5-7
LDH
U/L
251
Bacteria
Moderate Quantity
Moderate Quantity
Analysis of pleural fluid from 01/27/2011: 2500 ml yellow, cloudy. Revolta test negative. Protein 30 g/l. Leukocytes 6.2*109/l, erythrocytes 17.7*109/l, macrophages, mesothelium, epithelial cells 3.25*109/l. Leukocytes are represented by 70% lymphocytes. Macrophages make up 15%; in macrophages and neutrophils there are cocci, single diplococci. Mesothelial cells are single. VC were not identified.
Analysis of the pleural fluid from 01/31/2011: 1400 ml of a lemon-yellow liquid, slightly cloudy, was delivered. Protein 30.1 g/l. Revolt's test is negative. Leukocytes 15.25*109/l, erythrocytes 63.75*109/l, macrophages, mesothelium, histiocytes 55.75*109/l. There are a large number of cell complexes in the chamber grid and outside it. Glucose 6.14 mmol / l. LDH 240 U/l.
Sputum analysis from 02/03/2011: Pink, viscous, mucous with an admixture of blood. Epithelium squamous 0-3 in p/s, ciliated 0-5 in p/s, alveolar 0-3 in p/s, atypical cells were not found, leukocytes 10-20-50 in p/s, erythrocytes cover all p/s . VK not found. Staphylococci in moderation. Diplococci in small numbers. Yeast-like mushrooms.
Examination of pleural exudate for the activity of Adenosine DesAminase (a marker of tuberculosis): 14 U / l (the threshold value for the diagnosis of tuberculosis is 35 U / l).
Discharged in a satisfactory condition under the supervision of polyclinic doctors
Recommended:
13. Observation of a general practitioner, cardiologist, endocrinologist, hepatologist at the place of residence
14. Compliance with the diet, normalization of the regime of work and rest. Avoid psycho-emotional stress. Limit salt and liquid intake. Control of blood pressure and heart rate. exercise therapy.
15. Performing an analysis of the pleural fluid for atypical cells (Foundry 37, tel. 272-67-67). Glasses with smears of pleural fluid were handed out.
16. Consultation of cardiologists in the Federal Center. Almazov, tel. 702-37-06
17. Consultation of a thoracic surgeon at the place of residence for periodic pleural punctures.
18. Continue taking:
• Tab. Digoxin 0.00025 ½ tablet in the morning (except Saturday and Sunday)
• Tab. Metoprolol (Betaloc-ZOK) 0.05 ¼ tablet 2 times a day constantly.
• Tab. Enalapril 0.01 ¼ tablet 2 times a day continuously.
• Tab. Preductal MB (Trimetazidine) 1 tablet 2 times a day for a month.
• Tab. Maninil 0.0035 1 tablet 2 times a day continuously.
• Tab. Diuver 0.01 1 tablet on an empty stomach - in the presence of edema.
• Tab. Aspirin (Acecardol, Thrombo-ASS, Aspicor) 0.1, 1 tab. in the evening all the time.
• Tab. Panangin 1 tablet 3 times a day for 10 days of each month.
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
Discharge summary No. 963
was examined and treated at the hospital therapy clinic
from August 30 to September 13, 2010 with a diagnosis of
hypertension stage III. (AH 2, CVE risk is extremely high).
IHD: stable exertional angina 3 FC. Atherosclerotic cardiosclerosis. Atherosclerosis of the aorta and coronary arteries. Persistent form of atrial fibrillation. CHF 2a st., 3FC. Cerebrovascular disease. Dyscirculatory encephalopathy of the 3rd stage of mixed (atherosclerotic, post-stroke (December 2010), hypertensive) genesis in the form of diffuse neurological symptoms, vestibulopathic and unexpressed psychoorganic syndromes. Osteochondrosis of the thoracic spine with pain syndrome. Cholelithiasis. Chronic calculous cholecystitis without exacerbation. Diffuse nephroangiosclerosis of mixed (atherosclerotic, hypertensive, dysmetabolic) genesis. CKD stage 3, chronic renal failure stage 1a. Omission of the right kidney 1 degree. Varicose disease of the lower extremities, superficial form. HVN-2st. Primary cataract in both eyes. Severe angiosclerosis of the retina. Initial macular degeneration of both eyes.
Upon admission, she complained of periodic pressing pains in the region of the heart, of varying duration, shortness of breath that occurs after climbing to the 1st floor, stopping on its own after the cessation of physical activity; periodic heartbeats, interruptions in the work of the heart; episodic increase in blood pressure up to 180/90 mm Hg, episodic dull aching headache without clear localization with an increase in blood pressure; pain in the spine, aggravated by physical exertion, unsteady gait, hearing loss and vision loss during the last month, memory loss, fatigue.
Results of instrumental studies:
Ultrasound of the OBP from 09/01/2010. Multiple gallbladder stones up to 12 mm in diameter, the right kidney is located 3 cm below its usual location. Visceroptosis. Ultrasound signs of nephrosclerosis.
Ultrasound of the thyroid gland No. 1067 dated 10.09.2010. Conclusion: a cyst of the right lobe of the thyroid gland, the volume of the gland is at the upper limit of normal.
X-ray of the chest organs No. 1766 dated 09/01/10: on the chest radiograph and on fluoroscopy in the lungs without focal and infiltrative changes. Moderately expressed diffuse emphysema, diffuse pneumofibrosis. The roots are structural, not expanded, free fluid in the pleural cavity is not determined. The diaphragm is flattened on the left, the costophrenic sinus is obliterated on the left. The heart is slightly dilated to the left, "hanging". The aorta is compacted, elongated and deployed.
On ECG No. 1815 dated 08/30/10. sinus rhythm is recorded with a heart rate of 65 per 1 minute, the EOS is deflected to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His).
On ECG No. 1846 dated 06.09.10. sinus rhythm is recorded with a heart rate of 78 per 1 minute, the EOS is deviated to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His). No negative momentum.
ECHO-KG from 09/06/2010: The cavities are not enlarged, free, the myocardium is not thickened, the kinetics is not disturbed, the aorta is sealed, the walls are thickened, calcification of the aortic crescents. Sealing, calcification of the mitral valve leaflets. Regurgitation of the 1st degree on the TC and MC. Pulmonary blood flow is not disturbed. The pericardium is not changed. Without dynamics with ECHO-KG from 01/08/2010.
Holter ECG monitoring (against the background of therapy) dated 09/01/2010: during the observation period, the following rhythms were recorded: pacemaker migration through the atria, 4 prolonged episodes of atrial fibrillation, tachysystolic form (11:10-11:28; 13:58) -15:45; 18:20-19:28; 23:41-00:50) and many short episodes of atrial fibrillation lasting up to 2 minutes, 5 short episodes of atrial flutter, turning into atrial fibrillation. Heart rate from 52 to 166 in 1 minute. The decrease in heart rate at night is adequate. Average heart rate 81/89/69 in 1 minute. Single ventricular extrasystoles were registered (22 in total); ultra-frequent supraventricular extrasystoles (total 4632), periodically aberrant, paired, group, bi- and trigeminy type. Against the backdrop of atrial fibrillation,
Monitor observation of Holter ECG (against the background of therapy) dated 09.09.2010: during the observation period, migration of the pacemaker through the atria was recorded, many short episodes of atrial flutter-fibrillation, normosystolic form, were recorded. Heart rate from 52 to 116 in 1 minute. The decrease in heart rate at night is adequate. Average heart rate 81/89/69 in 1 minute. Registered single ventricular extrasystoles (total 12); frequent supraventricular extrasystoles (total 1562), periodically paired, group, bi- and trigeminy type. Against the background of atrial fibrillation, tachysystole, ST segment depression up to 2 mm is recorded.
Daily monitoring of blood pressure (against the background of therapy) from 09/01/2010: Mean systolic blood pressure during the day and mean diastolic blood pressure during the day are within the normal range, mean systolic blood pressure at night is characteristic of mild labile hypertension. At night, systolic blood pressure paradoxically rises (nightpicker), diastolic blood pressure does not decrease enough (nondipper). The variability of systolic and diastolic blood pressure during the day is increased, at night the variability of systolic and diastolic blood pressure is within the acceptable range. 3 episodes of hypotension in systolic blood pressure up to 94 mmHg were registered. (time index 6%), and 2 episodes of hypotension in diastolic blood pressure up to 48 mm Hg. (time index 23%). There is an increase in the average pulse blood pressure, the magnitude and speed of the morning rise in diastolic blood pressure.
The results of laboratory examination:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
Ht, %
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
31.08
123
3.94
5.2
37.6
32
269
1
34
11
1
53
09.09
121
3.83
5.2
37.0
30
309
5
50
6
1
38
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
31.08
clear
1010
yellow
6.5
no
no
no
-
-
no
0-3
-
4-8
1-2
09.09
clear
1010
yellow
5.5
no
no
no
2
-
no
2-5
-
8-15
0-2
Biochemical blood test:
Name
Unit. rev.
Norm
31.08
09.09
Creatinine
µmol/l
53-124
101.1
urea
mmol/l
2.5-6.4
9.3
glucose
mmol/l
3.9-6.2
5.7
potassium
mmol/l
3.5-5 .1
4.9
4.6
sodium
mmol/l
136-145
141.8
139.3
total cholesterol
mmol/l
3.7-6.0
9.56
8.93
triglycerides
mmol/l
0-2.37
0.7
o. bilirubin
mmol/l
6.8-26
7.1
Total protein
g/l
63-87
74.6
albumin
g/l
30-55
43.5
ALT
U/L
8.4-53.5
16.1
AST
U/L
7-39.7
15.5
Amylase
U/L
28-100
68.7
prothrombin index
%
70-120
102
Fibrinogen
mg/dl
200-400
408
Creatinine clearance according to the Cockcroft-Gault formula = 31 ml/min. GFR by MDRD = 47.5ml/min/1.73m2
Endoscopic examination of the gastrointestinal tract was not performed due to the patient's condition.
Treatment was carried out: regimen, diet, noliprel, cordarone, aspicor, cytoflavin, actovegin, tanakan, phenibut, amitriptyline, movalis, piracetam, betaserc.
Discharged home in a satisfactory condition under the supervision of medical specialists of the clinic. A temporary disability sheet was not issued.
Recommended:
1. Supervision by a neurologist, a cardiologist.
2. Continue taking:
• Tab. Noliprel ½ tab. in the morning all the time.
• Tab. Kordaron 0.2 1 tab. morning and evening for 1 month, then ½ tab. in the morning constantly
• Tab. Thrombo ASS 0.05 1 tab. in the morning all the time.
• Tab. Amitriptyline 25mg ½ tab. 2 times a day for 1 month
• Tab. Lucetam 0.8 1 tab. morning 1 month
• Tab. Preductal MB 1 tab. 2 times a day all the time.
• Quinax - 2 drops in each eye 4 times a day for 1 month.
• Tanakan 1 tab 2 times a day until September 30, 2010.
3. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
4. Limit the intake of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
5. Re-hospitalization after 3 months or earlier according to indications.
This block includes a number of mental disorders grouped together on the basis of the presence of clear etiological factors, namely, the cause of these disorders was brain disease, brain injury or stroke, leading to cerebral dysfunction. Dysfunction can be primary (as in diseases, brain injuries and strokes that directly or selectively affect the brain) and secondary (as in systemic diseases or disorders when the brain is involved in the pathological process along with other organs and systems).
Dementia [dementia] (F00-F03) is a syndrome caused by damage to the brain (usually chronic or progressive) in which many higher cortical functions are impaired, including memory, thinking, orientation, understanding, counting, learning ability, speech and judgment. Consciousness is not obscured. Cognitive decline is usually accompanied, and sometimes preceded, by deterioration in control of emotions, social behavior, or motivation. This syndrome is noted in Alzheimer's disease, in cerebrovascular diseases, and in other conditions that primarily or secondarily affect the brain.
If necessary, an additional code is used to identify the underlying disease.
MILITARY-MEDICAL ACADEMY. HOSPITAL THERAPY CLINIC
Reference No.
(53 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy with a diagnosis of
Chronic gastroduodenitis in remission. Dolichocolon. Myopia of both eyes 1.25 D with visual acuity with a correction of 1.0 in both eyes.
The clinic was admitted in a planned manner with complaints of recurrent cutting pains in the epigastric region and along the colon, bloating, loosening of the stool; subfebrile body temperature during the last month, headaches, periodic nosebleeds that occur against the background of a rise in blood pressure to 150/90 mm. rt. Art.
Results of laboratory researches:
General analysis of blood, urine, feces dated 12/12/2006 was normal. Blood biochemical parameters (AST, urea, creatinine, glucose, creatinine phosphokinase, total protein, total bilirubin, K+, Na+, Cl-, lipase) dated 11/28/2006 were normal. Antibodies to HIV 1.2 from 11/30/2006 were not found. 04/09/2006 HbsAg, anti-HCV antibodies were not detected. 04/08/2006 CRP - 0. RW microreaction-precipitation with cardiolipin antigen from 11/28/2006 - negative. RSK with chlamydial antigen from 29.11.2006 was negative. RNHA with tuberculosis antigen, with dysentery antigens of Shigella (Zone, Flexner, Newcastle), with complex salmonella antigen, with pseudotuberculous antigen, yersiniosis antigen from 11/30/2006 - negative. ECG dated April 27, 2006, sinus rhythm, heart rate 50 beats per minute. Incomplete blockade of the right leg of the bundle of His. Initial manifestations of left ventricular hypertrophy. Rotation of the heart with the right ventricle forward. Ultrasound of the abdominal organs dated November 30, 2006: the liver is not enlarged, the right lobe is 13.5 cm, the left lobe is 7.5 cm, the contours are even, the structure is homogeneous, the vessels are not dilated, the portal and hepatic veins, intrahepatic bile ducts are without features. The gallbladder is not enlarged, the contours are even, the walls are thin, the contents are homogeneous, calculi and polyps are not visualized. Pancreas, spleen without features. The kidneys are not enlarged, mobile. The parenchyma is homogeneous, without signs of pathology. The cavity system is not expanded. No pathological formations were found in the projection of the adrenal glands. The spleen is not enlarged, the structure is homogeneous. X-ray examination of the chest organs from 02.10.2006: no pathological changes. FCC dated December 11, 2006: the device is inserted 20 cm from the anus. Further study was terminated due to the patient's inappropriate behavior and at his urgent request. In the examined area of the intestine, the mucosa is thinned, the vascular pattern is enhanced. In the lumen fluid with an admixture of feces. Ampoule of the rectum without features. RRS dated 12/15/2006: the tube of the proctoscope was inserted up to 15 cm. Due to the patient's inadequate behavior, the study was not completed. No organic pathology was found in the rectum. The mucosa is pink, shiny, a vascular pattern can be traced. The tone of the intestinal wall is normal. FGDS from 8.12.2006: The esophagus is passable, the socket of the cardia does not close completely. In the stomach, a significant amount of mucus, liquid (foamy with an admixture of bile). The folds are rough, edematous, tortuous. The mucosa is hyperemic. The gatekeeper gapes
Treatment was carried out: regimen, diet, omeprazole 0.02 (1 tab 2 times a day), Almagel (1 spoon 4 times a day), Creon 10,000 IU (1 dr 3 times a day 30 minutes before meals), allochol (2 tablets 3 times a day).
On the background of the therapy, the patient's condition improved. Certified by VVK. Recognized on the basis of the articles of column III of the Schedule of Diseases and TDT (annex to the Regulations on the military medical examination, approved by the Decree of the Government of the Russian Federation of 2003 No. 123) "A" - fit for military service.
Recommended:
1. Observation of a therapist (gastroenterologist).
2. Omeprazole 0.02 (1 tab 2 times a day, morning and evening) - 1 week, then 1 tab at night - 2 weeks.
3. Almagel A or Maalox (1 spoon 4 times a day an hour after meals and at night) - 3 weeks
Does not need a sick leave. Discharged in a satisfactory condition.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1937 (69 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy with a diagnosis
of duodenal ulcer in the acute phase. Multiple (ulcer of the duodenal bulb, ulcer of the back of the bulb) ulcers of the duodenum. Cholelithiasis. Asymptomatic stone carrying. Atherosclerotic cardiosclerosis. Solitary cyst of the right kidney.
He was admitted to the clinic with complaints of acute burning pain in the epigastric region, not associated with eating.
Laboratory results:
General clinical blood test:
Date
Hb, units.
Er., *1012/L
Leuk., *109/L
CP
Ht
%
ESR, mm/h
Thrombus
*109/L
E
%
B
% Lf
%
Pl.cl
%
M
%
Pia
%
Xia
%
20.12.
140
4.54
6.9
0.92
13
4
1
29
1
9
1
55
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
20.12
clear
1017
yellow
sour
no
no
no
1
no
no
0-2
no
0-2
no
Urinalysis according to Nechiporenko dated 12/14/06: Leu-0.75×109/l, Er.-0.25×109/l
Analysis feces: no features
Biochemical blood test:
Name
Unit. rev.
Norm
11.12
Name
Unit. rev.
Norm
11.12
Creatinine
mmol / l
53-124
CS
mmol / l
3.7-7
4.18
Urea
mol / l
3-8.4
TG
mmol / l
0-2.37
1.54
Prothrombin
%
70-120
90
LDL
units
350-650
500
Fibrinogen
g/l
2.0-4.0
3.5
Alpha 1
%
4.1
Total protein
g/l
63-87
67.8
Alpha 2
%
12.7
Albumin
%
50-70
56.1
Beta
%
12.8
a/g
1.1-2.5
1.28
gamma
%
14.4
ALT
U/L
8.4-53.5
Cl
mmol/l
95- 108
102.8
AST
U/L
7-39.7
16.1
Na
mmol/l
130-150
158.5
AP
U/L
36-92
56.4
K
mmol/l.
4-6
3.76
LDH
U/L
100-220
TSH
mmol/l
0.27-4.2
GGTP
U/L
7-63
ALP
Ukat/L
0.70-2.30
Glucose
mmol/l
4.2-6.4
4.5
form 50
quality
neg
. bilirubin
µmol/l
6.8-26
10.3
HBsAg
quality
neg
Sial
. k-ty
g/l
1.9-2.5
AntiHCV qual negative
Neg
Results
of
instrumental studies:
ECG dated 12/11/2006: Sinus rhythm with a frequency of 66 beats/min, EOS is not rejected (α=400), signs of hypertrophy of the left ventricle.
ECHO-KG No. 25 dated 12/10/2006: MZHP-10.0mm, ZS-11.3mm, KDRLV-52.4mm, KSRLZh-37.5mm, FV-54.5%, FU-28.4%, UO -72ml, LP-33.3mm, RV-24mm, E/A=0.7 Myocardium is not thickened. The cavities are free, not dilated, the valves are not changed. The pericardium is intact. The kinetics is not broken. The aortic valve annulus is sealed. Diastolic dysfunction of the left ventricle.
Ultrasound of the abdominal organs from 12/13/2006: the liver is not enlarged, the right lobe: 13cm; left 7.5 cm, smooth contours, homogeneous structure, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein and hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder has a regular shape, dimensions 7.1×3.4 cm, smooth contours, walls 2 mm, calculi N4-5 up to 9-11 mm. The pancreas is not located. Kidneys of normal size, normal location, with uneven contours, heterogeneous parenchyma 17 mm thick, cavitary systems are not expanded. There are no concretes. Spava cysts with a diameter of 30 and 32 mm. The spleen is not enlarged, 9.9×6.8×4.4 cm in size. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: Cholelithiasis (cholecystolithiasis). Cysts of the right kidney.
Fibrogastroduodenoscopy dated December 6, 2006: In the duodenal bulb on the posterior surface there is an ulcerative defect 0.7 * 0.7 cm under fibrin, the mucosa around is hyperemic, edematous with many acute erosions 0.1 cm under fibrin. In the postbulbar region there is a shallow ulcerative defect 2.0 * 2.0 cm under fibrin with areas of hemosiderin.
X-ray of the chest organs No. 71 dated 12/11/2006: Conclusion: On the survey radiograph of the chest cavity organs in the lungs without fresh infiltrative changes.
Treatment: regimen, diet, asparkam, omeprazole, amoxicillin, almagel, metronidazole, vikalin, motilium.
On the background of the therapy, the patient's condition improved. Does not require sick leave.
Discharged according to the report in a satisfactory condition.
Recommended:
110. Outpatient observation of a gastroenterologist.
111. Dispensary observation:
a. Frequency of observation by a doctor: - 4 times a year.
b. clinical blood test (with platelet count), urinalysis - 4 times a year;
c. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - 2 times a year;
112. Continue taking:
a. Omeprazole 0.02 (1 tab 2 times a day, morning and evening) - 1 week, then 1 tab at night - 2 weeks
b. 3. Almagel A or Maalox (1 spoon 4 times a day one hour after meals and at night) - 3 weeks
AND ABOUT. Deputy Head of the Department for Clinical Work M. Sarazov
Head of the 1st Department I. Pavlovich
Attending physician N. Gulyaev
December 23, 2006.
ENT /A.F. Sirotinin /
Complaints of periodic discomfort, a feeling of sore throat in the cold season, which have been bothering for 2 years.
Objectively: the maxillary lymph nodes are enlarged, painless on palpation. Pharyngoscopy: the mucous membrane in the area of the lateral ridges and palatine arches is hyperemic and edematous. Palatine tonsils of the 1st degree, loose, clear in the gaps. Swallowing is not difficult. Other ENT organs without features. Hearing acuity in the study of whispered speech - 6 m in both ears.
Diagnosis: Chronic compensated tonsillitis. Lateral pharyngitis.
Recommended:
f. Spray "Tantum Verde" 2 inhalations 3 times a day for 10 days,
g. Rinse with warm decoctions of sage, chamomile - 10 days
h. Suprastin - 10 days
i. Peach oil in the nose 1 drop in both nasal passages 3 times a day
j. Repeated examination in dynamics
OPHTHALMOLOGIST /A.Yan/
Complaints of discomfort when reading and writing
Vis.OD=0.6 with correction cyl. –1.0D = 1.0 (ax 1800→)
Vis.OS=0.6 with cyl correction. –1.0D = 1.0 (ax 1800→)
Intraocular pressure: OD=OS=21 mmHg
The eyelids are not changed, the usual form, the palpebral fissure is not narrowed. The position of the eyeballs is correct, the movements are full. Conjunctiva slightly hyperemic, superficial injection of blood vessels. The corneas are transparent, spherical, without pathological changes. The anterior chambers are of medium depth, moisture is transparent, does not opalize. Pupils are centered, regular round shape, photoreactions are alive, D=S. Deep optical media are transparent. The reflex from the fundus is pink. The discs are pale pink, in the plane of the retina, with clear boundaries, regular round shape. Vessels A:B=1:3, arteries are narrowed, veins are somewhat dilated, tortuous, a symptom of arteriovenous decussation of the first degree. No pathology was detected in the macular zone and on the periphery of the fundus.
Diagnosis: Simple myopic direct type astigmatism in 1.0 D, hypertensive angiopathy of the retina in both eyes.
SPH
CYL
AX
R
+0.50
-1.75
168
L
0.00
-1.25
19
PD=61, VD=12
Complaints of headaches, dizziness, unsteadiness when walking, numbness in the fingers of the upper extremities.
Neurological status: conscious, oriented. The pupils are D=S, the physiological reflexes of the pupils are reduced, the reaction of accommodation with convergence is reduced. There is no nystagmus. The face is symmetrical. Tongue in the midline. Swallowing, phonation are not disturbed. Reflexes of oral automatism are negative. Tendon reflexes D=S, functional areas are expanded. There are no pathological signs. Decreased sensitivity in the upper extremities of the radicular type (C5-C6, C6-C7). Performs coordination tests with a slight intention. He staggers in the Romberg pose. There are no meningeal signs.
Diagnosis: Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of cerebellar insufficiency. Widespread osteochondrosis of the spine.
REG from 18.09.03: the blood flow is slightly reduced in the basin of the carotid and vertebral arteries, symmetrical. The cerebrovascular tone is normal. The hyperventilation test is weakly positive. The elasticity of the vessels is moderately reduced. Venous outflow is difficult in the vertebrobasilar basin.
Makes no complaints.
The face is symmetrical. The mouth opens freely, in full. The mucosa is clean, moist. No foci of odontogenic infection were found. Dental formula:
km o pl o km km km o km o o o pl
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
km o o km pl km o o o km o
Diagnosis: partial secondary adentia.
Needs dentures.
ECHO-KG No. 631 dated 11/13/2006: MZHP-9.9mm, ZS-7.0mm, KDRLV-47mm, KSRLZh-24.1mm, FV-79%, FU-48.5%, UO-80.93ml , LP-33.3mm, RV-25.5mm, E/A=1.0 Myocardium is not thickened. The cavities are free, not dilated, the valves are not changed, on the mitral valve regurgitation I stage. The pericardium is intact. The kinetics is not broken. Diastolic dysfunction of the left ventricle.
MILITARY MEDICAL ACADEMY
Hospital Therapy Clinic The
discharge summary from the medical history No. 1033
was examined and treated at the Military Medical Academy Hospital Therapy Clinic from 06.11.2009 to 20.11.2009.
DIAGNOSIS:
IHD, stable exertional angina 3 FC. Atherosclerotic cardiosclerosis. Atherosclerosis of the aorta and coronary arteries. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation from 08.11.09. stopped medically on 08.11.09.
Hypertension III degree. (AH 2, CVE risk is extremely high). NK 2a st., 3 FC.
Dyscirculatory encephalopathy of the 3rd stage of mixed (atherosclerotic, hypertonic) genesis with a predominant lesion in the vertebrobasilar basin. Syndrome of intellectual-mnestic disorders.
Osteochondrosis of the thoracic spine with pain syndrome.
Cholelithiasis. Chronic calculous cholecystitis without exacerbation.
Omission of the right kidney 1 degree.
Varicose disease of the lower extremities, CVI-2st.
Upon admission, she complained of periodic pressing pains in the region of the heart, of varying duration, that occur after climbing to the 2nd floor, stopping spontaneously after the cessation of physical activity; periodic heartbeats, interruptions in the work of the heart; episodic increase in blood pressure up to 180\90 mm Hg, pain in the spine, aggravated by physical activity, weight loss by 5 kg during the year, memory loss, fatigue.
Results of instrumental studies:
X-ray of the chest organs No. 2590 dated 09.11.09: on the chest radiograph and on fluoroscopy, the lung fields are emphysematous, at the level of the 2nd rib on the left, areas of limited pneumofibrosis 1.5 * 1.0 cm are determined. The roots are structural, not expanded, the diaphragm is flattened, free fluid in the pleural cavity is not determined. The heart is slightly dilated to the left. The aorta is compacted and deployed.
X-ray of the thoracic spine No. 2681 dated 11/17/09. in 2 projections - physiological kyphosis is enhanced (senile round back). Osteochondrosis in the mid-thoracic region with a decrease in the height of the discs, osteochondral sclerosis and marginal exophytes in direct projection up to 0.1 cm.
On ECG No. 2487 dated 06.11.09. and 08.11.09. sinus rhythm is recorded with a heart rate of 90 per 1 minute, EOS is deflected to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His). Left ventricular hypertrophy.
ECHO-KG: The cavities are not enlarged, free, the myocardium is not thickened, the kinetics are not disturbed, the Aorta is sealed, the walls are thickened, calcification of the aortic crescents. Sealing, calcification of the mitral valve leaflets. Regurgitation of the 1st degree on the TC and MC. Pulmonary blood flow is not disturbed. The pericardium is not changed
by ultrasound of the OBP. Multiple gallbladder stones up to 10 mm in diameter, the right kidney is located 3 cm below its usual location.
Laboratory results:
Clinical blood test (automatic processing):
Date
Hb, units
Er., *1012/l
Leuk., *109/l
MCHC, g/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
09.11.
119
4.06
6.4
29.4
40
1
40
5
64
13.11.
116
3.74
5.9
31.0
34
2
1
31
4
3
59
Urinalysis (automatic processing):
Date
W.w
Reak
Protein
Sach
Cylind
Lei
Er.neiz
Urobil
29.10
1020
5.9
-
-
No
-
-
3.2
Biochemical blood test:
Name
Unit of measure.
Norm
09.11.2009
AST
U/l
11-50
23.5
ALT
U/l
11-50
16.4
CPK
U/l
10-160
64.3
Cholesterol
Mmol/l
3.7-6.0
5.78
Triglycerides
Mmol /l
0 - 2.37
Creatinine
mmol/l
0.05-0.12
0.11
Potassium
mmol/l
3.5-5.1
4.54
Serum iron
mmol/l
10.5-25
9.2
Total protein
g/l
64-83
68.3
Other blood tests: prothrombin 88%, fibrinogen 3.5 g/l,
F-50, HBsAg, HCV, RW: negative
Examination of feces on 11/13/2009: no pathology, I/g were not detected
Endoscopic examination of the gastrointestinal tract was not performed due to the patient's condition.
Treatment was carried out: regimen, diet, noliprel-forte, cordaron, aspicor, zovirax, cytoflavin, rudotel, gliatilin, phezam, mildronate.
Discharged home in a satisfactory condition under the supervision of medical specialists of the clinic. A temporary disability sheet was not issued.
Recommended:
1. Observation by a neurologist, cardiologist
2. Continue taking:
• Tab. Noliprel 1 tab. in the morning. (or noliprel-forte ½ tab. in the morning).
• Tab. Thrombo ASS 0.05 1 tab. in the morning.
• Tab. Preductal MB 1 tab. 2 times a day all the time.
• Caps. Cytoflavin 1 caps. 2 times a day for 1 month.
• Tab. Gliatilin 0.4 1 tab. 3 times a day for 2 months.
• Caps. Phezam 2 caps. morning and afternoon for 2 months.
3. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
4. Limit the intake of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
442 DISTRICT MILITARY CLINICAL HOSPITAL
Discharge summary No.
1950, b. (56 years old), was under examination and treatment in 23 m / o 442 OVKG with a diagnosis of:
ischemic heart disease. Angina pectoris 2 f.cl. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and postinfarction (of unknown age) cardiosclerosis, complicated by a permanent form of atrial fibrillation, normosystolic variant. dilated cardiomyopathy. Aneurysm of the left ventricle. Hypertensive disease of the third stage (AH-2, Risk-4). NK-2b, KhSN-3 f.cl. Anasarka. Cardiac fibrosis of the liver. Varicose veins. Right-sided hypostatic pneumonia.
He was admitted to the clinic by ambulance with complaints of shortness of breath at rest, severe weakness, an enlarged abdomen, and swelling of the lower extremities.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuc., *109/l
CP
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
21.11
136
4.49
6.7
0.92
17
222
28.9
5.6
2
63.5
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
21.11
clear
1020
yellow
5.0
0.025
no
no
no
no
no
1-2
no
3-5
no
_
_
_ rev.
Norm
21.11
Name
Unit. rev.
Norm
21.11
Creatinine
mmol/l
53-124
76
cholesterol
mmol/l
3.7-7
3.92
Urea
mol/l
3-8.4
4
TG
mmol/l
0-2.37
Prothrombindex
%
70-120
72.6
β-LP
u
350-650
Fibrinogen
g/l
200-400
414
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
75
LDL
mmol/l
1.9- 4
Albumin
%
50-70
Cholesterol/HDL
times
3-5
1
%
3-6
VLDL
mmol/l
0.6-1.2
2
%
9-15
coef. atheros.
Unit
0-3
%
8-18
amylase
U/L
28-100
%
15-25
trypsin
units/l
0-0.35
globulins
g/l
17-35
ing. trypsin
u
18-36
a/g
1.1-2.5
Ig M
g/l
0.65-1.65
ALT
U/L
8.4-53.5
57
Ig G
g/l
7.5-15.5
AST
U/ L
7-39.7
33
Ig A
g/l
1.25-2.5
AP
U/L
36-92
163
CEC
u
6-66
LDH
U/L
100-220
Cl
mmol/l
95-108
97.3
GGTP
U/ L
11-63
351
Na
mmol/l
130-150
131.1
Glucose
mmol/l
4.2-6.4
6.13
Ca
mmol/ l
2.0-2.7 Tot
. bilirubin
µmol/l
6.8-26
21.7
K
mmol/l.
4-6
4.28
Ex. bilirubin
mmol/l
0-7
Fe
mmol/l
10.5-25
Sial. to-you
g / l
1.9-2.5
TSH
mmol / l
0.27-4.2
Revm.
negative factor
T3
mmol/l
66-181
Urinary
acid fmol/l
150-420
T4
mmol/l
1.3-3.1
CPK
u/l
10-160
19
RW
quality
CPK-MB
u/l
0-12.5
HBsAg
quality
negative
form 50
AntiHCV
quality
negative
Results of instrumental studies:
ECG from. 11/21/2006: Atrial fibrillation, HR=88 per minute, normosystole, EOS sharply deviated to the left. Blockade of the anterior branch of the left leg of the bundle of His. Cicatricial changes in the anterior septum X-
ray of the chest organs from 04.05.2006. Conclusion: the organs of the chest cavity without deviations from the norm.
DUCHG from 05/06/2006: V ex 40.9 ml, K about 32.7%, T abbreviated 65 min, V with 0.5% / min. Conclusion: violation of the contractile function of the gallbladder by hypomotor type.
Treatment was carried out: a regimen, a diet, a polarizing mixture with ascorbic acid, riboxin IV No. 8, platyfillin 0.2%–1 ml s / c 2-1 times a day, omeprazole 0.02 (1 tab 2 times a day ), Almagel (1 spoon 4 times a day), novocaine 0.5% - 10 ml NaCl 0.9% - 100 ml IV No. 5, Vit B6 IM 1 ml, Vit B12 IM 600 mcg, Creon 10000 IU (1 dr 3 times a day 30 minutes before meals), allochol (2 tablets 3 times a day).
Against the background of the therapy, the patient's condition improved, the abdominal pain syndrome decreased in intensity, frequency of occurrence and duration.
Recommended:
1. Observation of a therapist (gastroenterologist).
2. Omeprazole 0.02 (1 tab 2 times a day, morning and evening) - 1 week, then 1 tab at night - 2 weeks.
3. Almagel A or Maalox (1 spoon 4 times a day an hour after meals and at night) - 3 weeks
4. Pancitrate (creon) - 1 capsule 3 times a day, with meals - 1 week, then 1 capsule 2 times a day (morning and evening) - 2 weeks, then 1 capsule in the afternoon - 1 week.
5. Hymecromon (odeston) 200 mg (1 tab 3 times a day) - 30 minutes before meals - 3 weeks
6. Complete blood count - after 3 weeks
Does not need a sick leave. Discharged in a satisfactory condition.
DISTRICT MILITARY CLINICAL HOSPITAL IM. Z.P. SOLOVIEV
Discharge summary No.
born in 1948 (58 years old), was examined and treated in the 23rd cardiological department of the 442th OVKG with a diagnosis of:
Ischemic heart disease, angina pectoris of the third functional class, atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis. Hypertensive disease of the second stage (arterial hypertension-2 Risk-4). Circulatory insufficiency stage IIa. Chronic heart failure of the third functional class. Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of diffuse neurological symptoms. Osteochondrosis of the thoracic, lumbar spine with a slight dysfunction. Chronic vertebrogenic sciatica with L5-S1 with radicular syndrome in remission. Chronic atrophic gastritis in remission. Angioectasia of the stomach. Prostate adenoma. Partial secondary adentia.
He was admitted to the clinic in a planned manner with complaints of dull pressing pain in the left half of the chest and behind the sternum with irradiation to the left hand when climbing to the 2nd floor or walking on a flat area for 100-150m, dull diffuse headache, dizziness, rise in blood pressure to 170/110 mm Hg, shortness of breath, palpitations, nausea.
Laboratory results:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
24.11
132
4.51
6.0
4
248
-
-
30.2
5.3
3
61.5
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
14.11
clear
1030
yellow
sour
no
no
urate
no
no
no
no
no
1-2
1-2
Biochemical blood test:
Name
Unit. rev.
Norm
24.11
CS
mmol/l
3.7-7
5.97
Total protein
g/l
63-87
69
ALT
U/L
8.4-53.5
14
AST
U/L
7-39.7
21
Cl
mmol/l
95-108
106
Na
mmol/ l
130-150
142
K
mmol/l.
4-6
4.8
GGTP
U/L
7-63
24
Glucose
mmol/l
4.2-6.4
5.3 Vol
. bilirubin
µmol/l
6.8-26
22.9
Fibrinogen
g/l
2.0-4.0
2.47
1.12.2006: APTT (1.12.06) =46 sec, INR (1.12.06)=0.88
Results of instrumental studies:
ECG dated 24.11.2006 .: Sinus rhythm with a frequency of 60 bpm, vertical EOS (α=800), increased potentials of the left ventricle.
ECHO-KG from 11/24/2006: MZHP-11.0mm, ZS-11.0mm, KDRLV-48mm, KSRLZh-33mm, EF-45%, E/A=0.6 Myocardium is symmetrically thickened. The cavities are free, not dilated, the valves are not changed, the leaflets of the mitral and aortic valves, the aorta is sealed. The pericardium is intact. The kinetics is not broken. Diastolic dysfunction of the left ventricle.
Ultrasound of the abdominal organs dated 11/15/2006: the liver is not enlarged, the contours are even, the vascular pattern is not clear, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein 13 mm, hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder is of the correct form, the contours are even, calculi and polyps are not visualized. The pancreas is located indistinctly, diffusely heterogeneous structure, the contours are clear, even, echogenicity is increased; Wirsung's duct is not dilated. Kidneys of normal size, normal location, with smooth contours, homogeneous parenchyma. The spleen is not enlarged. In the projection of the location of the adrenal glands, no pathological formations were found. The bladder is full, with a volume of 250 ml, the contours are even, the walls are not thickened (3-4 mm) The prostate gland V = cm3, the contours are fuzzy, the structure is heterogeneous due to compaction areas. Fibrosis in the right lobe. Smoothed interlobar furrow. The middle lobe protrudes slightly into the lumen of the bladder. The volume of residual urine is 30 ml.
Fibrogastroduodenoscopy No. 1156 dated December 8, 2006: in the study of the esophagus, stomach, duodenum, cardiac sphincter insufficiency, chronic gastritis with diffuse atrophy of the mucous membrane of the antrum of the stomach is determined. In the prepyloric and antral regions, two angioectasias are determined along the lesser curvature. The duodenal bulb and postbulbar section are not visually changed.
X-ray of the chest organs dated November 25, 2006: Conclusion: On the survey radiograph of the chest cavity organs in the lungs without fresh infiltrative changes. The roots are structural, the diaphragm is flattened, no free fluid was found in the pleural cavity. The heart is expanded in diameter to the left, the aorta is sealed.
On spondylograms of the thoracic spine in 2 projections from 26.11.06: increased physiological kyphosis due to a decrease in the height of the vertebral bodies in the anterior section Th5-6-7-8 small cartilaginous hernias on the upper and lower areas of the vertebral bodies. Deforming spondylosis Th4-11. X-ray picture of the consequences of osteochondropathy.
Treatment was carried out: regimen, diet, polarizing mixture, asparkam, atenolol, thrombolytic ACC, enalapril, sydnopharm, metabolic therapy.
On the background of the therapy, the patient's condition improved. Does not require sick leave.
Discharged in a satisfactory condition.
Recommended:
113. Outpatient monitoring by a cardiologist.
114. Exclude animal fats, fried, spicy foods from the diet.
115. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
116. Dispensary observation:
a. clinical blood test (with platelet count), urinalysis - 4-6 times a year;
b. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - at least 2 times a year;
c. Echocardiography - 2 times a year;
117. Continue taking:
a. Concor 5mg - 1 tab. in the morning - constantly
b. Sidnopharm - 1 tab. 3 times a day - constantly
c. Thrombo ACC 0.01 - 1 tab. In the morning
d. Ko-renitek - ¼ tab 2 times a day
MILITARY MEDICAL ACADEMY. HOSPITAL THERAPY CLINIC
Reference No.
(53 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy with a diagnosis of
Chronic gastroduodenitis in remission. Dolichocolon. Myopia of both eyes 1.25 D with visual acuity with a correction of 1.0 in both eyes.
The clinic was admitted in a planned manner with complaints of recurrent cutting pains in the epigastric region and along the colon, bloating, loosening of the stool; subfebrile body temperature during the last month, headaches, periodic nosebleeds that occur against the background of a rise in blood pressure to 150/90 mm. rt. Art.
Results of laboratory researches:
General analysis of blood, urine, feces dated 12/12/2006 was normal. Blood biochemical parameters (AST, urea, creatinine, glucose, creatinine phosphokinase, total protein, total bilirubin, K+, Na+, Cl-, lipase) dated 11/28/2006 were normal. Antibodies to HIV 1.2 from 11/30/2006 were not found. 04/09/2006 HbsAg, anti-HCV antibodies were not detected. 04/08/2006 CRP - 0. RW microreaction-precipitation with cardiolipin antigen from 11/28/2006 - negative. RSK with chlamydial antigen from 29.11.2006 was negative. RNHA with tuberculosis antigen, with dysentery antigens of Shigella (Zone, Flexner, Newcastle), with complex salmonella antigen, with pseudotuberculous antigen, yersiniosis antigen from 11/30/2006 - negative. ECG dated April 27, 2006, sinus rhythm, heart rate 50 beats per minute. Incomplete blockade of the right leg of the bundle of His. Initial manifestations of left ventricular hypertrophy. Rotation of the heart with the right ventricle forward. Ultrasound of the abdominal organs dated November 30, 2006: the liver is not enlarged, the right lobe is 13.5 cm, the left lobe is 7.5 cm, the contours are even, the structure is homogeneous, the vessels are not dilated, the portal and hepatic veins, intrahepatic bile ducts are without features. The gallbladder is not enlarged, the contours are even, the walls are thin, the contents are homogeneous, calculi and polyps are not visualized. Pancreas, spleen without features. The kidneys are not enlarged, mobile. The parenchyma is homogeneous, without signs of pathology. The cavity system is not expanded. No pathological formations were found in the projection of the adrenal glands. The spleen is not enlarged, the structure is homogeneous. X-ray examination of the chest organs from 02.10.2006: no pathological changes. FCC dated December 11, 2006: the device is inserted 20 cm from the anus. Further study was terminated due to the patient's inappropriate behavior and at his urgent request. In the examined area of the intestine, the mucosa is thinned, the vascular pattern is enhanced. In the lumen fluid with an admixture of feces. Ampoule of the rectum without features. RRS dated 12/15/2006: the tube of the proctoscope was inserted up to 15 cm. Due to the patient's inadequate behavior, the study was not completed. No organic pathology was found in the rectum. The mucosa is pink, shiny, a vascular pattern can be traced. The tone of the intestinal wall is normal. FGDS from 8.12.2006: The esophagus is passable, the socket of the cardia does not close completely. In the stomach, a significant amount of mucus, liquid (foamy with an admixture of bile). The folds are rough, edematous, tortuous. The mucosa is hyperemic. The gatekeeper gapes
Treatment was carried out: regimen, diet, omeprazole 0.02 (1 tab 2 times a day), Almagel (1 spoon 4 times a day), Creon 10,000 IU (1 dr 3 times a day 30 minutes before meals), allochol (2 tablets 3 times a day).
On the background of the therapy, the patient's condition improved. Certified by VVK. Recognized on the basis of the articles of column III of the Schedule of Diseases and TDT (annex to the Regulations on the military medical examination, approved by the Decree of the Government of the Russian Federation of 2003 No. 123) "A" - fit for military service.
Recommended:
1. Observation of a therapist (gastroenterologist).
2. Omeprazole 0.02 (1 tab 2 times a day, morning and evening) - 1 week, then 1 tab at night - 2 weeks.
3. Almagel A or Maalox (1 spoon 4 times a day an hour after meals and at night) - 3 weeks
Does not need a sick leave. Discharged in a satisfactory condition.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1937 (69 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy with a diagnosis
of duodenal ulcer in the acute phase. Multiple (ulcer of the duodenal bulb, ulcer of the back of the bulb) ulcers of the duodenum. Cholelithiasis. Asymptomatic stone carrying. Atherosclerotic cardiosclerosis. Solitary cyst of the right kidney.
He was admitted to the clinic with complaints of acute burning pain in the epigastric region, not associated with eating.
Laboratory results:
General clinical blood test:
Date
Hb, units.
Er., *1012/L
Leuk., *109/L
CP
Ht
%
ESR, mm/h
Thrombus
*109/L
E
%
B
% Lf
%
Pl.cl
%
M
%
Pia
%
Xia
%
20.12.
140
4.54
6.9
0.92
13
4
1
29
1
9
1
55
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
20.12
clear
1017
yellow
sour
no
no
no
1
no
no
0-2
no
0-2
no
Urinalysis according to Nechiporenko dated 12/14/06: Leu-0.75×109/l, Er.-0.25×109/l
Analysis feces: no features
Biochemical blood test:
Name
Unit. rev.
Norm
11.12
Name
Unit. rev.
Norm
11.12
Creatinine
mmol / l
53-124
CS
mmol / l
3.7-7
4.18
Urea
mol / l
3-8.4
TG
mmol / l
0-2.37
1.54
Prothrombin
%
70-120
90
LDL
units
350-650
500
Fibrinogen
g/l
2.0-4.0
3.5
Alpha 1
%
4.1
Total protein
g/l
63-87
67.8
Alpha 2
%
12.7
Albumin
%
50-70
56.1
Beta
%
12.8
a/g
1.1-2.5
1.28
gamma
%
14.4
ALT
U/L
8.4-53.5
Cl
mmol/l
95- 108
102.8
AST
U/L
7-39.7
16.1
Na
mmol/l
130-150
158.5
AP
U/L
36-92
56.4
K
mmol/l.
4-6
3.76
LDH
U/L
100-220
TSH
mmol/l
0.27-4.2
GGTP
U/L
7-63
ALP
Ukat/L
0.70-2.30
Glucose
mmol/l
4.2-6.4
4.5
form 50
quality
neg
. bilirubin
µmol/l
6.8-26
10.3
HBsAg
quality
neg
Sial
. k-ty
g/l
1.9-2.5
AntiHCV qual negative
Neg
Results
of
instrumental studies:
ECG dated 12/11/2006: Sinus rhythm with a frequency of 66 beats/min, EOS is not rejected (α=400), signs of hypertrophy of the left ventricle.
ECHO-KG No. 25 dated 12/10/2006: MZHP-10.0mm, ZS-11.3mm, KDRLV-52.4mm, KSRLZh-37.5mm, FV-54.5%, FU-28.4%, UO -72ml, LP-33.3mm, RV-24mm, E/A=0.7 Myocardium is not thickened. The cavities are free, not dilated, the valves are not changed. The pericardium is intact. The kinetics is not broken. The aortic valve annulus is sealed. Diastolic dysfunction of the left ventricle.
Ultrasound of the abdominal organs from 12/13/2006: the liver is not enlarged, the right lobe: 13cm; left 7.5 cm, smooth contours, homogeneous structure, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein and hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder has a regular shape, dimensions 7.1×3.4 cm, smooth contours, walls 2 mm, calculi N4-5 up to 9-11 mm. The pancreas is not located. Kidneys of normal size, normal location, with uneven contours, heterogeneous parenchyma 17 mm thick, cavitary systems are not expanded. There are no concretes. Spava cysts with a diameter of 30 and 32 mm. The spleen is not enlarged, 9.9×6.8×4.4 cm in size. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: Cholelithiasis (cholecystolithiasis). Cysts of the right kidney.
Fibrogastroduodenoscopy dated December 6, 2006: In the duodenal bulb on the posterior surface there is an ulcerative defect 0.7 * 0.7 cm under fibrin, the mucosa around is hyperemic, edematous with many acute erosions 0.1 cm under fibrin. In the postbulbar region there is a shallow ulcerative defect 2.0 * 2.0 cm under fibrin with areas of hemosiderin.
X-ray of the chest organs No. 71 dated 12/11/2006: Conclusion: On the survey radiograph of the chest cavity organs in the lungs without fresh infiltrative changes.
Treatment: regimen, diet, asparkam, omeprazole, amoxicillin, almagel, metronidazole, vikalin, motilium.
On the background of the therapy, the patient's condition improved. Does not require sick leave.
Discharged according to the report in a satisfactory condition.
Recommended:
118. Outpatient observation of a gastroenterologist.
119. Dispensary observation:
a. Frequency of observation by a doctor: - 4 times a year.
b. clinical blood test (with platelet count), urinalysis - 4 times a year;
c. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - 2 times a year;
120. Continue taking:
a. Omeprazole 0.02 (1 tab 2 times a day, morning and evening) - 1 week, then 1 tab at night - 2 weeks
b. 3. Almagel A or Maalox (1 spoon 4 times a day one hour after meals and at night) - 3 weeks
AND ABOUT. Deputy Head of the Department for Clinical Work M. Sarazov
Head of the 1st Department I. Pavlovich
Attending physician N. Gulyaev
December 23, 2006.
ENT /A.F. Sirotinin /
Complaints of periodic discomfort, a feeling of sore throat in the cold season, which have been bothering for 2 years.
Objectively: the maxillary lymph nodes are enlarged, painless on palpation. Pharyngoscopy: the mucous membrane in the area of the lateral ridges and palatine arches is hyperemic and edematous. Palatine tonsils of the 1st degree, loose, clear in the gaps. Swallowing is not difficult. Other ENT organs without features. Hearing acuity in the study of whispered speech - 6 m in both ears.
Diagnosis: Chronic compensated tonsillitis. Lateral pharyngitis.
Recommended:
k. Spray "Tantum Verde" 2 inhalations 3 times a day for 10 days,
l. Rinse with warm decoctions of sage, chamomile - 10 days
m. Suprastin - 10 days
n. Peach oil in the nose 1 drop in both nasal passages 3 times a day
o. Repeated examination in dynamics
OPHTHALMOLOGIST /A.Yan/
Complaints of discomfort when reading and writing
Vis.OD=0.6 with correction cyl. –1.0D = 1.0 (ax 1800→)
Vis.OS=0.6 with cyl correction. –1.0D = 1.0 (ax 1800→)
Intraocular pressure: OD=OS=21 mmHg
The eyelids are not changed, the usual form, the palpebral fissure is not narrowed. The position of the eyeballs is correct, the movements are full. Conjunctiva slightly hyperemic, superficial injection of blood vessels. The corneas are transparent, spherical, without pathological changes. The anterior chambers are of medium depth, moisture is transparent, does not opalize. Pupils are centered, regular round shape, photoreactions are alive, D=S. Deep optical media are transparent. The reflex from the fundus is pink. The discs are pale pink, in the plane of the retina, with clear boundaries, regular round shape. Vessels A:B=1:3, arteries are narrowed, veins are somewhat dilated, tortuous, a symptom of arteriovenous decussation of the first degree. No pathology was detected in the macular zone and on the periphery of the fundus.
Diagnosis: Simple myopic direct type astigmatism in 1.0 D, hypertensive angiopathy of the retina in both eyes.
SPH
CYL
AX
R
+0.50
-1.75
168
L
0.00
-1.25
19
PD=61, VD=12
Complaints of headaches, dizziness, unsteadiness when walking, numbness in the fingers of the upper extremities.
Neurological status: conscious, oriented. The pupils are D=S, the physiological reflexes of the pupils are reduced, the reaction of accommodation with convergence is reduced. There is no nystagmus. The face is symmetrical. Tongue in the midline. Swallowing, phonation are not disturbed. Reflexes of oral automatism are negative. Tendon reflexes D=S, functional areas are expanded. There are no pathological signs. Decreased sensitivity in the upper extremities of the radicular type (C5-C6, C6-C7). Performs coordination tests with a slight intention. He staggers in the Romberg pose. There are no meningeal signs.
Diagnosis: Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of cerebellar insufficiency. Widespread osteochondrosis of the spine.
REG from 18.09.03: the blood flow is slightly reduced in the basin of the carotid and vertebral arteries, symmetrical. The cerebrovascular tone is normal. The hyperventilation test is weakly positive. The elasticity of the vessels is moderately reduced. Venous outflow is difficult in the vertebrobasilar basin.
Makes no complaints.
The face is symmetrical. The mouth opens freely, in full. The mucosa is clean, moist. No foci of odontogenic infection were found. Dental formula:
km o pl o km km km o km o o o pl
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
km o o km pl km o o o km o
Diagnosis: partial secondary adentia.
Needs dentures.
ECHO-KG No. 631 dated 11/13/2006: MZHP-9.9mm, ZS-7.0mm, KDRLV-47mm, KSRLZh-24.1mm, FV-79%, FU-48.5%, UO-80.93ml , LP-33.3mm, RV-25.5mm, E/A=1.0 Myocardium is not thickened. The cavities are free, not dilated, the valves are not changed, on the mitral valve regurgitation I stage. The pericardium is intact. The kinetics is not broken. Diastolic dysfunction of the left ventricle.
MILITARY MEDICAL ACADEMY
Hospital Therapy Clinic
Discharge summary No.
born in 1964 (43 years old), was examined and treated at the hospital therapy clinic with a diagnosis of:
ischemic heart disease. Angina pectoris II f.k. Atherosclerosis of the aorta, coronary arteries. Atherosclerotic cardiosclerosis. Hypertension stage II. (AH grade 2, risk 4). NC I Art. Dyscirculatory encephalopathy of the second stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders. Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (27.02.02) due to a closed fracture of the surgical neck of the shoulder (15.02.02) and its repeated fracture (18.07.02) with moderate dysfunction of the left upper limb. A consolidating fracture of the neck of the right femur with a construction (09/25/2006) with a slight dysfunction of the right lower limb.
He was admitted to the clinic in a planned manner with complaints of compressive pain in the chest, shortness of breath during exercise, aching headaches with increased blood pressure, dizziness, general weakness, impaired concentration, memory loss, pain in the right shoulder and right thigh.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
CP
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
21.03
141
4.5
11.0
0.94
24
1
27
3
6
63 Rehberg's
test
Date
Blood
creatinine Urine creatinine
Diuresis in 1 min
Glomerular filtration
Tubular reabsorption
22.03
0.08
18.65
0.83
193.5
99.6
Biochemical blood test:
Name
Unit. rev.
Norm
22.03
Name
Unit. rev.
Norm
11.12
Creatinine
mmol/l
53-124
CS
mmol/l
3.7-7
2.87
Urea
mol/l
3-8.4
6.4
TG
mol/l
0-2.37
0.44
Prothrombindex
%
70-120
β-LP
U
350-650
450
Fibrinogen
g/l
200-400
HDL
mol/l
0.78-2.33
Total protein
g/l
63-87
65
LDL
Mole/l
1.9-4
Albumin
%
50-70 Cholesterol
/HDL
Times
3-5
1
%
3-6
VLDL
Mole/l
0.6-1.2
2
%
9-15
coef. atheros.
Unit
0-3
%
8-18
amylase
U/L
28-100
%
15-25
trypsin
u/l
0-0.35
a/g
1.1-2.5
Ig M
g/l
0.65-1.65
ALT
U/L
8.4-53.5
14.6
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
11.02
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
CEC
U
6-66
LDH
U/L
100-220
Cl
Mole /l
95-108
GGTP
U/L
11-63
11.8
Na
Mole/l
130-150
Glucose
mmol/l
4.2-6.4
4.5
Ca
Mole/L
2.0-2.7
1.85
Total bilirubin
µmol/l
6.8-26
5.6
K
mmol/l.
4-6
ALK pos
U/L
36-92
102.3
T3
Mol/l
66-181
Urinary
acid fmol/l
150-420
T4
Mol/l
1.3-3.1
CPK
u/l
10-160
RW
qual
Results of instrumental studies:
ECG from. 03/21/2007, Sinus rhythm with a heart rate of 58 beats, horizontal EOS. Left ventricular hypertrophy. Syndrome of early repolarization. Local violations of intraventricular conduction, violations of repolarization in the region of the lower wall.
Ultrasound examination from 30.03.2007. The liver is not enlarged, the right lobe is 13.8 cm, the left lobe is 6.4 cm. The contours are even, the structure is homogeneous, the echogenicity is medium, the vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape (curved, partially reduced). The pancreas is located indistinctly, it is not enlarged, the contours are fuzzy, even, the structure is homogeneous echogenicity is average, the Wirsung duct is not dilated. Kidneys: location and size are normal. Right - the contours are even, the parenchyma is homogeneous 16 mm, the cavity system is not expanded, there are no stones: the left one - the contours are not even, the parenchyma is homogeneous 18 mm, the cavity system is not expanded, there are no stones. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 8.8x3.6 cm, the structure is homogeneous. Flatulence.
EchoCG from 03/29/2007. Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed, calcifications in the AC. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no pericardial effusion.
The results of VEM and ECG Holter monitoring are on hand
X-ray of the chest organs dated 30.03.2007. In the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is slightly dilated to the left. The aorta is elongated.
X-ray of the skull from 30.03.2007. On survey craniograms in two projections, the Turkish saddle is normal. There is thinning of the bones of the cranial vault.
Radiography of the right hip joint dated April 2, 2007: on the radiograph of the right hip joint in two projections. Condition after metal osteosynthesis in the area of comminuted fracture of the upper third of the femur. The callus is expressed satisfactorily. The bolt of a metal structure protrudes into the soft tissue by 2.5 cm.
Specialist consultations
Optometrist: VIS OD 1.0; OS 1.0 IOP OD,OS - 18mm Hg
The auxiliary apparatus and the outer parts of the eyeballs are not changed, the optical media are transparent. The fundus of the eye: optic nerve disc of satisfactory nutrition, the contours are clear. The veins are moderately dilated, the arteries are sealed. Focal pathology is not defined.
Neurologist: Dyscirculatory encephalopathy of the 2nd stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders.
ENT: Endoscopic ENT organs without visible pathology. SR 6 m.
Traumatologist: Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (02/27/02) due to a closed fracture of the surgical neck of the shoulder (02/15/02) and its repeated fracture (07/18/02) with moderate dysfunction of the left upper limb . A consolidating fracture of the neck of the right femur with a construction (25.09.2006) with a slight dysfunction of the right lower limb.
Treatment was carried out: regimen, diet, olicard, ACC thrombosis, metoprolol, phenazepam.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
1. Observation of a therapist, neuropathologist, traumatologist of the TsKDP VMA.
2. Optimization of the regime of work, rest, nutrition.
2. Continue taking
• Olikard 0.04 1 caps. 1 r / d after breakfast
• Thrombo ACC 0.1 1 tab. 1 r / d after breakfast
• Metoprolol 0.05 ½ tablet 2 r / d (after breakfast and dinner)
• Asparkam 1 tablet 3 r / d the first 10 days of each month.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Reference No.
1918 (88 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy with a diagnosis of:
ischemic heart disease. Angina pectoris 3 f.cl. Atherosclerosis of the aorta, coronary and cerebral arteries, atherosclerotic and postinfarction (1996) cardiosclerosis. Hypertensive disease of the third stage (AH-3, Risk-4). NK-2a, KhSN-3 f.cl. Diabetes mellitus of the second type, mild. Dyscirculatory encephalopathy 2 tbsp. mixed (atherosclerotic, hypertensive) genesis. Chronic pyelonephritis in remission. HPN-0. Cataract in both eyes. Mild iron deficiency anemia.
The hospital was hospitalized in a planned manner with complaints of pain in the heart, shortness of breath with little physical exertion, weakness, swelling of the lower extremities, headache with an increase in blood pressure to 200/100 mm. Hg
Objectively: consciousness is clear, position is active, physique is normosthenic, satisfactory nutrition (BMI=23.8 kg/m2). The skin and visible mucous membranes are clean, of normal color. Skin turgor is somewhat reduced. Peripheral lymph nodes are not enlarged. The thyroid gland is not changed. There are no edema and pastosity. The pulse is rhythmic, the same on both hands, the frequency is 68 beats per minute, satisfactory filling, normal tension. Borders of the heart: right - along the right edge of the sternum, upper - III rib on the left, left - 1 cm outward from the left mid-clavicular line. Heart sounds are muffled, there are no noises, accent 2 tones over the aorta. Blood pressure - 140/80 mm Hg. Above the lungs percussion clear pulmonary sound. Breathing is vesicular, no wheezing. Respiration rate 16 per minute. The abdomen is soft and painless. The liver is not enlarged according to Kurlov 9×8×7 cm, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Neurological status: asthenic, not inhibited, pupils on the right and left are the same, photoreactions are alive, convergence and accommodation are somewhat weakened, the face is symmetrical. Tendon reflexes are evenly animated, flexor signs, abdominal reflexes are low and exhausted. There are no sensitive, coordinating disorders. Whispered speech six meters in both ears. There are no sensitive, coordinating disorders. Whispered speech six meters in both ears. There are no sensitive, coordinating disorders. Whispered speech six meters in both ears.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Retic.
‰
Leuc., *109/l
CP
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
10.05
96
3.2
7.6
0.90
21
-
5
2
22
10
61
16.05
80
3.0
6.8
0.8
22
-
1
1
17
8
3
70
17.05
85
3.05
13
6.8
0.83
23
161
1
1
31
7
2
58
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epithelium Profit center in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
10.05
clear
1016
yellow
sour
no
no
no
1
no
no
1-2
no
0-2
no
16.05
clear
1010
acidic
no
no
no
no
no
no
0-2
no
0-2
no
Biochemical blood test:
Name
Unit
. rev.
Norm
10.05
Name
Unit. rev.
Norm
10.05
Creatinine
mmol/l
53-124
CS
mmol/l
3.7-7
4.18
Urea
mol/l
3-8.4
8.1
TG
mmol/l
0-2.37
1.07
Prothrombindex
%
70-120
85
β-LP
u
350-650
Fibrinogen
g/l
200-400
3.72
HDL
mmol/l
0.78-2.33
Total protein
g/l
63 -87
69.1
LDL
mmol/l
1.9-4
Albumin
%
50-70
CS/HDL
times
3-5
ALT
U/L
8.4-53.5
11.2
Ig G
g/l
7.5-15.5
AST
U /L
7-39.7
9.73
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
66.4
CEC
u
6-66
LDH
U/L
100-220
Cl
mmol/l
95-108
GGTP
U/L
11-63
26.1
Na
mmol/l
130-150
140.7
Glucose
mmol/l
4 .2-6.4
6.6
Ca
mmol/l
2.0-2.7 Tot
. bilirubin
µmol/l
6.8-26
8.2
K
mmol/l.
4-6
5.01
Ex. bilirubin
mmol/l
0-7
Fe
mmol/l
10.5-25
4.06
Glucose (mmol / l, 16.05 / 18.05.07): 8.00 - 7.2 / 5.9; 11.00 - 9.6 / 8.5; 13.00 - 5.2 / 6.3
Results of instrumental studies:
ECG from. 8.05.07: sinus rhythm, HR=70 in 1 min. EOS is deflected to the left. Cicatricial changes in the anterior septal region. Left ventricular hypertrophy. Violation of repolarization of the apex-lateral region.
X-ray of the chest organs from 16.05.2007. Conclusion: the organs of the chest cavity are within the limits of age-related changes.
Ultrasound of the abdominal organs dated May 14, 2007: signs of nephrosclerosis.
ECHO-KG dated 9.05.07: Aorta - 32 mm, AK dilatation - 22 mm, RA - 46 mm, RV EDD - 24 mm, LA - 41 mm, LV ED - 36 mm, LV EDD - 47 mm, FU -25 %, EF 50%, IVS=ZS=14.5 mm, DLA – 24 mm Hg. Dilatation of the left chambers of the heart. The cavities are free. Pronounced symmetric hypertrophy of the myocardium of the left ventricle. A-dys-kinesia of the apical segments of the interventricular septum, lateral and anterior wall. Systolic dysfunction of the left ventricle. Consolidation and thickening of the aorta, aortic crescents, mitral valves. Calcification of the aortic and mitral rings. The pericardium is not changed. Mitral, tricuspid and pulmonary regurgitation.
The patient refused to undergo FEGDS and FCS.
Treatment: regimen, diet, efox-long, hypothiazide, enalapril, thrombo-ASS, asparkam, piracetam.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition. Does not require sick leave.
Recommended:
121. Outpatient monitoring by a cardiologist in a polyclinic.
122. Sanatorium treatment in the sanatoriums of the Leningrad region.
123. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
124. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
125. Dispensary observation:
a. clinical blood test (with counting of platelets and reticulocytes), urinalysis - every three months in the first year, then 1 time per year;
b. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - at least 2 times a year;
c. Echocardiography - 1 time per year;
126. Continue taking:
a. Efoks-long 50 mg - 1 tab in the morning.
b. Ko-renitek - ½ tab 2 times a day
c. Concor-Cor 2.5 mg - 1 tab. in the morning - constantly
d. Thrombo ACC 0.01 - 1 tab. in the morning
e. Phezam 0.8 - 1 tab in the morning and 1 tab. in the afternoon
MILITARY MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1963 (43 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis:
Main disease: Chronic bronchitis in the acute phase. Deviation of the nasal septum. Chronic right-sided sinusitis in the acute phase.
Concomitant diseases: hypertension of the second stage (AH 2st, Risk 3)
Complications: DN-0, NK-0
Hospitalized for urgent indications with complaints of chest pain when coughing, cough with a small amount of yellow discharge, dull headache , general weakness.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
CP
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pi
%
Xia
%
29.05
163
5.1
10.8
0.95
35
3
34
8
15
40
05.06
162
5.08
7.1
0.95
12
1
2
37
7
3
50
_
_
_
_
_
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MVP epithelium in pz
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
29.05
mud
1025
yellow
sour
0.09
no
no
2
no
no
1-2
0-1
0-6
20-30
05.06
clear
1014
yellow
sour
no
no
no
no
no
no
0-1
no
1-2
0-2
Nechiporenko test dated 06.06.07: leukocytes - 0.5 * 106 / l, erythrocytes - 0.25 * 106 / l
Biochemical blood test:
Name
Unit. rev.
Norm
29.05
Name
Unit. rev.
Norm
29.05
Creatinine
mmol/l
53-124
CS
mmol/l
3.7-7
5.63
Urea
mol/l
3-8.4
5.0
TG
mmol/l
0-2.37
Prothromb.index
%
70-120
106
β-LP
u
350-650
Fibrinogen
g/l
200-400
137
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
77.2
LDL
mmol/l
1.9-4
ALT
U/L
8.4-53.5
13.2
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
17.25
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
92.9
CEC
u
6-66
LDH
U/L
100-220
Cl
mmol/l
95- 108
GGTP
U/L
11-63
Na
mmol/l
130-150
Glucose
mmol/l
4.2-6.4
4.6
Ca
mmol/l
2.0-2.7
2.28
Total. bilirubin
µmol/l
6.8-26
7.7
K
mmol/l.
4-6
On the survey radiograph of the chest organs dated May 29, 2007. in direct and right lateral projections without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is slightly dilated to the left, the aorta is thickened.
On the radiograph of the paranasal sinuses dated May 29, 2007. total shading of the right maxillary sinus is noted.
ECHO-KG No. 394 dated 30.05.07. .: Aorta - 34 mm, AK opening - 19 mm, PP - 38 mm, RV EDD - 24.8 mm, LP - 33 mm, LV ECR - 25.6 mm, LV EDR - 48.8 mm, FU - 47, 5%, EF - 78.8%, IVS=12mm, AP=14mm, LA - 12 mm Hg. symmetrical hypertrophy of the left ventricular myocardium. The cavity is not expanded. The aorta, the rings of the aortic and mitral valves are sealed, the valves are intact, the blood flow on the valves is laminar, valvular regurgitation on the mitral and tricuspid valves. Diastolic dysfunction of the left ventricle. The pericardium is intact, there is no effusion.
ECG No. 1523 dated June 5, 2007: sinus rhythm with a frequency of 64 beats per minute, EOS is not rejected, hypertrophy of the left atrium and ventricle, impaired repolarization of the inferolateral region of the left ventricle.
Treatment: regimen, diet, ceazolin, amoxicillin, hypothiazide, enalapril, secretolytics, restorative therapy
Against the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
Disability certificate issued No. _________
Recommended:
127. Outpatient supervision of a polyclinic therapist.
128. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
129. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
130. X-ray examination of the paranasal sinuses after 1 month.
131. Continue taking:
a. Noliprel-forte - 1 tab in the morning constantly
b. Thrombo ACC 0.01 - 1 tab. in the morning constantly
MILITARY MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Discharge summary №
1960 b. (48 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy of the Year with a diagnosis of
systemic lupus erythematosus, a chronic progressive course with skin lesions ("butterfly", Raynaud's syndrome, ecchymosis), joints (arthralgia, osteoporosis of small joints of the hands), myocardium (myocardial dystrophy), lymphadenopathy, mild secondary hypochromic anemia, leukopenia; secondary Itsenko-Cushing's syndrome, active phase with a moderate (II) degree of activity, FNS-I, DN-0. Symptomatic arterial hypertension (AH-2 Risk-3).
Ischemic heart disease, angina pectoris of the first functional class, atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis with arrhythmias of the type of paroxysmal form of atrial fibrillation. Mitral valve insufficiency of the first degree. Circulatory failure of the first stage. Chronic heart failure of the second functional class.
Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of cerebellar insufficiency.
Osteochondrosis of the cervical, thoracic and lumbar spine with a slight dysfunction of the spine.
Chronic erosive gastritis in the acute phase. Sliding hernia of the esophageal part of the diaphragm of mixed type (axial and paraesophageal), secondary reflux esophagitis of the 2nd degree. Gastroptosis stage I Polyp of the gallbladder. Partial secondary adentia. Lateral pharyngitis. Chronic compensated tonsillitis.
Simple myopic astigmatism of the direct type in 1.0 D, hypertensive angiopathy of the retina in both eyes.
Subserous uterine myoma of small size, cicatricial deformity of the cervix, bilateral fibrocystic mastopathy.
She was admitted to the clinic for urgent indications with complaints of dull diffuse headache, dizziness, rise in blood pressure to 170/100 mm Hg, chest discomfort with irradiation to the left arm with little physical exertion, shortness of breath, palpitations; heartburn, belching sour, nausea, vomiting; soreness in the shoulder, knee, ankle, small joints of the hands and feet, itching of the skin of the face, hands, forearms, hyperemia of the back and wings of the nose, swelling of the face in the morning; weight gain, general weakness; internal discomfort and feeling of lack of air mainly at night; dull aching pain in the lumbar region.
Anamnesis morbi: She fell ill acutely in November 2005, when, against the background of relative well-being, severe morning stiffness, soreness, redness and swelling appeared in the area of small joints of both hands, shoulder, elbow and knee joints, fever up to 400C, sweating, severe general weakness, rapid fatigue. On November 14, she was examined by a general practitioner, and a course of anti-inflammatory therapy (diclofenac retard, prednisone 30 mg/day) was prescribed, which resulted in a significant improvement in her state of health. Due to the deterioration of her condition in January 2006, she was hospitalized at military unit 25515 with a diagnosis of rheumatoid arthritis, seropositive, articular form. She received cytostatic therapy with methotrexate, mini-pulse therapy with methylprednisolone, movalis, physiotherapy with a positive effect. Subsequently, against the background of outpatient cytostatic therapy (methotrexate 7.5 mg/week, prednisolone 10 mg/day), she felt satisfactory for the next three months. In May 2006, against the background of constant use of methotrexate, prednisolone and washing, pain, heaviness in the epigastric region and nausea after taking medications, in the left and right hypochondria, appeared, and therefore she independently refused to take medications. Against the background of refusal of treatment, the pain in the joints intensified, pains in the right elbow joint joined, subfibrile fever appeared. She resumed taking medications again without a positive effect. 26.06.06 for urgent indications, she was hospitalized in the rheumatology department of the NLMK Medical Unit, where she was diagnosed with systemic lupus erythematosus for the first time. Received treatment: methotrexate 10 mg/week, prednisolone 20 mg/day, movalis, chimes, pentoxifylline, physiotherapy with a positive effect. However, against the background of constant intake of these drugs, at the end of October 2006, pain in the joints increased again, there was hyperemia of the back of the nose and cheeks, itching of the skin of the face, hands, swelling on the face and hands, periodic pain behind the sternum and in the left half of the chest, palpitations, shortness of breath with little physical exertion, general weakness, pain in the mouth, nagging pain in the lumbar region after physical exertion and a decrease in the dose of prednisolone taken. Stationary held a course of plasmapheresis and plasmasorption, pulse therapy with methylprednisolone. After this course of therapy in the next 6 months, while taking 10 mg of prednisolone and 7.5 mg of methotrexate, she felt well. Exacerbations of the disease were noted in October-November 2007 and February-March 2007 and 2008, however, an increase in the dose of prednisolone to 80 mg/day for 3 weeks, followed by a gradual decrease in the dose to 15-40 mg/day, made it possible to stop exacerbations. Annually, she underwent planned inpatient treatment for the underlying disease, where the dose of medications taken was adjusted.
The last exacerbation of the disease was noted in September 2008. In the day hospital regimen, treatment was carried out: regimen, diet, intravenously: pulse therapy "Solu-medrol" 1000 mg (18.09.08 and 19.09.2008), asparkam, cardionate, cytoflavin and riboxin No. 5, neoton 4g No. 2, vitamins: C, B1, trental No. 3, cerebrolysin No. 1, piracetam No. 3, prednisolone 40 mg in the morning, methotrexate 10 mg / week. After the therapy, there was a short-term improvement in well-being, however, from mid-October, the condition progressively worsened in the form of discomfort behind the sternum with irradiation to the left arm and shortness of breath with little physical exertion (rise to the 1st floor), palpitations, heartburn, sour belching, nausea, pain in the chest. shoulder, knee, ankle, small joints of the hands, feet, swelling of the face in the morning, general weakness, internal discomfort and itching of the skin of the face, forearms, hands, as well as a feeling of lack of air mainly at night, hyperemia of the back and wings of the nose. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. brushes, as well as a feeling of lack of air mainly at night, hyperemia of the back and wings of the nose. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. brushes, as well as a feeling of lack of air mainly at night, hyperemia of the back and wings of the nose. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. as well as a feeling of lack of air mainly at night, hyperemia of the back and wings of the nose. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. as well as a feeling of lack of air mainly at night, hyperemia of the back and wings of the nose. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. An increase in the dose of methotrexate taken up to 15 mg/week and prednisolone up to 40 mg/day did not lead to the desired result. The existing complaints, despite taking omeprazole and almagel for the purpose of gastroprotection, were accompanied by pain in the epigastric region, heartburn, sour belching, nausea, episodic vomiting after taking medications, progressively increasing general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. pain in the epigastric region, heartburn, sour eructation, nausea, episodic vomiting after taking drugs, progressively increased general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner. pain in the epigastric region, heartburn, sour eructation, nausea, episodic vomiting after taking drugs, progressively increased general weakness, numbness in the fingers and toes. On an outpatient basis in the clinic in the general blood test, signs of a mild degree of normochromic anemia were revealed, laboratory data for the activity of the process (increased ESR, CRP) were not noted, and therefore hospitalization in the rheumatology department was recommended in a planned manner.
Over the past two years, he has noted an increase in blood pressure up to 170/110 mmHg, accompanied by dizziness, nausea, and palpitations. He takes antihypertensive drugs regularly (noliprel 2 mg in the morning). For the first time, systolic murmur over the apex of the heart appeared in 2006, with time its intensity increased. Episodic pain in the epigastric region notes for ten years, was treated independently with a temporary positive effect. During the last two years, she notes unsteadiness when walking, numbness in the fingers of the upper limbs, she was not treated, she did not seek medical help.
Around 5:00 p.m. on November 17, 2008. I woke up with an unbearable headache and nausea. There was a single vomiting of food eaten the day before. Given the increase in blood pressure to 170/100 mm Hg. self-administered captopril 50 mg po, nifedipine 10 mg po without effect. Given the appearance of flies before the eyes, severe heaviness in the head, nausea, weakness caused an ambulance. She was taken to the VMA Hospital Therapy Clinic for further diagnosis and treatment.
The results of laboratory studies in dynamics:
General clinical analysis of blood:
Date
Hb, units.
Er., *1012/l
MCV
fl
Rt
‰ Leuc
., *109/l
Ht
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
22.09
92
3.83
78
6.2
29.8
5
306
1
46
4
3
46
5.11
100
3.1
CP=0.96
9
5.5
6
3
21
10
5
61
18.11
105
4.68
74
15.7
4.3
34.6
10
303
2
-
37
9
1
51
Anisopoikilocytosis-1, anisochromia (hypochromia)-2
03.12
93
4.17
75
25
8.2
31.3
6262
1
38
2
1
58
Anisopoikilocytosis
-
2, anisochromia (hypochromia
)
-2 rev.
Norm
22.09
18.11
3.08
Name
Unit. rev.
Norm
22.09
18.11
3.08
Creatinine
mmol/l
53-124
72.1
80.0
90
cholesterol
mmol/l
3.7-7
5.24
Urea
mol/l
3-8.4
7.2
7.4
6.6
TG
mmol/l
0-2.37
0.58
PTI
%
70-120
103
93
Ig M
g/l
0.65-1.65
7, 0
Fibrinogen
g/l
2.0-4.0
2.07
3.7
Ig G
g/l
7.5-15.5
8.5
Total protein
g/l
63-87
60.0
65.8
56.9
Ig A
g/l
1.25-2.5
0.8
Albumin
g/l
30.55
41.0
35.9
CEC
u
6-66
14
28
globulins
g/l
17-35
25.0
Cl
mmol/l
95-108
120.8
ALT
U/L
8.4-53.5
21.9
17.6
14.7
Na
mmol/l
130-150
139.9
56.9
AST
U/L
7-39.7
12.5
17.2
12.6
K
mmol/l.
4-6
4.39
4.5
ALP
U/L
36-92
56.6
42.4
37.0
Sa
mmol/l
2.1-2.55
2.09
2.04
GGTP
U/L
7-63
7 .3
5.2
Fe (serum)
mmol/l
10.5-25.0
3.53
3.12
Glucose
mmol/l
4.2-6.4
4.5
4.9
4.41
CPK-MB
U/l
0.0 -12.5
2.45
Rev. bilirubin
µmol/l
6.8-26
4.6
CPK
U/l
36-92
17.8
Sial. to-you
g / l
1.9-2.5
1.9
Rheumofactor
IU / ml
<30
Neg.
O-streptolysin
IU/ml
<200
<200
C-react. protein
mg/l
<6
<6
Safety factors [HBsAg, Anti-HCV (Core-n NS3-p NS4-n; Core-n NS4-p NS5-n), AT-HIV 1 and 2; Microreaction with cardiolipin antigen (RW)] from 11/19/2008. - negative.
Complete
urinalysis
date
_
PH
Protein
sugar
Ley in p / z
Er. in p/z
Epit.
Salts
Mucus
05.11.08
1018
turbid
sour
ref
2-3-4
no
flat a lot
of
oxalates
-
11.18.08
1025
clear
5.5
no
no
-
no
no
no
-
Reberg's test from 20.11.08. - a variant of the norm
Zimnitsky's test dated 11.21.08. – specific weight: 1005-1023; day diuresis - 1220 ml, night - 300 ml.
Nechiporenko test from 24.11.08. – leukocytes 0.5×106/l, erythrocytes were not detected
Antinuclear antibodies 03.06.08:
(serum dilution 1:100 screening)
• Antinuclear antibodies /+/ positive
• Fluorescence intensity: 2+ (moderate)
• Luminescence type: homogeneous nuclear fluorescence, chromosomal regions of dividing cells are stained at all stages of mitosis
• Probable types of autoantibodies: antibodies to DNA, DNP (deoxyribonucleoprotein), antibodies to histones, antibodies to other chromatin components.
• Recommended additional tests: determination of antibody titer, determination of antibodies to DNA, specific tests for rheumatoid factors, confirmatory and differentiating test with purified nuclear antigens by immunoblotting (ANA-profile)
• Antibodies to cytoplasmic components: /-/ negative
Dynamic immunological analysis of blood 2006 – 2008:
Indicator
norm
Result
11/15/2006
Result No. 10009 11/14/2008
before PF+PS
Result 12/3/2008
after PF+PS
Antinuclear factor on the HEp-2 cell line
<1:40
1:160 homogeneous type of luminescence
1:320 fine granular type of glow of the nucleus
<1:40
Antibodies to double-stranded DNA by ELISA
<25 U/ml - no antibodies to dsDNA detected
25-50 U/ml - low concentration
>50 U/ml - high concentration
79.73 U/ml
17.71 U/ml
1.9 U/ml
Antibodies to cardiolipin class IgG
<10 GPL-U/ml - no antibodies
10-30 GPL-U/ml - borderline concentration
>30 GPL-U/ml - high concentration
1.387 GPL-U/ml
-
8.11 U/ml
IgM anti-cardiolipin antibodies
<10 MPL-U/ml - no antibodies
10-20 MPL-U/ml - borderline concentration
>20 MPL-U/ml - high concentration
1.789 MPL-U/ml
-
2.2 MPL-U/ml
Antibodies to total extractable nuclear antigen (ENA screening)
Antibodies to the common extractable nuclear antigen were not detected Antibodies to the common extractable nuclear antigen were
detected -
Antibodies to the common extractable nuclear antigen were
detected
Antibodies to β2 glycoprotein of the IgG class by ELISA
Less than 12 U/ml - no antibodies were detected
5.79 U/ml
-
-
Antibodies to β2 glycoprotein of IgM class by ELISA method
Less than 12 U/ml - no antibodies detected
7.656 U/ml
-
-
Determination of the spectrum of antinuclear antibodies using immunoblot
Antibodies Sm, RNP/Sm, SS-A (60 kDa), SS-A (52 kDa) , SS-B, Scl-70, PM-Scl, PCNA, CENT-B, dsDNA/Histone/Nucleosome, Rib-P, AMA-M2, Jo-1 not detected
Detected antibodies to SS-A 60 kDa
-
-
Detection of cryoglobulins with RF activity
Cryocrit 0%
RF 37 deg - <1:20
RF 4 deg - <1:20
Cryocrit 0%
RF 37 deg - <1:20
RF 4 deg - < 1:20
-
-
Technical commentary on the study 11/15/2006:
Antibodies to the common extractable nuclear antigen of antibodies to the 60 kDa SS-A antigen have been found Antibodies to the 60 kDa Ro/SS-A antigen are relatively more frequently detected in patients with SLE than in those with Sjogren's syndrome and skin forms. Antibodies to the 60 kDa Ro/SS-A antigen are relatively more frequently detected in patients with SLE than in Sjogren's syndrome and cutaneous lesions, secondary dry syndrome, photosensitivity, and articular syndrome. A dangerous manifestation of SLE associated with antibodies against Ro / SS-A 60 kDa is the syndrome of congenital lupus, which develops in newborns from parturient women with SLE. This disease is based on the penetration of antibodies to Ro/SS-A into the blood of the newborn through the placenta. The main manifestation of congenital lupus is dermatosis and lesions of internal organs, including congenital transverse AV blockade, hepatitis, hemolytic anemia and thrombocytopenia. Antibodies to dsDNA are the main serological marker of SLE with kidney damage, since they are involved in the pathogenesis of lupus nephritis, in addition, they are included in the 10th criterion of SLE. Low titers of anti-DNA antibodies without concomitant ANF and antibodies to an extractable nuclear antigen can be observed against the background of viral and infectious diseases and, if isolated, are not a sign of SLE. There is a correlation between the increase in titers of antinuclear factor (ANF), antibodies to dsDNA and hypocomplementemia before the development of an exacerbation of SLE, which requires periodic determination of titers of antibodies to dsDNA and the level of complement factors C3 and C4 in all patients with SLE with a frequency of once every 3-6 months. Antibodies to dsDNA are the main serological marker of SLE with kidney damage, since they are involved in the pathogenesis of lupus nephritis, in addition, they are included in the 10th criterion of SLE. Low titers of anti-DNA antibodies without concomitant ANF and antibodies to an extractable nuclear antigen can be observed against the background of viral and infectious diseases and, if isolated, are not a sign of SLE. There is a correlation between the increase in titers of antinuclear factor (ANF), antibodies to dsDNA and hypocomplementemia before the development of an exacerbation of SLE, which requires periodic determination of titers of antibodies to dsDNA and the level of complement factors C3 and C4 in all patients with SLE with a frequency of once every 3-6 months. Antibodies to dsDNA are the main serological marker of SLE with kidney damage, since they are involved in the pathogenesis of lupus nephritis, in addition, they are included in the 10th criterion of SLE. Low titers of anti-DNA antibodies without concomitant ANF and antibodies to an extractable nuclear antigen can be observed against the background of viral and infectious diseases and, if isolated, are not a sign of SLE. There is a correlation between the increase in titers of antinuclear factor (ANF), antibodies to dsDNA and hypocomplementemia before the development of an exacerbation of SLE, which requires periodic determination of titers of antibodies to dsDNA and the level of complement factors C3 and C4 in all patients with SLE with a frequency of once every 3-6 months. Low titers of anti-DNA antibodies without concomitant ANF and antibodies to an extractable nuclear antigen can be observed against the background of viral and infectious diseases and, if isolated, are not a sign of SLE. There is a correlation between the increase in titers of antinuclear factor (ANF), antibodies to dsDNA and hypocomplementemia before the development of an exacerbation of SLE, which requires periodic determination of titers of antibodies to dsDNA and the level of complement factors C3 and C4 in all patients with SLE with a frequency of once every 3-6 months. Low titers of anti-DNA antibodies without concomitant ANF and antibodies to an extractable nuclear antigen can be observed against the background of viral and infectious diseases and, if isolated, are not a sign of SLE. There is a correlation between the increase in titers of antinuclear factor (ANF), antibodies to dsDNA and hypocomplementemia before the development of an exacerbation of SLE, which requires periodic determination of titers of antibodies to dsDNA and the level of complement factors C3 and C4 in all patients with SLE with a frequency of once every 3-6 months.
The results of instrumental studies in dynamics:
ECG from 11/17/2008: Sinus rhythm with a frequency of 66 bpm, normal EOS (α=400), local violation of intraventricular conduction in the posterior diaphragmatic region of the left ventricle. No dynamics from 2006 ECG.
ECHO-KG dated 11/22/2008: MZHP-8.0mm, ZS-8.0mm, KDRLZh-47.5mm, KSRLZh-27mm, FV-74%, FU-43%, UO-78ml, LP-33×34 ×46mm, RV-25.5mm, E/A=1.05 Myocardium is not thickened. The kinetics is not broken. The cavities are free, not dilated, the mitral leaflets and chords of the mitral valve are thickened, with an uneven surface, there are no vegetations, the rest of the valves are not changed, on the mitral valve regurgitation I-II st. Diastolic dysfunction of the left ventricle. The aorta is sealed. The pericardium is intact.
ECHO-KG from 04.12.2008: Aorta 28mm, aortic valve opening 20mm, MZHP-8.0mm, ZS-8.0mm, KDRLV-50mm, KSRLZh-33mm, FV-63%, FU-34%, UO-75ml , LP-37×30×45mm, RV-25mm, E/A=1.10 Myocardium is not thickened. The kinetics is not broken. The cavities are free, not dilated, the mitral leaflets and chords of the mitral valve are thickened, with an uneven surface, there are no vegetations, the other valves are not changed, on the mitral valve regurgitation I-II st. Diastolic dysfunction of the left ventricle. The aorta is sealed. The pericardium is intact. No significant dynamics.
Monitor observation of ECG and blood pressure according to Holter ID: IBK01 dated 11/20/2008: Duration of observation 21 hours 49 minutes. Leads A, I, D were recorded. The average heart rate during the day was 83 bpm (min.-57, max.-151), the average during night sleep was 96 bpm (min.-51, max.-186). In general, the dynamics of heart rate without features, the decrease at night is within the normal range. Against the background of sinus rhythm, which continued throughout the entire observation period, the following types of arrhythmias were registered: I. solitary supraventricular extrasystole with a pre-ectopic interval from 421 to 882 (average-570) msec; in total – 2, II. Paroxysm of atrial fibrillation-flutter (AF) with a heart rate of 121 beats/min., once a day at 23:04, subjectively manifested by a sharp attack of dizziness. Episodes of ST segment depression up to -1.8 mm, in leads characterizing the potentials of the anterior wall, lateral wall of the left ventricle, painless, occurring at the height of physical activity with different threshold heart rate >160 beats/min; stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. painless, occurring at the height of physical activity with different threshold heart rate >160 beats/min; stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. painless, occurring at the height of physical activity with different threshold heart rate >160 beats/min; stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. arising at the height of physical activity with different threshold heart rate >160 beats/min; stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. arising at the height of physical activity with different threshold heart rate >160 beats/min; stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. stresses characteristic of angina pectoris 1 FC. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. During the observation time, two control physical loads were performed in the form of climbing stairs with a power of 0 to 89 (average - 44) W. The volume of work performed is from 0 to 640 (average-320) kg × m s. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning. The average value of systolic blood pressure (against the background of selected antihypertensive therapy) during the entire observation period without significant features; The average value of diastolic blood pressure without significant features. Pressure load index of systolic and diastolic blood pressure during the entire observation period without significant features. The decrease in systolic and diastolic pressure at night is insufficient. Increased fluctuations in systolic blood pressure in the evening and early morning.
The function of external respiration 12/11/2006: a variant of the norm. VC = 3.36l (VC = 3.37l), FVC = 3.47l (107%), FEV1 = 2.92l (107%), RO inhalation = 0.77 l, RO inhalation = 1.83 l, FEV05 = 1.99 l , FEV1% VC=86.90 (107%), POS=4.7l/s (76%), MOS25=4.4l/s (79%), MOS50=3.99l/s (99%), MOS75 =1.73l/s (92%), SOS25-75=3.21l/s (98%), SOS0.2-1.2=4.22l/s, FEVOS=1.25l, FEVOS% FVC=36 .04, TPOS=0.32s, TFVC=1.54s, Aex=10.25l×l/s, IS BP=2.00c.u. DO=0.99l, BH=28
Ultrasound of the abdominal organs from 09/20/2008: the liver is not enlarged, the right lobe: 12.8 cm; left 7.7 cm, smooth contours, homogeneous structure, increased echogenicity; intrahepatic vessels are not dilated; portal vein 10 mm, hepatic veins of normal size (7-8 mm). Intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape, the contours are even, the walls are 2 mm, the calculi are not visualized, a polyp is located on the anterior wall with a diameter of 2.5-3.2 mm. The pancreas is located indistinctly, not enlarged, the contours are fuzzy, uneven, the structure is heterogeneous, echogenicity is increased; Wirsung's duct is not dilated. The kidneys are of normal size (right 10.8×3.8 cm, left 9.9×4.5 cm), normal location, with even contours, homogeneous parenchyma 14 mm thick, abdominal systems are not dilated. In the middle third of the right kidney, calicectasia up to 17.7 mm, in the left kidney in the middle and upper third of calicectasia up to 21.2 mm. The spleen is not enlarged, measuring 11×7.2×6.8 cm. In the projection of the location of the adrenal glands, no pathological formations were found. The bladder is filled, the contours are even, the walls are not thickened (3-4 mm). Uterus in anteflexio, to the left, enlarged up to 6 weeks, dimensions 80.4 × 54.8 × 68.3 mm, contours are uneven, deformed, the structure is heterogeneous, the formation of a heterogeneous structure with a diameter of 10 mm is visualized subserously along the anterior wall, the echostructure of the myomertium is cellular. The uterine cavity is not expanded, with a gap up to 3.8 mm with homogeneous contents, the endometrium is 6 mm wide. The ovaries are usually located, oval in shape, dimensions: left 45×28mm, enlarged along the uterine rib, anechoic D=21.6mm along the lateral contour; right 32×25mm, not enlarged contours are even, clear, cellular structure, along the lower contour, an anechoic formation D = 23.7 mm. On the anterior wall of the cervix, 2 endocervical cysts D=5 and 6 mm. Conclusion: gallbladder polyp, diffuse changes in the pancreas, calicectasia of both kidneys, subserous-interstitial uterine myoma of small sizes in combination with adenomyosis PE, cysts of both ovaries.
Ultrasound of the abdominal organs dated November 26, 2008: the liver is not enlarged, the right lobe: 14.1 cm; left 7.0 cm, smooth contours, homogeneous structure, increased echogenicity; intrahepatic vessels are not dilated; portal vein 10 mm, hepatic veins of normal size (7-8 mm). Intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape, the contours are even, the walls are 2 mm, stones are not visualized, a polyp is located on the anterior wall with a diameter of 4.5 mm. The pancreas is located indistinctly, not enlarged, the contours are fuzzy, uneven, the structure is heterogeneous, echogenicity is increased; Wirsung's duct is not dilated. The kidneys are of normal size (right 10.8×3.8 cm, left 9.9×4.5 cm), normal location, with even contours, homogeneous parenchyma 14 mm thick, abdominal systems are not dilated. The spleen is not enlarged, 12.7×8.7×6.0 cm in size. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: gallbladder polyp, diffuse changes in the pancreas.
Fibrogastroduodenoscopy No. 2124 dated 11.06.08: The esophagus is freely passable. The socket of the cardia closes incompletely. The mucous membrane of the esophagus is pink. The dentate line is higher than normal. The legs of the diaphragm close below the "toothed" line. STOMACH. The stomach contains foamy mucus. Peristalsis of the stomach can be traced throughout. The mucous membrane of the stomach is edematous, focally hyperemic. The mucosa of the antrum with focal atrophy. The gatekeeper is rounded, we pass. The mucosa of the duodenal bulb and the postbulbar section is pink. Biopsy of the gastric mucosa of different departments: chronic gastritis with restructuring of the glands according to the intestinal type. Conclusion: Hiatal hernia. Chronic atrophic antral gastritis.
Fibrogastroduodenoscopy dated 11/26/2008: the distal end of the apparatus was inserted into the esophagus, the latter was shortened. Z-line above the crura of the diaphragm, indistinct, barely visible, uneven (at the level of 32 cm from the upper incisors). At the same level, single erosions are determined, expanding distally to form, as it were, an additional cavity, there is a significant prolapse of the gastric mucosa into the esophagus. In the stomach, the folds are unexpressed, straighten out during insufflation, the mucosa is pale pink, in some places a vascular pattern is traced, petechial and hemorrhagic erosions are noted in the body and antrum. The gatekeeper does not close completely. In the bulb and postbulbar section, the mucosa is thinned, the circular folds are smoothed out. Conclusion: sliding hiatal hernia of mixed type: axial and paraesophageal. Erosive reflux esophagitis grade 2. Barrett's esophagus (?). Moderately pronounced atrophic gastroduodenitis, against which petechial and hemorrhagic erosions are noted in the stomach. Taken: from the esophagus and the antrum of the stomach, 2 pieces of biopsy.
Histological examination No. 10965-66 dated 05.12.08. (Material 26.11.08), biopsy No. 1 from the antrum of the stomach: moderate erosive gastritis of the outlet section of the 2nd (second) degree of activity with dysplasia of the 2nd (second) degree and foveolar hyperplasia of the integumentary epithelium. HP (-). / Time: Rumakin V.P. /
Histological examination No. 10963-64 dated 03.12.08. (Material 26.11.08) biopsy No. 2 from the esophagus: a section of stratified squamous non-keratinized epithelium with a submucosal base without an inflammatory component and a fragment of the muscular layer. There is no metaplasia of the gastric glands. /time: V. Yudaev/
X-ray of the stomach from 03.12.08: the esophagus and cardia are freely passable for barium suspension. The contours of the esophagus are even, longitudinal folds can be traced throughout. In a horizontal position, the patient's gastric mucosa prolapses into the esophagus, the fornix of the stomach falls into the posterior mediastinum. The stomach is hypokinetic, empty on an empty stomach. The contours of the stomach are even, the walls are elastic. Folds of mucous longitudinal are traced in all departments. Peristalsis is segmented, evacuation is not disturbed. Bulb with smooth contours. The loop of the duodenum is usually located. After 1.5 hours, a small amount of contrast medium in the stomach. The first portions of the barium suspension fill the blind and ascending colon. Conclusion: mixed hiatal hernia - esophageal with paraesophageal displacement of the upper stomach. gastroptosis. Hypermotor dyskinesia of the small intestine.
X-ray of the chest organs No. 2414 dated 11/21/2008: Conclusion: On the survey radiograph of the chest cavity organs in the lungs without fresh focal and infiltrative changes. The roots are structural, no free fluid was found in the pleural cavity. The heart is moderately expanded in diameter to the left, the aorta is sealed.
Spondylograms of the cervical spine in 2 projections No. 2414 dated November 21, 2008: osteochondrosis of the C4-5 motor segment with a decrease in disc height, subchondral sclerosis and marginal bone growths in the anterior sections at the same level, C4 displacement posteriorly by 0.4 cm.
On spondylograms of the thoracic spine in 2 projections No. 2414 dated November 21, 2008: physiological kyphosis is enhanced. Moderately reduced disc height Th7-8 Th8-9 end plates are compacted, small marginal bone growths in the anterior sections at the same levels are R-signs of osteochondrosis Th7-8 Th8-9 motor segments.
On spondylograms of the lumbar spine in 2 projections No. 2414 dated November 21, 2008: physiological lordosis is enhanced. The height of the disc L4-5 is moderately reduced - the phenomenon of chondrosis. L5-S1 - Schmorl's hernia.
Treatment: regimen, diet, polarizing mixture, lasix, asparkam, prednisolone 20 mg in the morning, methotrexate 7.5 mg/week, perindopril 5 mg/day, symptomatic and restorative therapy.
Operations:
11/24/08: plasmapheresis (1000ml) and plasmasorption (1200ml), mass transfer device - column SKN-1D, "Solu-medrol" 500 mg
11/27/08: plasmapheresis (900ml) and plasmasorption (1200ml), mass transfer device - column SKN -1D
01.12.08: hemosorption (4000 ml), mass transfer device - column SKN-1D, "Solu-medrol" 250 mg
Against the background of the therapy, the patient's condition improved.
Does not require sick leave. Discharged in a satisfactory condition.
Recommended:
132. Outpatient observation of a rheumatologist.
133. Annual inpatient treatment in a specialized hospital.
134. Dispensary observation:
a. Frequency of observations by a rheumatologist: - 4 times a year.
b. Examination by an ENT doctor, gynecologist, ophthalmologist 2 times a year; gastroenterologist - 1 time per year.
c. clinical blood test (with counting platelets and reticulocytes), urinalysis - 4-6 times a year; when changing the dose of cytostatic drugs - monthly control;
d. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - at least 2 times a year;
e. x-ray (fluorography) of the chest organs 2 times a year; x-ray of the joints - according to indications;
f. a blood test for the content of antinuclear factor and antibodies to double-stranded DNA and the level of complement C3 and C4 - 3 times a year and during exacerbation.
g. Echocardiography - 2 times a year;
h. FGDS - 1 time per year, with a biopsy of dubious areas of the lower third of the esophagus. If signs of Barrett's esophagus are detected (the presence of gastric metaplasia of the esophageal mucosa proximal to 2.5 cm from the gastroesophageal junction) - consultation of an abdominal surgeon
i. Dental consultation and oral hygiene
135. Lifestyle changes:
a. Exclusion of a strictly horizontal position during sleep (raise the head end of the bed by 15 cm)
b. Exclusion of wearing corsets, bandages, tight belts
c. The exclusion of lifting weights over 4-5 kg, work associated with tilting the torso forward, physical exercises associated with overstrain of the abdominal muscles (including yoga classes)
136. Changing the mode and nature of nutrition:
a. Avoid overeating, snacking, eating at night, lying down after eating
b. Exclude from the diet foods rich in fat (whole milk, cream, fatty fish, goose, duck, pork, fatty beef, lamb, cakes, pastries), drinks containing caffeine (coffee, strong tea, Coca-Cola), chocolate, foods containing mint and pepper, citrus fruits, tomatoes, onions, garlic, fried foods.
c. Do not use alcoholic drinks, carbonated mineral water
d. Limit consumption of butter and margarine
e. 5 meals a day in small portions with a high protein content
f. Eat at least 3 hours before bedtime, after eating take a 30-minute walk.
137. Continue taking:
a. Prednisolone 5mg - 4 tab. in the morning with breakfast until 9 am – all the time
b. Methotrexate 2.5 mg - 1 tab. 3 times a week (Saturday morning and evening 1 tab, Sunday morning 1 tab) - constantly
c. Wobenzym - 5 tablets × 3 times a day × a month, then 3 tablets × 3 times a day - at least 6 months.
d. Ca-D3-Nycomed-forte - 1 tab. in the evening daily
e. Multivitamin preparations: "Complivit" 1 tablet daily for 3 months
f. Sorbifer durules - 1 capsule in the morning for 3 months
g. Venter 0.5 op 1 tab 1-1.5 hours after meals 4 times a day, in the absence of effect - 8 times a day after 3 hours, regardless of food
h. Motilium - 10 mg in the morning 30 minutes before meals for 1 month
i. Omeprazole 20mg - 1 capsule in the morning on an empty stomach for 1 month
j. Maalox on demand
MILITARY MEDICAL ACADEMY
Clinic of hospital therapy
Discharge summary №
1968 b. (40 years old), was on examination and treatment in the hospital therapy clinic with a diagnosis of
Hypertension Stage I. (AH grade 2, risk 3). NC I Art. Initial manifestations of cerebrovascular insufficiency with diffuse neurological symptoms.
He was admitted to the clinic in a planned manner with complaints of aching headaches with increased blood pressure, impaired concentration, and memory loss.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
CP
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
10.12
155
4.69
5.5
2
270
2
42
14
1
41
Complete urinalysis dated 10.12.08 without features
Biochemical blood test:
Name
Unit. rev.
Norm
22.03
Name
Unit. rev.
Norm
11.12
Creatinine
mmol / l
53-124
CS
mmol/l
3.7-7
2.87
Urea
mol/l
3-8.4
6.4
TG
mol/l
0-2.37
0.44
Prothromb.index
%
70-120
β-LP
U
350-650
450
Fibrinogen
g/l
200-400
HDL
mol/l
0.78-2.33
Total protein
g/l
63-87
65
LDL
mol/l
1.9-4
Albumin
%
50-70 Cholesterol
/HDL
Times
3-5
1
%
3-6
VLDL
Mole/l
0.6-1.2
2
%
9-15
odds atheros.
Unit
0-3
%
8-18
amylase
U/L
28-100
%
15-25
trypsin
u/l
0-0.35
a/g
1.1-2.5
Ig M
g/l
0.65-1.65
ALT
U/L
8.4-53.5
14.6
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
11.02
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
CEC
U
6-66
LDH
U/L
100-220
Cl
Mol/l
95-108
GGTP
U/L
11-63
11.8
Na
Mole/l
130-150
Glucose
mmol/l
4.2-6.4
4.5
Ca
Mole/l
2.0-2.7
1.85
Tot. bilirubin
µmol/l
6.8-26
5.6
K
mmol/l.
4-6
ALK pos
U/L
36-92
102.3
T3
Mol/l
66-181
Urinary
acid fmol/l
150-420
T4
Mol/l
1.3-3.1
CPK
u/l
10-160
RW
qual
Results of instrumental studies:
ECG from. 03/21/2007, Sinus rhythm with a heart rate of 58 beats, horizontal EOS. Left ventricular hypertrophy. Syndrome of early repolarization. Local violations of intraventricular conduction, violations of repolarization in the region of the lower wall.
Ultrasound examination from 30.03.2007. The liver is not enlarged, the right lobe is 13.8 cm, the left lobe is 6.4 cm. The contours are even, the structure is homogeneous, the echogenicity is medium, the vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape (curved, partially reduced). The pancreas is located indistinctly, it is not enlarged, the contours are fuzzy, even, the structure is homogeneous echogenicity is average, the Wirsung duct is not dilated. Kidneys: location and size are normal. Right - the contours are even, the parenchyma is homogeneous 16 mm, the cavity system is not expanded, there are no stones: the left one - the contours are not even, the parenchyma is homogeneous 18 mm, the cavity system is not expanded, there are no stones. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 8.8x3.6 cm, the structure is homogeneous. Flatulence.
EchoCG from 03/29/2007. Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed, calcifications in the AC. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no pericardial effusion.
The results of VEM and ECG Holter monitoring are on hand
X-ray of the chest organs dated 30.03.2007. In the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is slightly dilated to the left. The aorta is elongated.
X-ray of the skull from 30.03.2007. On survey craniograms in two projections, the Turkish saddle is normal. There is thinning of the bones of the cranial vault.
Radiography of the right hip joint dated April 2, 2007: on the radiograph of the right hip joint in two projections. Condition after metal osteosynthesis in the area of comminuted fracture of the upper third of the femur. The callus is expressed satisfactorily. The bolt of a metal structure protrudes into the soft tissue by 2.5 cm.
Specialist consultations
Optometrist: VIS OD 1.0; OS 1.0 IOP OD,OS - 18mm Hg
The auxiliary apparatus and the outer parts of the eyeballs are not changed, the optical media are transparent. The fundus of the eye: optic nerve disc of satisfactory nutrition, the contours are clear. The veins are moderately dilated, the arteries are sealed. Focal pathology is not defined.
Neurologist: Dyscirculatory encephalopathy of the 2nd stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders.
ENT: Endoscopic ENT organs without visible pathology. SR 6 m.
Traumatologist: Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (02/27/02) due to a closed fracture of the surgical neck of the shoulder (02/15/02) and its repeated fracture (07/18/02) with moderate dysfunction of the left upper limb . A consolidating fracture of the neck of the right femur with a construction (25.09.2006) with a slight dysfunction of the right lower limb.
Treatment was carried out: regimen, diet, olicard, ACC thrombosis, metoprolol, phenazepam.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
1. Observation of a therapist, neuropathologist, traumatologist of the TsKDP VMA.
2. Optimization of the regime of work, rest, nutrition.
2. Continue taking
• Olikard 0.04 1 caps. 1 r / d after breakfast
• Thrombo ACC 0.1 1 tab. 1 r / d after breakfast
• Metoprolol 0.05 ½ tablet 2 r / d (after breakfast and dinner)
• Asparkam 1 tablet 3 r / d the first 10 days of each month.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate No.
1932 (76 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis:
ischemic heart disease. Angina pectoris II FC. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (1983) cardiosclerosis. Hypertension stage III (AH 2st, Risk 4) NK-II, CHF-II FC. Diabetes mellitus type II, moderate, compensated. Dyscirculatory encephalopathy II st. in the form of scattered neurological symptoms. Benign prostatic hyperplasia.
He was admitted to the clinic for urgent indications with complaints of discomfort in the region of the heart during moderate (ascending to the 2nd floor) physical activity, shortness of breath, frequent nighttime urination, memory loss.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
CP
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
11.12
141
4.88
8.0
-
16
2
34
6
2
55
17.12
142
4.8
9.4
-
15
2
35
10
3
50
General clinical analysis urine:
Date
Clarity
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
11.12
prose
1015
yellow.
sour
no
no
no
no
no
no
no
no
no
no
Biochemical blood test:
Name
Unit. rev.
Norm
11.12
Name
Unit. rev.
Norm
11.12
Creatinine
mmol/l
53-124
0.09
cholesterol
mmol/l
3.7-7
5.48
Urea
mol/l
3-8.4
4.7
TG
mmol/l
0-2.37
0.85
Prothrombindex
%
70-120
106
β-LP
u
350-650
Fibrinogen
g/l
200-400
385
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
67.1
LDL
mmol/l
1.9-4
ALT
U/L
8.4-53.5
32.5
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
35, 0
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
60.2
CEC
units
6-66
LDH
U/L
100-220
Cl
mmol/l
95-108
GGTP
U/L
11-63
8.7
Na
mmol/l
130-150
146.1
Glucose
mmol/l
4.2-6.4
6 .42
Ca
mmol/l
2.0-2.7
Tot. bilirubin
µmol/l
6.8-26
14.0
K
mmol/l.
4-6
4.8
Daily fluctuation of blood sugar from 12/17/08: 8.00-4.7 mmol/l; 10.00-5.5 mmol/l; 12.00-5.4 mmol/l.
ECHO-KG No. 32 dated 12/15/08: Aorta - 31 mm, AV dilatation - 17 mm, RA - 36 mm, RV EDR - 26 mm, LA - 44 mm, LV ECR - 27 mm, LV EDR - 44 mm, FU - 37%, EF - 67%, IVS=14mm, WS=14mm, LA - 19 mm Hg, e/a = 0.62 symmetrical concentric hypertrophy of the left ventricular myocardium, hypokinesia of the posterior and posterolateral segments in the basal region. LP dilatation. The aorta is sealed. Calcification of the aortic crescents, limiting the opening of the valves. Flattening of fibrous rings and cusps of AC and MK. Applied regurgitation on PC and MC, TC. The pericardium is not changed.
Ultrasound of the abdominal organs dated 12.12.08: The liver is not enlarged, the thickness of the right lobe is 13 cm, the contours are even, the structure is homogeneous. Gallbladder without stones. Portal vein - 13 mm., Hepatocholedoch - 4 mm. The pancreas is not enlarged, the contours are even, the structure is hyperechoic, moderately heterogeneous. Kidneys without visible pathology. The spleen is not enlarged.
ECG No. 85 dated 10.12.08: sinus rhythm with a frequency of 60 beats per minute, horizontal EOS, left ventricular hypertrophy, impaired conduction along the right branch of the His bundle.
Treatment: regimen, diet, polarizing mixture, vinpocetine, enalapril, cordaflex, siofor, restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
138. Outpatient supervision of a polyclinic therapist.
139. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
140. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
141. Continue taking:
a. Enalapril 0.01 - 1 tab. 2 times a day (morning and evening) continuously
b. Cordaflex (retard) 0.02 - ½ tab. 2 times a day (morning and evening) continuously
c. Verapamil 0.08 - ½ tab in the morning and in the evening constantly
d. Siofor 500 - 1 tab in the morning and in the evening 15 minutes before meals
MILITARY MEDICAL ACADEMY. HOSPITAL THERAPY CLINIC
Reference No.
born in 1970 (39 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy Diagnosis: community-acquired focal pneumonia in the lower lobe of the left lung, mild severity DN-0. Astheno-vegetative syndrome. Right-sided nephroptosis I degree, lipoma of the left kidney, CRF-0.
She was admitted to the clinic for urgent indications with complaints of shortness of breath with moderate physical exertion, general weakness, cough with green discharge, and fever.
Laboratory results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l MSI
,
pg
n, %
e, %
b, %
l, %
m, %
p %
c, %
ESR, mm/h
12.11
139
4.13
5.6
300
33.8
1
1
48
15
2
34
23
16.11
148
4.43
6.3
325
33.5
4
4
29
10
1
52
22
Urine analysis
Date
Clear.
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
12.11
clear
1.025
Yellow
7.0
-
-
-
-
-
-
-
-
-
-
Feces per I/g 13.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11.09
Total protein
G/l
63.0-87.0
67.2
Cholesterol
Mmol/l
3.7-6.0
5.32
triglycerides
Mmol/l
0-2.37
0.94
Glucose
Mmol/l
4.2-6.4
4.86
Prothrombin
%
80-105
98
Fibrinogen
g/l
2-4
2.9
Sialic acids
Mmol
/
l
1.9-2.5 infiltrative changes. The roots of the lungs are structural, not expanded. The heart is not enlarged.
On the survey radiograph and fluoroscopy of the chest in the direct and right lateral projection No. 317 (D = 0.52 mSv) dated 11/19/09: a stranded pattern is noted in the basal segments of the left lung. Pleural cords in the C8 projection on the left. The roots of the lungs are structural, not expanded. The heart is not enlarged.
ECG No. 2528 dated 11/11/09: sinus rhythm with a heart rate of 80/min. EOS is deflected to the left. Partial violation of intraventricular conduction. The predominance of the potentials of the left ventricle.
ECHO-KG No. 790 dated 11/18/09 Ao=27mm, ascending Ao=23mm, opening AC=19mm, LA=30mm, RA=34mm, RV=22mm, LV=43/30mm, IVS=9mm, AP=8mm, EF=58%, FU=31% , SV=55ml, E/A=1.39 The myocardium is not thickened, the kinetics is not disturbed, the cavities of the heart are not dilated. The aorta is not changed. The blood flow on the valves is laminar. Systolic and diastolic functions are not disturbed. The free edge of the anterior leaflet of the mitral valve is thickened, loosened. Applied regurgitation on MK and TK. The pericardium is not changed.
Ultrasound of the OBP from 23.11.09. No. 1278: the liver is not enlarged, the right lobe is 10 cm, the left lobe is 3.7x7.6 cm, the contours are even, the structure is homogeneous, echogenicity is average, the vessels are not dilated. The gallbladder is bent in the middle third 4.5x1.6 cm, the contours are even, the walls are 2 mm, it contains bile, calculi and polyps are not detected, the common bile duct is 3 mm. The pancreas is located clearly, the contours are clear, even, the head is 13mm, the body is 10mm, the tail is 11mm, echogenicity is increased, the structure is homogeneous, the Wirsung duct is not dilated. The lower pole of the right kidney to the edge of the liver is 10x3.4 cm, the parenchyma is homogeneous 15 mm, the PCS is not changed; the left kidney is located typically 8.5 x 4.4 cm, the parenchyma is homogeneous 19 mm, the PCS is not changed. In the projection of the adrenal glands, no pathological formations were revealed, the spleen was not changed.
FVD No. 106 dated 11/18/2009 results in hand.
Treatment: regimen, diet, antibacterial, anti-inflammatory, expectorant, sedative and restorative therapy.
Against the background of the therapy, the patient's condition improved: the general intoxication syndrome was stopped, there is no compaction of the lung tissue. However, a cough persists with a slight discharge of a light color, signs of asthenia. Discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
142. Outpatient supervision of a doctor in accordance with DM-1.
143. Control general blood test as of 30.11.2009.
144. Release from performance of official duties for a period of 3 (three) days.
145. Exemption from physical. preparation for 30 days.
146. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
147. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
148. Continue taking:
a. Linex - 1 capsule 3 times a day for 1 month
b. Ascoril - 1 tablespoon in the morning for 7 days
c. Antigrippin – 1 powder 2 times a day for 3 days
d. Eleutherococcus - 1 teaspoon in the morning (dilute in 1/3 cup of water).
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Reference No.
1925 (83 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis:
ischemic heart disease. Progressive angina from 12/17/08, with stabilization at the level of angina pectoris III FC from 12/22/08. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and post-infarction (of unknown duration) cardiosclerosis complicated by paroxysmal form of atrial fibrillation (paroxysm of unknown duration) was stopped on 18.12.08. Hypertension stage III (AH 2st, Risk 4) NK-I, CHF-IV→II FC. Obesity of the first degree, alimentary genesis. Chronic cholecystitis without exacerbation. Chronic pyelonephritis without exacerbation, multiple (two) cysts of the left kidney, CRF-I st. Benign prostatic hyperplasia.
He was admitted to the clinic for urgent indications with complaints of discomfort in the region of the heart during moderate (ascending to the 2nd floor) physical activity, shortness of breath, frequent nighttime urination, memory loss.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
17.12
146
4.87
8.0
47
8
1
1
19
7
72
19.12
144
4.62
6.4
44.7
9
5
27
8
60
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MV epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
11.12
mutn
1014
yellow
sour
0.04
no
no
++
no
no
0-2
no
2-4
12-15 Rehberg's
test
Date
Blood
creatinine Urine creatinine
Diuresis in 1 min
Glomerular filtration
Tubular reabsorption
24.12
0.16
14.53
0.95
86.3
98.9
Biochemical blood test:
Name
Unit. rev.
Norm
17.12
24.12
Name
Unit. rev.
Norm
17.12
24.12
Creatinine
mmol/l
53-124
160
160
CS
mmol/l
3.7-7
6.11
Urea
mol/l
3-8.4
9.0
11.3
TG
mmol/l
0-2.37
Prothrombindex
%
70-120
95
β-LP
u
350-650
Fibrinogen
g/l
200-400
330
HDL
mmol/l
0.78-2.33
Total protein
g/l
63- 87
67.5
72.2
LDL
mmol/l
1.9-4
ALT
U/L
8.4-53.5
12.6
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
16.0
Ig A
g/l
1.25-2.5
AP
U/L
36-92
CPK
U/L
10-160
46.5
LDH
U/L
100-220
Cl
mmol/l
95-108
111.6
GGTP
U/L
11-63
Na
mmol/l
130-150
148.4
148.2
Glucose
mmol/l
4.2-6, 4
5.52
5.77
Ca
mmol/l
2.0-2.7
2.32
2.43
Total bilirubin
µmol/l
6.8-26
25.4
K
mmol/l.
4-6
5.14
5.06
ECHO-KG No. 32 dated 12/15/08: Aorta - 36 mm, AV dilatation - 17 mm, RA - 50 mm, RV EDR - 32 mm, LA - 53 mm, LV ECR - 39 mm, LV EDR - 50 mm, FU - 30%, EF - 60%, IVS=14mm, WS=14mm, LA - 21 mm Hg, Dla - 38 mm Hg e/a = 0.89. Symmetrical concentric hypertrophy of the left ventricular myocardium. Dilatation of the left atrium and right chambers of the heart. The aorta is sealed. Regurgitation on the TC 2 degrees, applied to the mitral valve. Pulmonary hypertension of the first degree. The pericardium is not changed.
Ultrasound of the abdominal organs dated 23.12.08: The liver is not enlarged, the thickness of the right lobe is 13 cm, the contours are even, the structure is homogeneous. The gallbladder is without calculi, the walls are compacted, thickened up to 4 mm. Portal vein - 12 mm., Hepatocholedochus - 5 mm. The pancreas is not enlarged, the contours are even, the structure is hyperechoic, homogeneous. Kidneys: right - 9 × 4 cm, parenchyma up to 12 mm, uneven contours, expansion of individual cups up to 16 mm, PCS deformed; left - 11.5 × 6 cm, parenchyma up to 10 mm, expansion and deformation of the PCS, in the middle third, two cysts 2.6 and 2.2 cm in diameter. The spleen is not enlarged.
ECG No. 156 dated 12/17/08. atrial fibrillation, tachysystole 85-120 per 1 min, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 161/162/177 dated December 18-22, 08: sinus rhythm with a frequency of 60-78 beats per minute, vertical EOS, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 185 dated 12/23/08. sinus rhythm with a frequency of 82 per 1 min., vertical EOS, hypertrophy of both ventricles, more than the right one, in dynamics some worsening of repolarization of the apical-lateral region of the left ventricle
Treatment: regimen, diet, polarizing mixture, vinpocetine, enalapril, cordaflex, siofor, restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
149. Outpatient supervision of a polyclinic therapist.
150. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
151. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
152. Continue taking:
a. Enalapril 0.01 - 1 tab. 2 times a day (morning and evening) continuously
b. Cordaflex (retard) 0.02 - ½ tab. 2 times a day (morning and evening) continuously
c. Verapamil 0.08 - ½ tab in the morning and in the evening constantly
d. Siofor 500 - 1 tab in the morning and in the evening 15 minutes before meals
MILITARY MEDICAL ACADEMY
Hospital therapy clinic Discharge
summary
No.
(43 years old), was examined and treated at the hospital therapy clinic with a diagnosis of:
Hypertension stage II. (AH grade 2, risk 3). ischemic heart disease. Angina pectoris II f.k. Atherosclerosis of the aorta, coronary arteries. Atherosclerotic cardiosclerosis. NC I Art. Dyscirculatory encephalopathy of the second stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders. Chronic toxic steatohepatitis with moderate activity. Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (27.02.02) due to a closed fracture of the surgical neck of the shoulder (15.02.02) and its repeated fracture (18.07.02) with moderate dysfunction of the left upper limb. A consolidating fracture of the neck of the right femur with the presence of a construct (September 25, 2006).
He was admitted to the clinic in a planned manner with complaints of compressive pain in the chest, shortness of breath during exercise, aching headaches with increased blood pressure, dizziness, general weakness, impaired concentration, memory loss, pain in the right shoulder and right thigh.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
22.12
138
4.36
15.0
42.4
33
396
1
10
7
7
75
Biochemical analysis of blood:
Name
Unit. rev.
Norm
22.12
Name
Unit. rev.
Norm
22.12
Creatinine
mmol/l
53-124
70
CS
mmol/l
3.7-6.0
6.31
Urea
mol/l
3-8.4
3.1
TG
Mole/l
0-2.37
1.32
Prothromb. index
%
70-120
102
β-LP
Unit
350-650
540
Fibrinogen
g/l
200-400
320
HDL
mol/l
0.78-2.33
Total protein
g/l
63-87
72.9 Cholesterol
/HDL
Times
3-5
Albumin
%
50-70
49.5
VLDL
mol/l
0.6-1.2
1
%
3 -6
6.2
odds atheros.
Unit
0-3
2
%
9-15
14.5
amylase
U/L
28-100
82.4
%
8-18
16.2
trypsin
u/l
0-0.35
%
15-25
13.6
Ig M
g/l
0.65-1.65
a/ G
1.1-2.5
0.98
Ig G
g/l
7.5-15.5
ALT
U/L
8.4-53.5
72.6
Ig A
g/l
1.25-2.5
AST
U/L
7-39.7
37 .0
CEC
U
6-66
ALP
U/L
36-92
54.6
Fe
Mmol/l
10.5-25
5.76
LDH
U/L
100-220
Na
Mmol/l
130-150
141.4
GGTP
U/L
11-63
77 .8
Ca mmol/
l
2.0-2.7
2.12
Glucose
mmol/l
4.2-6.4
5.49
K
mmol/l.
4-5.5
4.63
Tot. bilirubin
µmol/l
6.8-26
8.1
Sialic
acids mmol/l
1.9-2.5
3.1
Urinary
acid fmol/l
150-420
287
T3
mmol/l
66-181
CPK
units/ l
10-160
148.1
T4
Mmol
/l
1.3-3.1
HBsAg, antiHCV qual negative ref
RW
qual
Results
of
instrumental studies:
X-ray examination and ECG registration was refused due to a "recent study".
Ultrasound examination from 30.03.2007. The liver is enlarged, the right lobe is 17.8 cm, the left lobe is 10.4 cm. The contours are even, the structure is homogeneous, echogenicity is increased, the vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape (curved, partially reduced). The pancreas is located indistinctly, it is not enlarged, the contours are fuzzy, even, the structure is homogeneous, echogenicity is average, the Wirsung duct is not dilated. Kidneys: location and size are normal. Right - the contours are even, the parenchyma is homogeneous 16 mm, the cavity system is not expanded, there are no stones: the left one - the contours are not even, the parenchyma is homogeneous 18 mm, the cavity system is not expanded, there are no stones. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 8.8x3.6 cm, the structure is homogeneous. Flatulence.
EchoCG from 12/25/2008. Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed, calcifications in the AC. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no pericardial effusion.
Treatment was carried out: regimen, diet, olicard, ACC thrombosis, metoprolol, phenazepam.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
1. Observation of a therapist, neuropathologist, traumatologist of the TsKDP VMA.
2. Optimization of the regime of work, rest, nutrition.
2. Continue taking
• Olikard 0.04 1 caps. 1 r / d after breakfast
• Thrombo ACC 0.1 1 tab. 1 r / d after breakfast
• Metoprolol 0.05 ½ tablet 2 r / d (after breakfast and dinner)
• Asparkam 1 tablet 3 r / d the first 10 days of each month.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1957 (52 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis: Seropositive rheumatoid arthritis (M.05.8), very early stage, III degree of activity, stage I, with systemic manifestations (myocardial dystrophy, mild secondary normoregenerative normoblastic anemia, right-sided exudative pleurisy), anti-CCP (+), FC I, FNS I. Symptomatic arterial hypertension (AH 1, CVE risk 3)
She was admitted to the clinic on a planned basis with complaints of palpitations, fever up to 38.8 ° C, swelling and stiffness of the small joints of the hands and feet, "flying" swelling and pain of the large joints of the legs .
Laboratory results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l
MSN,
pg
Rt,
‰
e, %
b, %
l, %
m, %
p %
s, %
ESR, mm/h
11.11.
98
3.06
10.4
630
32.1
6.9
1
19
7
5
68
70
13.11
101
3.55
8.5
824
28.4
6.6
1
30
5
2
62
70
25.11
122
4.29
13.5
593
28.6
6.2
25
7
1
69
40
Complete urinalysis
Date
Clear
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
11.11
clear
1.020 Yellow
5.5
-
-
-
-
-
-
-
-
-
-
Nechiporenko
test 11.11.09 L=0.75х106/l, E=2.0х106/l
Cal on I/g 11.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11
Total protein
G/l
63.0-87.0
77.5
Cholesterol
Mmol/l
3.7-6.0
5.17
Creatinine
Mmol/l
0.05-0.12
0.06
Glucose
Mmol/l
4.2-6.4
5, 54
Prothrombin
%
80-105
Fibrinogen
g/l
2-4
Potassium
Mmol/l
3.5-5.1
4.38
Calcium
Mmol/l
2.0-2.7
2.07
AST
U/l
11-50
23, 3
ALT
U/l
11-50
25.9
CPK
U/l
10-160
12.3
CEC
U
6-66
567
Beta-lipoproteins
AU 350-650
Serology
for HIV, hepatitis - negative.
* Detailed serology of rheumatoid arthritis (AKA, ACE, ACCP/anti-SSR, RF) 11/17/09.
* Antibodies to cyclic citrulline-containing peptide
- Result options
* <5 U/ml - no antibodies to CCP detected
* 5-50 U/ml - low concentration
* >50 U/ml - high concentration
- Result 56.9 U/ml
* Rheumatoid factor
- normal <1:20 (less than 25 IU/ml), result - 1:80 (100 IU/ml)
* Antikeratin antibodies
- normal <1:10 result <1:10
* Antiperinuclear factor
- normal <1:10 result <1:10
Blood test for antinuclear factor with immunoblot from 11/17/09.
on the hands soft tissue compaction is noted at the level of the metatarsophalangeal and interphalangeal joints, more pronounced on the right.
On the survey radiograph of the chest in the direct and right lateral projection from 11.11.09. No. 2613 (D=0.52 mSv): in the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, not expanded. The right dome of the diaphragm is slightly elevated. Encapsulated fluid in the right pleural cavity at the level of the costophrenic sinus. A small amount of fluid in the interlobar fissures. The heart is not dilated, the aorta is sealed.
On the control radiograph of the chest in the direct and right lateral projection from 11.11.09. No. 329 (D=0.52 mSv): no fluid was found in the right pleural cavity, in the lungs without focal and infiltrative changes.
On the radiograph of the left knee joint No. 2662 dated November 13, 2009. (D=0.02 mSv): no pathological changes were detected in 2 projections.
Ultrasound of the abdominal organs No. 1235 dated 11/16/2009: no pathological changes were detected
On ECG No. 2515 dated 11/10/09: sinus rhythm with a heart rate of 80/min. Normal position of the EOS. Partial violation of intraventricular conduction. Violation of repolarization in the region of the posterior wall, apex.
ECHO-KG No. 762 dated 10.11.09. Ao=30mm, ascending Ao=30mm, opening AC=16mm, LA=30mm, RA=32mm, RV=24mm, LV=47/27mm, IVS=10mm, AP=09mm, EF=74%, FU=43% , SV=75 ml, E/A=0.84 myocardium is not thickened, the kinetics is not disturbed, the cavities of the heart are not expanded, free. The aorta, fibrous rings of the aortic and mitral valves are sealed. The blood flow on the valves is laminar. Diastolic dysfunction of the rigid type. Applied regurgitation on the mitral valve. The pericardium is not changed.
Consulted by the rheumatologist of the clinic. Diagnosis was clarified, therapy was adjusted.
Treatment: regimen, diet, prednisolone, methotrexate, noliprel, calcium-D3-nycomed, cytoflavin, diclofenac, omeprazole, almagel, sedative and restorative therapy.
Against the background of the therapy, the patient's condition improved: He is discharged in a satisfactory condition under the supervision of a rheumatologist at the polyclinic.
Recommended:
153. Outpatient observation of a rheumatologist at the place of residence.
154. In case of resumption of pain syndrome or stiffness of the joints in the morning - a consultation with a rheumatologist with a decision on the correction of the therapy and the need for inpatient treatment.
155. Control of the general blood test after 1 month (then 1 time in 3 months)
156. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
157. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
158. Continue taking:
a. Noliprel - ½ tab 1 time per day (in the morning) constantly
b. Methotrexate 2.5 mg - 1 tablet on Monday evening, Tuesday morning and evening (total 7.5 mg / week) - constantly.
c. Prednisolone 5 mg - daily 4 tab. in the morning, 1 in the afternoon, with food, drinking kissel. In the absence of pain and stiffness in the joints, starting from December 5, reduce by 0.5 tablets every 4 days until a maintenance dose of 7.5 mg (1.5 tablets) is reached, then constantly 1.5 tablets in the morning.
d. Calcium D3-Nycomed - 1 tab. in the evening all the time.
e. Cytoflavin - 1 tab. 3 times a day for 1 month
f. Asparkam - 1 tab. 3 times a day from the 1st to the 10th day of each month
MILITARY MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1952 (56 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy.
Diagnosis:
Hypertensive disease stage III (AH 2st, Risk 3) Uncomplicated hypertensive crisis of the first type from 08.12.08, stopped by medication on 09.12.08. ischemic heart disease. Angina pectoris I FC. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis. NK-I, CHSN-I FC.
He was admitted to the clinic for urgent indications with complaints of pain in the parietal region of the head, flies before the eyes, nausea, and an increase in blood pressure to 170/100 mm Hg.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
09.12.
145
4.84
10.9
45.3
13
2
17
7
74
Biochemical blood test:
Name
Unit. rev.
Norm
9.12
Name
Unit. rev.
Norm
9.12
Creatinine
mmol/l
53-124
70
CS
mmol/l
3.7-7
6.67
Urea
mol/l
3-8.4
5.8
TG
mmol/l
0-2.37
0.8
Prothromb.index
%
70-120
136
β-LP
u
350-650
540
Fibrinogen
g/l
200-400
399
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
68.3
Ig G
g/l
7.5-15, 5
ALT
U/L
8.4-53.5
17.9
Ig A
g/l
1.25-2.5
AST
U/L
7-39.7
16.4
CEC
u
6-66
ALP
U/L
36-92
Cl
mmol/l
95 -108
114.8
LDH
U/L
100-220
Na
mmol/l
130-150
139
GGTP
U/L
11-63
17.7
Ca
mmol/l
2.0-2.7
Glucose
mmol/l
4.2-6.4
5.7
K
mmol/l.
4-6
4.27
Tot. bilirubin
µmol/l
6.8-26
19.9
ECHO-KG No. 33 dated 12/15/08: Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no effusion in the pericardium
Ultrasound of the abdominal organs dated 12.12.08: The liver is not enlarged, the thickness of the right lobe is 13 cm, the contours are even, the structure is homogeneous. Gallbladder without stones. Portal vein - 13 mm., Hepatocholedoch - 4 mm. The pancreas is not enlarged, the contours are even, the structure is hyperechoic, moderately heterogeneous. Kidneys without visible pathology. The spleen is not enlarged.
ECG No. 67 dated 09.12.08: sinus rhythm with a frequency of 60 beats per minute, horizontal EOS, left ventricular hypertrophy
Treatment: regimen, diet, polarizing mixture, furosemide, vinpocetine, amlodipine, teveten, atenolol, restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
159. Outpatient supervision of a polyclinic therapist.
160. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
161. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
162. Continue taking:
a. Enalapril 0.01 - 1 tab. 2 times a day (morning and evening) continuously
b. Cordaflex (retard) 0.02 - ½ tab. 2 times a day (morning and evening) continuously
c. Verapamil 0.08 - ½ tab in the morning and in the evening constantly
d. Siofor 500 - 1 tab in the morning and in the evening 15 minutes before meals FGU "442 DISTRICT MILITARY
CLINICAL
HOSPITAL
LenVO" RF Ministry of Defense was on examination and treatment at 15 m / o 442 OVKG during the period with a diagnosis of:
Hypertensive disease of the third stage (deterioration). ischemic heart disease. Angina pectoris II f.k. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. HSN II FC. widespread atherosclerosis. Condition after aneurysm resection with its aortoiliac prosthesis and right nephrectomy due to renal artery occlusion (2006).
Dyscirculatory encephalopathy of the first stage in the form of diffuse neurological symptoms pseudoneurotic syndrome
Hospitalized with complaints of headache, burning pain behind the sternum, noise in the head, discomfort behind the sternum and shortness of breath with previously tolerated physical exertion, pain in the left lumbar region.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Nf%
07.07
159
5.22
9.5
4
1.4
0.2
27.6
8.6
62.4
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein , g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
07.07
clear
1020
yellow
5.0
no
no
no
0
0
0
0
0
to 6
0
Nechiporenko test L=0.75*10^6/l, E=0.5*10^6/l
Biochemical blood test:
Name
Unit. rev.
07.07
Name
Unit rev.
07.07
Creatinine
mmol/l
123
TG
u
Urea
mol/l
6.9
Glucose
mmol/l
5.90
Total protein
g/l
69
cholesterol
mmol/l
5.47
ALT
U/L
31
CAT
times
6.8
AST
U/L
19
Na
mmol/l.
131.4
LDH
U/L
124
K
mmol/L
4.28
CPK
U/L
0.94
Cl
mmol/L
106.7
Total Bilirubin
µmol/l
11.7
Prothrombindex
%
100
Uric acid
Mmol/l
Fibrinogen
g/l
2.57
Results of instrumental studies:
ECG from. 07/07/09 .: sinus rhythm with a heart rate of 60 in 1 min. EOS is deflected to the left. Left ventricular hypertrophy with systolic overload.
FLG of the chest organs dated 01/28/2009. Conclusion: chest organs without visible pathological changes.
Echo-CG from 09.07.09: Diameter of the aortic root 30mm, pulmonary artery 20mm, dilatation of AC 19.1mm, LA 39.7mm, ascending aorta 31mm, IVS 13.2mm, AP 14.7mm, LV EDR 52.1mm, LV ESR 31.3mm , EF 70%, FU 48%, LP 37mm, PP 35.7*47.5mm, RV 20.7mm. Symmetrical myocardial hypertrophy of the left ventricle. Fibrosis and adiskinesia of the posterior basal segment. Slight dilatation of the left atrium The aortic ring and the walls of the aorta are sealed. Cavities, pericardium free. Diastolic dysfunction of the hypertrophic type. Applied mitral regurgitation.
Ultrasound of the abdominal organs and kidneys from 9.07.09. Liver. Right share 15.0, left 4.0*6.0 Structure of uniform density. The gallbladder is not enlarged. There are 2 parietal formations 0.3 mm in the cavity, polyps. Choledoch is not expanded. The pancreas is not enlarged, compacted. The contours are clear. contour deformation. The right kidney has been removed. The bed is without features. The left kidney is 12.4*6.8 cm in size. The parenchyma is thickened to 3.0 cm. The contour is deformed due to fibrous inclusion along the lower pole. In the upper part of the kidney, there is a cyst 2.9*1.6 cm. The cavitary system is not expanded. Bladder The bladder is of medium volume.
Treatment: regimen, diet, piracetam, cytoflavin, milgamma, dilatrend, nifecardia, phenylin, thromboass, diclofenac, physiotherapy, acupuncture.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
Recommended:
163. Outpatient monitoring by a cardiologist in a polyclinic.
164. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
165. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
166. Dispensary observation:
a. clinical blood test, urinalysis - twice a year;
b. Echocardiography - 2 times a year;
c. ECG - 1 time per quarter
167. Continue reception:
a. Dilatrend 25 mg - 1/2 tab in the morning and in the evening
b. Niphecardia 30 mg - 1 tab at night
c. Thromboass 50 mg - 1 tab 1 time per day
d. Lescol forte 80 mg - 1 tab at night
e. Control blood test: ALT, AST, lipidogram, coagulogram in a month.
Diagnosis: Hypertensive disease of the second stage (AH-1, Risk-3). IHD. Angina pectoris 1 f.k. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. CHF 1. Condition after prosthetics of the abdominal aorta in 2003, nephrectomy on the right in 2003. Osteochondrosis of the cervicothoracic spine.
Diagnosis: Hypertensive disease of the second stage (AH-1, Risk-3). IHD. Angina pectoris 1 f.k. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. CHF 1. Condition after prosthetics of the abdominal aorta in 2003, nephrectomy on the right in 2003. Osteochondrosis of the cervicothoracic spine.
MILITARY-MEDICAL ACADEMY.
CLINIC OF
HOSPITAL THERAPY
(73 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy .
Diagnosis:
coronary artery disease. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (2008) cardiosclerosis. Permanent form of atrial fibrillation (paroxysm of atrial fibrillation from 05.10.09), tachy-normosystolic variant. Recurrent sustained ventricular tachycardia with the development of MAC-syndrome equivalents from 22.10.09. NK 2a st., CHF 3 FC.
TsVB. Dyscirculatory encephalopathy 2nd stage of mixed genesis. Chronic bilateral pyelonephritis in remission. HPN-1a. Obesity 1 stage, alimentary-constitutional genesis, stable phase.
He was admitted to the clinic for urgent indications with a paroxysm of atrial fibrillation. During the course of treatment, the patient developed paroxysm of sustained ventricular tachycardia twice (one recorded on HM-ECG, lasting 6 minutes, the second on the ICU monitor). Consulted by an arrhythmologist XUV-1 (Skigin I.O.), implantation of a cardioverter-defibrillator was recommended (indication class 1)
Results of laboratory tests:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pya
%
Xia
%
08.10
133
4.1
9.6
40.5
20
1
1
19
9
7
63
23.10
143
4.55
8.3
45.3
8
26
5
1
68
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epithelium of urinary tract in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
23.10
transparent
1020
yellow
sour
No
no
no
-
no
no
0-2
no
0-1
0-1
Biochemical blood test:
Name
Unit. rev.
Norm
08.10
23.10
Name
Unit. rev.
Norm
08.10
Creatinine
mmol/l
53-124
130
CS
mmol/l
3.7-7
3.76
Urea
mol/l
3-8.4
9.5
TG
mmol/l
0-2.37
Prothrombindex
%
70-120
75
β-LP
units
350-650
Fibrinogen
g/l
200-400
3.8
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
60.2
LDL
mmol/l
1.9-4
ALT
U/L
8.4-53.5
36.4
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
27.5
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
CPK
U/L
10-160
143.7
LDH
U/L
100 -220
Cl
mmol/l
95-108
GGTP
U/L
11-63
Na
mmol/l
130-150
Glucose
mmol/l
4.2-6.4
4.75
Ca
mmol/l
2.0-2.7
1.98
Total. bilirubin
µmol/l
6.8-26
23.6
K
mmol/l.
4-6
ECHO-KG No. 702 dated 10/22/09: Aorta - 34 mm, AV dilatation - 17 mm, RA - 46 * 64 mm, RV ERD - 28 mm, LA - 50 * 55 * 52 mm, LV ESR - 50 mm, LV EDR - 60 mm, FU - 13%, EF - 27%, IVS=11mm, WS=11mm, LA - 28 mm Hg, Dla - 60 mm Hg e/a = 0.89. the myocardium is not thickened, dilatation of the atria, left ventricle, total LV myocardial hypokinesia (akinesia and fibrosis of the posterior, lower walls and the adjacent part of the septum in the basal and middle sections) with a decrease in systolic heart function (EF ≤ 30%, VR ≤ 55 ml). The aorta, fibrous rings of AK and MK, aortic crescents and mitral leaflets are sealed. Expansion of the pulmonary artery up to 29mm (above the valve). Moderate pulmonary hypertension (according to Kitabatake). Regurgitation on all valves: 1-2st on MK, 1st on AK, PC and TK.
ECG No. 1568 dated 07.10.09. atrial fibrillation, tachysystole 85-120 per 1 min, hypertrophy of both ventricles
X-ray 08.10.09. - in the lungs without fresh focal and infiltrative changes. The pulmonary pattern is reinforced and deformed due to diffuse pneumosclerosis. The roots of the lungs are moderately compacted. Sinuses are free. The heart is dilated to the left. The aorta is compacted and deployed.
HM-ECG with VT episode is attached.
Treatment: regimen, diet, polarizing mixture, heparin, warfarin, cordarone, metoprolol, enalapril, sedative and restorative therapy.
He is transferred to the XUV-1 clinic for implantation of a cardiovarter-defibrillator.
Works foreman as a researcher, issued a certificate of temporary disability
No. ____________________________________
168. Adopts regularly:
a. Kordaron 0.2 - 1 tab. 3 times a day continuously
b. Metoprolol 0.05 - ½ tab. 2 times a day (morning and evening) continuously
c. Mildronate 0.5 1 caps. 2 times a day
d. The last injection of heparin (5000 units s.c.) today, 26.10.09 at 9:00 am
Discharge
summary No.
Hospital Therapy Clinic Military Medical Academy named after S.M. treatment of VMedA with a diagnosis of:
Main - Community-acquired focal pneumonia in the lower lobe of the left lung of mild severity. YN0
Results of the examination:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l MSI
,
pg
n, %
e, %
b, %
l, %
m, %
p %
s, %
ESR, mm/h
12.11
139
4.13
5.6
300
33.8
1
1
48
15
2
34
22
16.11
148
4.43
6.3
325
33.5
4
4
29
10
1
52
23
Urinalysis
Date
Transl.
Rel. Density
Colour
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
12.11
clear
1.025
Yellow
7.0
-
-
-
-
-
-
-
-
-
-
Feces per I/g 13.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11.09
Total protein
G/l
63.0-87.0
67.2
Cholesterol
Mmol/l
3.7-6.0
5.32
Triglycerides
Mmol/l
0-2.37
0.94
Glucose
Mmol/l
4.2-6.4
4.86
Prothrombin
%
80-105
98
Fibrinogen
g/l
2-4
2.9
Sialic acids
Mmol/l
1.9-2.5
2.3
ECG from 11.11.2009 g No. 2528 .: sinus tachycardia, deviation of the electrical axis of the heart to the left. Partial violation of intraventricular conduction. The predominance of the potentials of the left ventricle.
According to the results of Rg-graphy of the organs of the chest cavity on November 12, 2009 in frontal and lateral projections without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The median shadow is not expanded.
According to the results of FVD 13.11.09 - slight violations of bronchial conduction. moderate decrease in
Against the background of therapy (regime, diet, bromhexine) notes an improvement in the condition (normalization of body temperature, a decrease in the frequency and intensity of cough, a decrease in weakness).
Recommended:
1. Observation of the doctor's part;
2. Mode of work and rest, dietary nutrition;
3. Complivit 1 tablet 2 times a day after meals for 2 weeks.
4. Exemption from physical exercises, outfits, work for 15 days.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1969 (40 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis: Hypertension stage II (AH-3, Risk of CVE-4). Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis. NK-1. Osteochondrosis of the cervical, thoracic and lumbar regions, left-sided scoliosis of the II degree of the thoracic region, Schmorl's hernia Th6-7 and Th7-8 without dysfunction of the spine with pain syndrome. Initial manifestations of cerebrovascular insufficiency with scattered neurological symptoms, cephalgic, astheno-neurotic syndrome. Obesity II degree, alimentary-constitutional genesis, stable phase. Sliding hernia of the esophageal opening of the diaphragm 1 degree. GERD, reflux esophagitis without obstruction. Chronic gastroduodenitis, exacerbation. Fatty hepatosis without liver dysfunction. Mild catarrhal proctitis, anal fissure. External hemorrhoids without exacerbation.
She was admitted to the clinic for urgent indications with complaints of episodes of severe headache in the head with increased blood pressure, increased sweating after minor physical exertion, indoors at normal room temperature, fresh blood in the feces.
Laboratory results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l MSI
,
pg
e, %
b, %
l, %
m, %
n %
s, %
ESR, mm/h
09.11
149
5.13
8.4
484
29
1
32
4
3
60
10
Urinalysis
Date
Transpar.
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
09.11
clear
1.025
Yellow
5.5
-
-
-
-
-
-
-
-
3-5
2-4
Nechiporenko test 11.11.09
L= 0.75x106 /l, E=2.0x106/
l
Name
Unit
Norm
09.11
Total protein
G/l
63.0-87.0
74.4
Cholesterol
Mmol/l
3.7-6.0
6.41
Triglycerides
Mmol/l
0-2.37
1.13
Glucose
Mmol/l
4.2-6.4
4.84
Prothrombin
%
80 -105
98
Fibrinogen
g/l
2-4
2.8
potassium
Mmol/l
3.5-5.1
4.56
iron
mmol/l
10.5-25
7.4
AST
U/l
11-50
24.2
ALT
U/l
11-50
13.6
Total
bilirubin Umol/l
6.8-26
9.1
Beta-lipoproteins
U
350-650
660
T3
Nmol/l
1.0-2.8
1.4
T4
Nmol/l
53-158
79
TSH
μIU/ml
0.23-3.4
1.58
A/T
U/ml
0-65
0
Ab to TPO
U/ml
0-30
3
Ab for HIV, hepatitis – negative.
Ultrasound of the thyroid gland from 11/17/09. No. 1034: the thyroid gland is enlarged: the right lobe is 16x53x19mm, the left lobe is 19x51x21mm. In the right lobe, a rounded anechoic formation 11 mm in size, in the left lobe, two nodular formations 3-5 mm in diameter and one with a diameter of 9 mm are visualized.
Ultrasound of the OBP dated 12.11.09. No. 1221: the liver is enlarged in size (the thickness of the right lobe is 15 cm), the contours are even, the structure is compacted, the vascular pattern is "depleted" (fatty hepatosis). The gallbladder without calculi, a kink in the body area, the walls are unevenly compacted, thickened up to 2-3 mm. Portal vein 11 mm, hepatocholedochus - 4 mm. The pancreas is of normal size, the contours are even, the structure is hyperechoic, homogeneous. Kidneys of normal size, in both kidneys, more on the right, hyperechoic inclusions (microliths?, calcification?) are visualized. The spleen is not changed.
ECHO-KG No. 791 dated 11/18/09 Ao=28mm, ascend.Ao=26mm, opening AK=16mm, LA=38mm, PP=36mm, RV=26mm, LV=44/24mm, MZHP=WS=11mm, EF=77%, FU=45%, UV =67ml, E/A=1.09 Symmetric concentric LV myocardial hypertrophy, kinetics is not disturbed, heart cavities are not dilated. The aorta is sealed. The blood flow on the valves is laminar. Applied regurgitation on MK and TK. The pericardium is not changed.
ECG #2518 dated 11/10/09: Sinus rhythm with HR 64 per minute, EOS deviated to the left. Left ventricular hypertrophy, local disturbances of intraventricular conduction.
Radiography of the cervical spine No. 2728 dated 11/20/09. (D=0.22 mSv) in 2 projections, the physiological lordosis is straightened, the curvature of the neck to the right. Osteochondrosis of C4-5 C5-6 motor segments with a moderate decrease in the height of the discs, subchondral sclerosis and marginal exophytes 0.1 cm at the same levels in the projection of the discs.
Radiography of the thoracic and lumbar spine No. 2684 (D=1.92 mSv): on radiographs of the thoracic spine in 2 projections, left-sided scoliosis with an angle of deviation from the vertical of 150 with the center of the arc at the level of Th8 (II degree according to Chaklin). Osteochondrosis of Th6-7 and Th7-8 motor segments with reduced disc height, subchondral sclerosis, and marginal exophytes. Schmorl's hernia at the level of Th6-7 and Th7-8.
On spondylograms of the lumbar spine in 2 projections, the physiological lordosis is smoothed. Osteochondrosis L3-4 L4-5 motor segments with a decrease in the height of the discs, subchondral sclerosis and marginal exophytes 0.1 cm in the projection of the discs.
She was consulted by a neurologist at the Clinic of Nervous Diseases of the Military Medical Academy, the diagnosis was supplemented, and recommendations were made. In order to exclude volumetric formation of the brain, an MRI of the brain was recommended (3.12.2009 at 10:30 am).
Radiography of the stomach No. 327 dated November 25, 2009. the esophagus is freely passable for the barium mixture. The cardia does not close completely on inspiration. In a horizontal position, the patient's gastric mucosa falls into the esophagus. The stomach is hypertonic, located high, start on an empty stomach. Its contours are even. The walls are elastic, mucosal folds can be traced throughout, longitudinal. Peristalsis is segmented, waves of medium depth. Evacuation begins after a short spasm of the pylorus. Bulb and loop of the duodenum without features. There is duodeno-bulbar reflux. Conclusion: sliding hiatal hernia of the 1st degree. Functional disorders of the stomach and duodenum.
Sigmoidoscopy of 25.11.09, the tube of the proctoscope was inserted up to 30 cm - no organic pathology was detected. The mucosa is moderately hyperemic, somewhat edematous, dull, the vascular pattern is blurred. A collapsed, non-inflamed external hemorrhoid is noted. At 12 o'clock shallow crack. Conclusion: moderately pronounced catarrhal proctitis. Anal ring fissure. External hemorrhoids without exacerbation.
Treatment: regimen, diet, metoprolol, hypothiazide, enalapril, omeprazole, vascular and anti-inflammatory, sedative and restorative therapy.
Against the background of the therapy, the patient's condition improved: He is discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
169. Outpatient medical supervision of the unit according to DM-1.
170. MRI of the brain December 3, 2009 at 10.30.
171. Repeated consultation of a neurologist with the results of MRI
172. Release from duty for a period of 3 (three) days.
173. Exemption from physical. preparation for 10 days.
174. Exclude from the diet animal fats, fried, spicy, salty and spicy foods.
175. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
176. Continue taking:
a. Enap N - 1 tab 2 times a day constantly
b. Metoprolol 50 mg - 1 tab. 2 times a day continuously
c. Troxevasin 0.3 - 1 tab. 3 times a day for 3 weeks
d. Vazobral 2.0 - 1 tab. 2 times a day for 3 weeks.
e. Grandaxin - 1 tab at 9:00 and at 14:00 1 month
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1988 (21 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy
. Diagnosis:
Cardiac neurocirculatory dystonia without signs of heart failure. Mild myopia in both eyes. Deviated septum without obstruction of nasal breathing.
The clinic was hospitalized in a planned manner with complaints about.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuc., *109/l
Ht
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pi
%
Xia
%
24.11
151
4.85
5.1
44
7
35
8
4
53
Urinalysis, coprogram dated 24.11.09. – without pathology
Biochemical analysis of blood:
Name
Unit. rev.
Norm
24.11
Name
Unit. rev.
Norm
Creatinine
mmol/l
53-124
110
CS
mmol/l
3.7-7
2.8
Urea
mol/l
3-8.4
TG
mmol/l
0-2.37
0.44
Prothromb.index
%
70-120
86
β-LP
u
350-650
280
Fibrinogen
g/l
200-400
3.2
HDL
mmol/l
0.78-2.33
Total protein
g/l
63-87
74.6
Ig G
g/l
7.5-15.5
ALT
U/L
8.4-53.5
17
Ig A
g/l
1.25-2.5
AST
U/L
7-39.7
13
CEC
u
6-66
amylase
U/L
28-100
17.1
Cl
mmol/l
95-108
LDH
U/L
100-220
Na
mmol/l
130-150
136
GGTP
U/L
11-63
13
Ca
mmol/l
2.0-2.7
2.4
Glucose
mmol/l
4.2-6.4
5.2
K
mmol/l.
4-6
3.87
Tot. bilirubin
µmol/l
6.8-26
26
Sialic acids
mmol/l
1.9-2.5
2.0
ECHO-KG No. 810 dated 11/25/09: Aorta 27 mm, aortic ring 20 mm, asc. aorta 26 mm, aortic valve dilatation 21 mm, LA 33 mm, LV CR 30 mm, LV CR 49 mm, FU 39%, fr choice 65%, WS 9 mm IVS 9 mm, PP 34 mm, RV 24 mm; the myocardium is not thickened, the cavities are not dilated, the kinetics is not changed. Systolic and diastolic functions of the left ventricle are not disturbed. Aorta, valves intact, laminar blood flow, first degree regurgitation on the pulmonic valve. The pericardium is unchanged, there is no pericardial effusion.
Daily ECG monitoring by Holter from 30.11.09. sinus arrhythmia, rhythm and conduction disturbances, ischemic ST changes were not detected.
Ultrasound of the abdominal cavity and thyroid gland dated November 25, 2009: no pathological changes were detected.
Bicycle ergometry No. 4 of December 2, 2009: negative test. Tolerance to physical activity is high. BP response is adequate.
ECG No. 2636 dated 11/24/08: sinus tachycardia with a frequency of 94 beats per minute, posterior rotation of the apex.
Consulted by specialist doctors: surgeon, ENT, neurologist, dentist, ophthalmologist. Conclusion: "A" - fit for military service.
Treatment: regimen, diet, metabolic and restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged under the supervision of a doctor of the unit in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
177. Outpatient supervision of a doctor in accordance with DM-1.
178. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
179. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1964 (45 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis:
IHD: angina pectoris 1 FC. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and postinfarction (30.08.09) cardiosclerosis. Stenting of LEVZ from 08.11.2009. Hypertension III Art. (AG-2, R-4). Dyscirculatory encephalopathy II st. mixed genesis (atherosclerotic, hypertensive, vertebrogenic) in the form of scattered neurological symptoms and pseudoneurotic syndrome. Chronic gastroduodenitis in remission. Steatohepatitis without liver dysfunction. Nodule of the left lobe of the thyroid gland, euthyroidism. Osteochondrosis of the cervical spine, hypoplasia of the transverse processes of the seventh cervical, first thoracic vertebrae. Chronic vertebrogenic cervicothoracic sciatica with a predominant lesion of the V-VI roots without impaired spinal function. Longitudinal flat feet II st. both feet without arthrosis of the talonavicular joints. Hyperopia degree of 0.5 diopters in both eyes.
He was admitted to the clinic for urgent indications with complaints of episodic discomfort in the region of the heart, which occurs during psycho-emotional stress, which is relieved by rest; palpitations, shortness of breath during exercise above average; for recurrent headaches and dizziness with an occasional increase in blood pressure (BP max. = 160/100 mm Hg, blood pressure work. = 130/80 mm Hg).
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuc., *109/l
Ht,
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
02.12
140
4.31
5.7
42.9
5
3
35
8
2
52
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
01.12
mutn
1020
yellow
sour
0.04
no
no
no
no
no
0-2
no
2-4
-
Biochemical blood test:
Name
Unit. rev.
Norm
02.12
Name
Unit. rev.
Norm
02.12
Creatinine
mmol/l
53-124
90
CS
mmol/l
3.7-7
4.63
Urea
mol/l
3-8.4
TG
mmol/l
0-2.37
0.85
Total protein
g/l
63- 87
75.2
CPK
mmol/l
10-160
74.3
ALT
U/L
8.4-53.5
27.0
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
15.8
Ig A
g/l
1.25-2.5
GGTP
U/L
11-63
Na
mmol/l
130-150
136.4
Glucose
mmol/l
4.2-6.4
Ca
mmol/l
2.0 -2.7
2.43
Total bilirubin
µmol/l
6.8-26
K
mmol/l.
4-6
3.90
ECHO-KG from 2.12.09: Aorta - 31 mm, PP - 40 mm, LA - 53 mm, LV ECR -33 mm, LV EDR - 54 mm, FU - 38%, EF - 68%, IVS 10 mm, GS 10 mm, LA - 21 mmHg, e/a = 1.05. Dilatation of the left atrium. The myocardium is not thickened, akinesia of the posterior and lower segments in the middle and basal regions. Global systolic function is not impaired. The aorta and fibrous rings of AC and MC are sealed, the blood flow is laminar. Regurgitation of the 1st degree on the tricuspid and mitral valve. The pericardium is not changed.
Ultrasound of the abdominal organs dated 23.12.08: The liver is not enlarged, the thickness of the right lobe is 13 cm, the contours are even, the structure is homogeneous. The gallbladder is without calculi, the walls are compacted, thickened up to 4 mm. Portal vein - 12 mm., Hepatocholedochus - 5 mm. The pancreas is not enlarged, the contours are even, the structure is hyperechoic, homogeneous. Kidneys: right - 9 × 4 cm, parenchyma up to 12 mm, uneven contours, expansion of individual cups up to 16 mm, PCS deformed; left - 11.5 × 6 cm, parenchyma up to 10 mm, expansion and deformation of the PCS, in the middle third, two cysts 2.6 and 2.2 cm in diameter. The spleen is not enlarged.
ECG No. 156 dated 12/17/08. atrial fibrillation, tachysystole 85-120 per 1 min, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 161/162/177 dated December 18-22, 08: sinus rhythm with a frequency of 60-78 beats per minute, vertical EOS, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 185 dated 12/23/08. sinus rhythm with a frequency of 82 per 1 min., vertical EOS, hypertrophy of both ventricles, more than the right one, in dynamics some worsening of repolarization of the apical-lateral region of the left ventricle
Treatment: regimen, diet, polarizing mixture, vinpocetine, enalapril, cordaflex, siofor, restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
180. Outpatient supervision of a polyclinic therapist.
181. Exclude from the diet animal fats, fried, spicy, salty and spicy foods.
182. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
183. Continue taking:
a. Enalapril 0.01 - 1 tab. 2 times a day (morning and evening) continuously
b. Cordaflex (retard) 0.02 - ½ tab. 2 times a day (morning and evening) continuously
c. Verapamil 0.08 - ½ tab in the morning and in the evening constantly
d. Siofor 500 - 1 tab in the morning and in the evening 15 minutes before meals FGU "442 DISTRICT MILITARY
CLINICAL
HOSPITAL LenVO" RF Ministry of
Defense (54 years old), was examined and treated at 15 m/o 442 OVKG with a diagnosis of:
Hypertensive disease of the second stage (AH-1; Risk of CVE -3). Initial manifestations of atherosclerosis of the aorta and coronary arteries. NK-1, KhSN-1 f.cl. Peptic ulcer of the duodenal bulb in remission. Biliary dyskinesia of the hypomotor type. Chronic vertebrogenic cervicalgia and thoracalgia in the stage of unstable remission. Osteochondrosis of the cervicothoracic spine.
Hospitalized in a planned manner with complaints of recurrent pain in the epigastric region with errors in diet, headache, dizziness, pain in the cervical spine.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht, %
ESR, mm/h
Thrombus
*109/l
Lf
%
M
%
Granulocytes
%
18.12
133
4.67
7.1
37.9
6
163
30.1
5.5
64.4
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
21.12
transparent
1025
yellow
5.5
no
no
no
no
no
no
1-2
no
1-2
no
_
_
_ rev.
Norm
18.12
22.12
Name
Unit. rev.
Norm
18.12
22.12
Creatinine
mmol/l
53-124
93
cholesterol
mmol/l
3.7-7
5.9
Urea
mol/l
3-8.4
9.1
TG
mmol/l
0-2.37
Prothrombindex
%
70- 120
120.6
β-LP
u
350-650
Fibrinogen
g/l
200-400
2.61
HDL
mmol/l
0.78-2.33
1.17
Total protein
g/l
63-87
67
73
LDL
mmol/l
1.9-4
Albumin
%
37-50
40
CS/ HDL
times
3-5
1
%
3-6
VLDL
mmol
/l
0.6-1.2
2
%
9-15
atheros.
Unit
0-3
4.0
%
8-18
amylase
U/L
28-100
71
71
%
15-25
trypsin
u/l
0-0.35
Globulins
g/l
17-35
33
ing. trypsin
u
18-36
a/g
1.1-2.5
1.2
Ig M
g/l
0.65-1.65
ALT
U/L
8.4-53.5
128
99
Ig G
g/l
7.5-15, 5
AST
U/L
7-39.7
59
Ig A
g/l
1.25-2.5
ALP
U/L
0.7-2.3
1.2
CEC
u
6-66
LDH
U/L
100-220
194
224
Cl
mmol/l
95-108
GGTP
U/L
11-63
29
Na
mmol/l
130-150
Glucose
mmol/l
4.2-6.4
5.88
6.09
Ca
mmol/ l
2.0-2.7 Tot
. bilirubin
µmol/l
6.8-26
23.7
28.2
K
mmol/l.
4-6
CPK
u/l
0.46-2.96
5.15
RW
quality
Results of instrumental studies:
ECG from. 11/21/2009: sinus rhythm with a heart rate of 70 beats per minute, horizontal EOS. Indirect signs of left ventricular hypertrophy.
VEM No. 59 dated 12/23/2009: ECG at rest is normal. Load tolerance is high. The response of blood pressure to exercise is a hypertensive response. No chest pains were noted. Arrhythmias: no. There were no changes in the ST segment. The test is negative.
ECHO-KG No. 219 dated 12/18/09 Ao=35mm, AC expansion=17mm, LA=38mm, RA=45mm, RV=30mm, LV=59/40mm, IVS=WS=8.5mm, EF=59%, FU=32% Myocardium is not thickened, kinetics are not violated. The cavities of the left ventricle and atrium are dilated. The valves are intact. The aorta is sealed. The blood flow on the valves is laminar. Regurgitation 1 degree on the mitral valve. The pericardium is not changed.
X-ray of the chest organs from 12/17/2009. Conclusion: in the lung tissue without visible focal and infiltrative changes. The roots are structural, the sinuses are free. Heart with enlarged left ventricle. The aorta is not changed.
Ultrasound of the abdominal organs from 12/22/2009: no pathological changes.
Consulted by an ophthalmologist: the conclusion is a thorn in the right eye.
Conducted treatment: regimen, diet, metabolic and antihypertensive therapy.
Against the background of the therapy, the patient's condition improved, he is discharged under the dynamic supervision of the doctor of the unit.
Recommended:
1. Observation of a therapist (cardiologist).
2. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
3. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
4. Amlodipine 0.005 - 1 tab 1 time per day, in the morning.
Federal State Institution "442 DISTRICT MILITARY CLINICAL HOSPITAL LENVO" Ministry of Defense of the Russian Federation
Discharge summary No. 7349
Lieutenant colonel of the medical service, born in 1972 was on examination and treatment at 15 m / o 442 OVKG in the period from 14.05. on May 31, 2010 with a diagnosis of
Reiter's syndrome with damage to the right ankle joint and II and III metatarsophalangeal joints of the left foot of the II degree of activity. Hemorrhagic vasculitis, cutaneous form. Hypertensive disease of the first stage (Risk of CVE is moderate) without signs of heart failure. Polyp of the gallbladder. Chronic gastritis in remission.
He was hospitalized with complaints of rashes on the skin of the legs (small petechial confluent rash), subfebrile condition in the evening, pain during movement in the ankle joints, headaches and general weakness.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Xia
%
Pya%
Gran.
%
14.05
117
3.5
5.3
20
4
1
13
9
59
14
25.05
124
4.05
5.1
5
25.8
2.8
71.4
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MV epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
16.05
mud
1020
yellow
acid
0.15
no
no
0
0
0
0
0
1-2
0-0-1
In daily urine from 18.05.2010 protein not found
Biochemical blood test:
Name
Unit. rev.
14.05
Name
Unit. rev.
14.05
Creatinine
mmol/l
106
TG
units
Urea
mol/l
5.9
Glucose
mmol/l
6.42
Total protein
g/l
75
cholesterol
mmol/l
3.87
ALT
U/L
21
CAT
times
AST
U/L
13
Na
mmol/ l.
145
LDH
U/L
122
K
mmol/l
4.6
CPK
U/L
0.83
Cl
mmol/l
104
Tot. Bilirubin
µmol/l
14
Prothromb.index
%
100
Uric acid
mmol/l
Fibrinogen
g/l
4.08
Sowing from the pharynx for flora dated 05/17/2010: Staphylococcus epidermidis, Staphylococcus viridans
Nasal swab for flora dated 05/17/2010: Staphylococcus epidermidis in a small amount
Results of instrumental studies:
ECG from. 05/12/10 .: sinus rhythm with a heart rate of 60 in 1 min. EOS is horizontal.
FLG of the chest organs dated 14.05.2010. Conclusion: chest organs without visible pathological changes.
Echo-CG from 12.04.10: Aortic root diameter 33mm, pulmonary artery 20mm, dilatation of AC 19.1mm, LA 37x46x45mm, IVS 10mm, AP 8mm, LV EDR 53mm, LV ESR 35mm, EF 63%, FU 34%, PP 33*44mm, RV 25mm. Without dynamics with ECHO-KG from 04/09/2010. (see discharge summary).
Ultrasound of the abdominal cavity and thyroid gland from 17.05.10. Sick after eating Liver. Right lobe 14.6, left 9.0*7.0 Structure of uniform density, echogenicity is not changed. Gallbladder contracted (after eating). On the front wall there is a polyp 0.6 cm. The right kidney is 10.6x5.6 cm. The parenchyma is 2.8 cm. The left kidney is 11x5.6 cm in size. The parenchyma is up to 2.5 cm. The echogenicity of both kidneys is increased, the structure is homogeneous. PCLS with fibrosis. Ultrasound signs of toxic kidneys. The spleen is not enlarged 11x4.6 cm, the structure is homogeneous, echogenicity is not changed. The splenic vein is not changed. The prostate gland is not enlarged 3.6x2.8x3.4 cm (volume 21.6 cm3), the structure is homogeneous , echogenicity is not changed, there are no nodes. The thyroid gland is not enlarged: S=6.9 cm3, D=8.1 cm3 the structure of both lobes is homogeneous, there are no nodes. Echogenicity, blood flow are not changed.
Treatment: regimen, diet, nise, clexane, sulfasalazine, prednisolone, physiotherapy, acupuncture.
On the background of the therapy, the patient's condition improved. Discharged to the unit in a satisfactory condition.
Recommended:
184. Outpatient observation of therapists, rheumatologist.
185. Dispensary observation:
a. clinical blood test, urinalysis - twice a year;
b. Echocardiography - 1 time per year;
c. ECG - 1 time in 6 months
186. Continue taking:
a. Sulfasalazine at 2.0/day
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCUSSION REPORT CASE
HISTORY No. ARCHIVE No. _________
Last name, first name, patronymic
Was hospitalized
at the hospital therapy clinic
Total treatment days 9
Final diagnosis established ICD Code I 25.5 MES 291060;
Diagnosis:
Ischemic heart disease: stable angina pectoris 3 functional class. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and post-infarction (2004) cardiosclerosis with impaired conduction by the type of complete blockade of the left leg of the His bundle. Secondary ischemic cardiomyopathy. Chronic aneurysm of the apex of the left ventricle. Insufficiency of the tricuspid valve of the 3rd degree, mitral and pulmonary valve of the first degree.
Hypertensive disease of the third stage, drug normotension, the risk of CVE is extremely high.
Chronic heart failure stage 2B, IV functional class. Middle fibrothorax on the right. Chronic decompensated pulmonary heart of mixed (broncho-pulmonary, vascular, thoraco-diaphragmatic) genesis. Secondary severe pulmonary hypertension. Diffuse pneumofibrosis. DN 1st.
Liver fibrosis of mixed (cardiac, infectious (HBV), dysmetabolic) genesis (Child-Pugh class B). Chronic hepatocellular insufficiency of the 1st stage, compensation. Portal hypertension syndrome, ascites. Hepatosplenomegaly.
Chronic atrophic gastritis.
Chronic pyelonephritis, latent course, remission. Nephropathy of mixed (atherosclerotic, dysmetabolic, diabetic, hypertensive) genesis. CKD stage C3a (GFR=54ml/min).
Encephalopathy of the second stage of mixed (dyscirculatory, dysmetabolic, hepatic) genesis.
Type 2 diabetes mellitus, HbAc 7.11%, target HbAc<8.0% Diabetic distal sensory polyneuropathy, diabetic microangiopathy.
Varicose veins of the lower extremities, superficial form. Chronic venous insufficiency stage 2.
Unincarcerated easily reducible umbilical hernia.
Degenerative-dystrophic disease of the spine.
Secondary chronic drug gout. Chronic gouty arthritis of the first metatarsophalangeal joint of the left foot, exacerbation.
Clinical outcome: improvement
Outcome: discharged on improvement,
Complaints: on the growing pronounced general weakness, decreased exercise tolerance, an increase in the abdomen in volume, shortness of breath of a mixed, mainly inspiratory nature.
History of present illness. For a long time he suffers from coronary heart disease, hypertension. In 2006, she suffered a massive myocardial infarction. On October 17, 2010, surgical treatment was performed for bleeding (shock 2-3) from a chronic stomach ulcer. During the same hospitalization, decompensated diabetes mellitus was revealed. After discharge, she did not comply with the doctor's recommendations, she began to notice an increase in the volume of the abdomen. On this occasion, she was repeatedly hospitalized in the hospitals of the city, where complex treatment was performed with active diuretic therapy. The last hospitalization in the pulmonology department of City Hospital No. 26. After discharge from the hospital on December 14, 2010, she began to notice a sharp increase in dyspnea at rest, the appearance of a cough without discharge, and an increase in general weakness. On December 23, 2010, she was admitted to the hospital therapy clinic. After discharge, he feels well for 2 weeks, but later on there is a progressive increase in the feeling of weakness, shortness of breath, which requires re-hospitalization. In February, March and April 2011, for the reasons described above, she underwent inpatient treatment, where punctures of the pleural cavity and evacuation of the contents were performed. In June 2011, she was hospitalized in order to exclude a neoplasm (mesothelioma) at the Federal State Institution “Research Institute of Oncology named after N.N. N.N. Petrov” of the Ministry of Health and Social Development of the Russian Federation, where after a comprehensive examination, including pleural biopsy and thoracoscopy, no data for the neoplasm were obtained. Diagnosed with idiopathic right-sided hydrothorax, ischemic cardiomyopathy. Subsequently, she underwent inpatient treatment at the Regional Cardiological Dispensary of the Leningrad Region. After release, within 2 months she felt satisfactory, however, in the future, due to progressive weakness on an outpatient basis, at least 2,000 ml of fluid was evacuated monthly during punctures of the right pleural cavity. During hospitalization in March 2012, during the drainage of the pleural cavity from March 5 to March 8, about 6000 ml of hemorrhagic exudate was obtained, a drop in hemoglobin from 144 to 80 g/l was noted, which was the reason for transfer to a surgical hospital, where data for ongoing intrapleural bleeding was not received, received conservative therapy, terilitin therapy. Discharged with subfebrile fever. Due to the deterioration of health in May 2012 in the form of severe fever, pain in the right half of the chest, she was hospitalized in the hospital surgery clinic, where she underwent inpatient treatment for pleural empyema on the right. After discharge, she felt relatively well. October 2012 general weakness began to progressively increase again, tolerance to physical activity sharply decreased, and the stomach increased in volume. She underwent inpatient treatment in the hospital therapy clinic with a positive effect. During the year, there was a slow progression of ascitic phenomena, which by November 2013. acquired a pronounced decompensated character and required another hospitalization. She was hospitalized by an ambulance to the hospital therapy clinic for further diagnosis and treatment. Diagnosis at discharge: “Chronic viral hepatitis B, cirrhotic stage (Child-Pugh class B). Fibrosis of the liver of mixed (cardiac, dysmetabolic) genesis. Chronic hepatocellular insufficiency of the 1st stage, compensation. Portal hypertension syndrome, ascites. Hepatosplenomegaly. IHD: stable angina pectoris 3 functional class. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and postinfarction (2004) cardiosclerosis. Secondary ischemic cardiomyopathy. Chronic aneurysm of the apex of the left ventricle. CHF 2B stage, III functional class. Middle fibrothorax on the right. Chronic decompensated pulmonary heart of mixed (broncho-pulmonary, vascular, thoraco-diaphragmatic) genesis. Secondary severe pulmonary hypertension. DN 1st. Hypertensive disease of the third stage, drug normotension, the risk of CVE is extremely high. Chronic pyelonephritis, latent course, remission. Mixed nephropathy (atherosclerotic, dysmetabolic, diabetic, hypertonic) genesis. CKD stage C3b (GFR=44ml/min). HPN-1a. Dyscirculatory encephalopathy of the second stage of mixed (hypertonic, atherosclerotic, dysmetabolic) genesis. Degenerative-dystrophic disease of the spine. Type 2 diabetes mellitus, target HbAc<8.0%.” During hospitalization, there was a pronounced tolerance to the ongoing complex diuretic therapy in high doses. After discharge from the hospital, she was under dispensary dynamic supervision of a polyclinic doctor at her place of residence, she did not take the recommended therapy. There was a progressive increase in body weight, during the last month there was a pronounced general weakness, an increase in the volume of the abdomen, shortness of breath of a mixed, mainly inspiratory, nature with previously tolerated exercise tolerance.
Past diseases, injuries, contusions, operations: myocardial infarction-2006, suturing of a perforated stomach ulcer - 17.01.2010. Since 2010, more than 30 pleural punctures, in March 2012, intrapleural bleeding on the right, May 2012. empyema of the pleura on the right. Since 2012 - continuously recurrent ascites, since 2013 - tolerance to diuretic therapy.
Insurance anamnesis: disabled person of the 1st group due to a general disease.
Objective status at admission: Height 165 cm Body weight 82.6 kg BMI-29.4 kg/m2.
The general condition is moderate, due to signs of portal hypertension, heart failure. Consciousness is clear (SHG=15b). The situation is forced. The physique is correct, corresponds to age and sex. Normosthenic constitution. The skin is swarthy, dry, thinned. Icteric sclera. The elasticity of the skin is reduced. Subcutaneous tissue of a homogeneous consistency, no edema. The hairline is developed in accordance with age and sex. Swelling of the cervical veins is noted, which increases during the test with an increase in intrathoracic pressure. Peripheral lymph nodes are not enlarged. The muscular system is developed satisfactorily. On palpation of the radial arteries, the pulse is rhythmic, with a frequency of 80 beats. per minute, satisfactory filling, uneven, not tense. Sat O2 at rest 96%. Arterial pressure - 120/80 mm. rt. Art. The boundaries of relative cardiac dullness are extended to the left to the middle clavicular line, the right one is not defined. The width of the vascular bundle does not extend beyond the edges of the sternum. The number of heartbeats corresponds to the pulse. Heart sounds are muffled, the first tone at the apex is weakened, at the apex of the heart there is a coarse systolic murmur, the emphasis of the second tone is on the pulmonary artery. The chest is symmetrical. The respiratory rate at rest is 22 per minute, the respiratory movements are rhythmic, the right half of the chest lags sharply in the act of breathing. On percussion, dullness over the sinus on the right. On auscultation over the lungs, breathing is hard, on the right, breathing over the sinus is not heard, single congestive rales over the right lower lobe. Tongue wet, pink. The abdomen is significantly enlarged due to the accumulation of free fluid, the correct shape, symmetrical, soft, peritoneal symptoms are negative. The edge of the liver +2 cm from under the edge of the costal arch, dense texture, bumpy, painless on palpation. The size of the liver according to Kurlov is 18x14x10 cm. The spleen is 08/8 cm. Ragosa's symptom is positive. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless.
Treatment: mode 1, diet No. 9, metabolic therapy, hypoglycemic, diuretic metabolic, hepato- and cardioprotective therapy.
Results of instrumental studies:
ECG on admission dated February 05, 2014 shows sinus rhythm with a heart rate of 80 beats per minute. EOS is deflected to the right. Hypertrophy of the right and left ventricles. Widespread cicatricial changes in the anterior-septal-apical-lateral LV. Diffuse disorders of repolarization. Complete blockade of the left branch of the His bundle
ECHO-KG from 02/05/14:
PARAMETERS
Val.
NORMAL
PARAMETERS
Value
NORM
Aortic root diameter
21.1
20-37 mm
Left ventricular
EDR 69.5
38-56 mm
Opening of the leaflets of the aortic valve
17.4
more than 15 mm ESR of the
left ventricle
61.4
22-38 mm
Antero-posterior dimension of the left atrium
51.6
25-40 mm
Thickness of the free wall of the right ventricle
4.5
less than 5 mm
Frontal dimension left atrium
55.5
25-45 mm
Left ventricular ejection fraction
25
more than 55%
Vertical size of the left atrium
64.8
29-53 mm
Right atrial size
50.2
30-46
Interventricular septal thickness
7.4
7-11 mm
Vertical size of the right atrium
51.5
34-49 mm
Thickness of the posterior wall of the left ventricle
8.1
7-11 mm
EDR of the right ventricle anteroposterior
47.7
Less than 30 mm
Systolic pressure in the LA
69
to 30 mm Hg
Pulmonary trunk diameter
26, 8
12-23 mm
Conclusion: Dilatation of all chambers of the heart. Spherical deformation of the heart cavities, the phenomenon of spontaneous pseudocontrasting of the cavities Paradoxical movement of the IVS. Against the background of total myocardial hypokinesia, fibrosis and thinning of the IVS. Dyskinesia of the apex in the area of the IVS, anterior and lateral walls with a transition to akinesia of the anterior and lateral walls in the middle section without signs of parietal thrombus formation. Dilatation of the pulmonary artery up to 26 mm. Regurgitation in all valves. The aorta, the fibrous rings of all valves are sealed with inclusions of calcifications in the structures of the aortic crescents and mitral cusps. the phenomenon of spontaneous pseudocontrasting. Hypertrophy of the right ventricle. Pulmonary hypertension III degree. Regurgitation in all valves. Pseudonormal type of transmitral blood flow. The leaves of the pericardium are thickened, compacted.
Ultrasound of the abdominal and thoracic cavities on 02/05/2014: the liver is enlarged, the right lobe is 20.5 cm, the left lobe is 9.0 cm, the contours are even, the structure is heterogeneous, the echogenicity is significantly increased, the vascular pattern is depleted, the vessels (portal vein, hepatic veins) are not expanded, volume educations are not revealed. The gallbladder of the correct form, 5.0 - 4.2 cm, the walls are 4 mm, the contents are homogeneous bile, the common bile duct is 0.4 cm. The pancreas is not clearly located, the contours are not clear, not even. 16.0 * 13.5 increased echogenicity, Wirsung's duct is not dilated. The kidneys are located in a typical place, normal mobility, wavy contours; the right kidney is 10.0*5.5, the parenchyma is homogeneous 16 mm, PCS is not expanded, the left kidney is 10.0*5.7 cm, the contours are even, the parenchyma is homogeneous 17.0 mm, PCS is not expanded. No pathological formations were found in the projection of the adrenal glands. The spleen is not enlarged 10.2*6.1, the structure is homogeneous. Conclusion: hepatomegaly, diffuse changes in the liver, pancreas. A significant amount of fluid is located in the right pleural cavity. Ascites.
FLG OGK from 02/06/2014: in the lungs, the phenomena of venous congestion (expressed). The roots of the lungs are sealed due to the vessels. In the right pleural cavity, the encysted fluid is projected at the level of the 15th rib (counting along the anterior segments). The heart is significantly expanded due to all departments. Atriovasal angles are raised (fluid in the pericardium). The aorta is sealed.
Results of laboratory researches:
Analysis of urine:
Indicator
05.02
18.02
Color
Yellow
Yellow
Transparency
Slightly cloudy.
Weak - cloudy.
Specific Weight
1020
1020
Reaction
5.5
6.5
Protein (g/l)
no
no
Sugar
no
no
Urobilin
3.2 umol\l
16 umol\l
Leukocytes in p/
s 2-3-3
2-3
Erythr. unchanged in p/
s 3-4-6
0-1
Erythr. Vyschi. In p / sp
Epithelium pl in p / sp.
up to 5 p/sp
1-2-4 p/sp
Bacteria
1 CBC
:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pya
%
Xia
%
04.02.
122
4.62
6.3
6
2
24
6
3
65
05.02
127
4.67
4.7
6
1
22
5
2
70
10.02.
123
4.53
5.6
10
4
3
20
6
4
63
17.02
118
4.29
6.2
7
2
25
6
1
66
_
_
_
Norm
04.02.
10.02
17.02.
18.02
Creatinine
µmol/l
53-124
0.10
0.10
0.19
0.13
Urea
Mole/l
2.5-6.4
12.0
12.3
25.3
26.7
Cholesterol
Mole/l
3.7-6.0
2 .75
1.05
Triglycerides
Mole/L
0-2.37
1.00
1.1
HDL
mmol/L
0.78-2.33
0.97
LDL
ratio
1.9 – 4.4
1.32
VLDL
ratio
0.6 – 1.2
0.46
0.5
Total protein
G/l
63.0-87.0
73
73
62
Calcium
Mole/l
2.1-2.5
2.19
2.15
2.43
Potassium
Mole/l
3.5-5.1
4.78
3.51
4.35
4.86
Sodium
Mole/l
136-145
137.7
146 ,8
142.6
141.9
Prothrombin
%
70-120
48%
61%
72
Fibrinogen
Mg/dl
200-400
2.64
411
CK
U/l
10.0-160.0
52
AST
U/l
11.0-50.0
16
15
ALT
U/l
11 -50
13
9
alkaline phosphatase
U/l
45 - 129
121
Amylase
U/l
30 - 118
52
Uric acid
µmol/l
150-420
655
193
Glucose
Mole/l
4.2-6.4
5.97
4.0
8.64
SK-MB
Mole/l
0-25
10.5
HBs antigen
+
+
Hb A%
7.11
-
INR
2-3
1.55
1.31
albumin
g/l
30-55
40.47
LDH
U/l
120-246
220
o. bilirubin
umol/l
6.8-26
26.9
14.2
GGTP
U/l
8-63
81
Aβ (II) Rh (+) positive (10.02.14 g).
Currently, using the available therapeutic methods of treatment, an unstable, maximum possible compensation for the insufficiency of internal organs and metabolic processes has been achieved. Taking into account the severity of post-infarction myocardial remodeling, severe systolic dysfunction of the left ventricle, lack of prospects for surgical treatment and high risk of mortality during surgical intervention from coronary angiography, active fibrinolytic therapy, it was decided to abstain.
The patient is discharged in a state of moderate severity under the supervision of specialists from the clinic at the place of residence. Body weight at discharge 71.6 kg.
Recommended:
19. Supervision by a cardiologist, endocrinologist, hepatologist at the place of residence.
20. Consultation with a cardiac surgeon-arrhythmologist to resolve the issue of implanting a three-chamber cardioverter-defibrillator (CRT)
21. Diet, normalization of work and rest. Limit salt and liquid intake. Self-monitoring of blood pressure and heart rate, thermometry, body weight.
22. With an increase in body weight over 76 kg - control of the ultrasound of the abdominal cavity and the decision on hospitalization!
23. Control of the general analysis, the level of urea, blood potassium 1 time per month
24. X-ray control of the right chest cavity and ultrasound of the abdominal cavity 1 time per month
25. Continue taking:
• Tab. Digoxin 0.00025 ½ tablet daily in the morning
• Tab. Carvedilol 12.5 mg 1 tablet 2 times a day continuously.
• Tab. Prestarium A 0.005 ½ tablet in the evening constantly.
• Tab. Furosemide 2 tablets 3 times a day continuously
• Tab. Veroshpiron 25 mg 2 tablets 4 times a day continuously.
• Tab. Hepa-Merz inside, after meals, 1 sachet of granulate, previously dissolved in 200 ml of liquid, 2 times a day for a long time.
• Caps. Ursosan 2 capsules 2 times a day for a long time
• Suspension Duphalac 5 ml 2 times a day
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
EXECUTIVE SUMMARY
CASE HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1978
Was on inpatient treatment (in the day hospital mode)
in the clinic of hospital therapy
Total treatment days were 14
The final diagnosis was established ICD code I 11.9
Diagnosis:
First stage hypertension, (AH-3, the risk of CVC is moderate). Initial manifestations of cerebrovascular insufficiency in the form of scattered neurological symptoms and pseudoneurotic syndrome. Left-sided scoliosis of the first degree, osteochondrosis of the thoracic spine without dysfunction. Shoulder periarthritis. Myopia 3.0 D in both eyes
A disability certificate was not issued.
Ability to work restored
Total exposure dose 0.52 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, _____ disability group, degree of disability _______________________________, other _____________________________________________
Outcome: discharged on improvement, discharged on recovery, transferred to another medical institution ( what) ____________________, transferred to rehabilitation treatment (where) _____________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a medical
examination
.
Complaints: headaches mainly in the occipital region of the head, episodic dizziness, absent-mindedness after psycho-emotional stress; fast fatigue; decrease in performance.
Medical history: Episodic headaches against the background of high blood pressure have been noted since 2007, but he did not seek medical help due to fear of being dismissed from military service. Upon admission to the VATT in 2008, the VVK was diagnosed as “healthy”. After admission, against the background of increased psycho-emotional stress, headaches became more frequent. On the recommendation of friends, he began to periodically measure blood pressure, while he noted a stable increase in blood pressure at the level of 140/100 mm Hg. Art. with periodic increases up to 170/100 mm Hg. In 2009, due to a significant increase in blood pressure (220/140 mmHg), he was hospitalized in 17 m / o 442 OVKG from February 18 to March 10, 2009, with a diagnosis of "Hypertension of the first stage (borderline). Hypertensive crisis from 17.02.2009, stopped with medication” (discharge summary No. 3434). After discharge, he does not take regular therapy. Occasionally, with an increase in blood pressure over 150/100 mm Hg. independently takes captopril with a moderate effect (“working” blood pressure 140/90 mm Hg).
A real deterioration in well-being over the past month, when rapid fatigue began to appear with previously tolerated physical exertion, with psychoemotional stress, frequent rises in blood pressure up to 190/110 mm Hg began to be noted, headaches with nausea developed, which required additional intake of antihypertensive drugs. funds (captopril up to 100 mg under the tongue).
Independently applied to the medical service 104 CDC, from where, given the inadequacy of the self-treatment, he was sent for hospitalization in order to diagnose and select adequate therapy.
Objective status: Height 187 cm. Body weight 95 kg. Chest circumference (calmly) 118 cm. The general condition is satisfactory. Consciousness is clear, contact, adequate. The position is active. The physique is correct, corresponds to age and sex. Normosthenic physique, increased nutrition (BMI 27.2). The elasticity of the skin is not changed. Subcutaneous tissue of a homogeneous consistency, no pastosity. The hairline is developed in accordance with age and sex. Hair and nails are not changed. The shape of the neck is normal, its contours are even. The thyroid gland is not visually determined, not palpated. Peripheral lymph nodes are not enlarged. The muscular system is developed satisfactorily. On palpation of the radial arteries, the pulse is synchronous, the same on both hands, rhythmic, with a frequency of 72 beats. per minute, satisfactory filling, uniform, tense, the vascular wall outside the pulse wave is not palpable. Blood pressure: on the right shoulder - 150/100, on the left shoulder - 150/100 mm Hg. Art. Limits of relative cardiac dullness: right and upper are normal; left - 0.5 cm medially from the left mid-clavicular line. The width of the vascular bundle does not extend beyond the edges of the sternum. The number of heartbeats corresponds to the pulse. Heart sounds are muffled, their ratio is not changed. The chest is of the correct form, symmetrical. The respiratory rate is 14 per minute, the respiratory movements are rhythmic, both halves of the chest evenly participate in the act of breathing. Voice trembling is expressed moderately, the same on the symmetrical parts of the chest. With comparative percussion over the entire surface of the lungs, a clear pulmonary sound is determined, which is the same in symmetrical sections of the chest. With topographic percussion, the lower borders of the lungs, the width of the Krenig fields are within normal limits. The mobility of the lower edge of the lungs is 5 cm on both sides. On auscultation over the lungs, breathing with a hard tone, wheezing is not heard. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. the width of the Krenig fields is within the normal range. The mobility of the lower edge of the lungs is 5 cm on both sides. On auscultation over the lungs, breathing with a hard tone, wheezing is not heard. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. the width of the Krenig fields is within the normal range. The mobility of the lower edge of the lungs is 5 cm on both sides. On auscultation over the lungs, breathing with a hard tone, wheezing is not heard. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. The mobility of the lower edge of the lungs is 5 cm on both sides. On auscultation over the lungs, breathing with a hard tone, wheezing is not heard. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. The mobility of the lower edge of the lungs is 5 cm on both sides. On auscultation over the lungs, breathing with a hard tone, wheezing is not heard. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. Bronchophony is negative on both sides. Tongue wet, pink. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, slightly painful at the Shofarr point, peritoneal symptoms are negative. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*9*7 cm. The spleen is not palpable. Ragosa's symptom is negative. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. Rumor: SR 6/6 m.
As a result of the treatment: regimen, diet No. 10, β-blockers (Betaloc ZOK - 25 mg 1 time per day), ACE inhibitors (Enalapril 5 mg 2 times a day), Mildronate 500 mg 2 times a day, Aspicor 100 mg in the morning, the state of health improved , BP stabilized at the target level.
The results of instrumental studies:
ECG No. 1271 dated 06/01/2011: sinus rhythm with a frequency of 62 per 1 minute, EOS is normal.
ECHO-KG from 06/02/11: MZHP-11mm, ZS-11mm, KDRLV-44mm, KSRLZh-31mm, Vlzh=85/37 ml, EF-57%, FU-30%, UO-47 ml, LP- 36×48×51mm, PP-40×45mm, RV-24mm, E/A=0.81 Myocardium is symmetrically thickened. The kinetics is not broken. The cavities are not dilated, the cavities are free in the visible areas. The aorta is slightly locally compacted. Systolic function is not broken. Diastolic dysfunction of the rigid type. Regurgitation applied to the MK and TK. Pulmonary blood flow is not changed. The pericardium is intact.
Ultrasound of the abdominal organs No. 903 dated 06/03/2011: the liver is slightly enlarged, the right lobe: 14 cm; left 9.0 cm, smooth contours, homogeneous structure, increased echogenicity; intrahepatic vessels are not dilated; portal vein 10 mm, hepatic veins 8 mm (up to 10 mm). Intrahepatic bile ducts are not dilated. Distal attenuation of the ECHO signal. The gallbladder is reduced after eating, stones are not visualized. The pancreas is located indistinctly, not enlarged, the contours are clear, even, the structure is heterogeneous, echogenicity is increased; Wirsung's duct is not dilated. The kidneys are of normal size (right 11×4.8 cm, left 11×5.3 cm), normal location, with even contours, homogeneous parenchyma 18-22 mm thick, cavitary systems are not dilated. The spleen is 10×5.4 cm in size, not enlarged. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: examination after eating, moderate hepatomegaly.
24-hour monitoring of ECG and blood pressure according to Holter against the background of selected therapy ID:L6602 dated 06/07/2011: during the observation period, sinus rhythm was recorded with a heart rate of 55 to 163 per 1 minute, a decrease in heart rate at night is sufficient. Average heart rate 85/91/74 in 1 minute. Single supraventricular extrasystoles were registered (23 in total). When performing the planned load (staircase test, 180 steps), the heart rate reached 163 in 1 minute, while palpitations, shortness of breath, and weakness in the legs were subjectively noted. Ischemic changes in the ST segment were not detected.
Average systolic and diastolic blood pressure in the daytime, their variability during the day within acceptable limits. Mean systolic BP at night is characteristic of mild stable hypertension, mean diastolic BP at night is characteristic of moderate stable hypertension.
At night, systolic blood pressure and diastolic blood pressure decrease insufficiently (nondipper). Episodes of hypotension were not registered. There is an increase in the rate of the morning rise in systolic blood pressure
. Plain radiograph of the chest No. 1665 dated 06/02/11: in the lungs without focal and infiltrative changes. The heart is not enlarged.
On spondylograms of the thoracic spine in 2 projections No. 1754 dated June 10, 2011: left-sided scoliosis with an angle of deviation from the vertical axis of 90 with the center of the arc at the level of Th4. The height of the disc Th5-6, Th6-7 is reduced, the end plates are compacted, marginal exophytes are 0.1 cm in the anterior parts of the bodies Th 5,6,7 in the projection of the discs. Conclusion: X-ray signs of left-sided scoliosis of the 1st degree (according to Chaklin), osteochondrosis Th5-6, Th6-7, motor segments.
On the radiograph of the left shoulder joint, no bone changes were found.
Results of laboratory tests:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
Rt,
‰
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
02.06
160
5.4
7.2
13.8
4
260
2
38
9
1
56
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar , mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
02.06
clear
1030
yellow
6.0
no
no
no
no
no
no
0-2
no
0-2
no Rehberg's
test - a variant of the norm
Creatinine clearance according to the Cockcroft-Gault formula = 186 ml / min.
GFR according to MDRD = 98 ml / min / 1.73
m2 Coprogram dated 06/02/2011 – without features
Safety factors [HBsAg, Anti-HCV (Core-n NS3-p NS4-n; Core-n NS4-p NS5-n), AT-HIV 1 and 2; Microreaction with cardiolipin antigen (RW)] from 02.06.2011. - negative.
Biochemical blood test:
Name
Unit. rev.
Norm
03.06
Creatinine
mmol/l
53-124
100
urea
mmol/l
2.5-6.4
7.1
Potassium
mmol/l.
3.5-5.1
4.44
glucose
mmol/l
3.9-6.3
Cholesterol
mmol/l
3.7-6
4.61
HDL
mmol/l
0.78-2.33
0.89
LDL
U
1 .9-4.4
3.33
VLDL
Unit.
0.6-1.2
0.39 Atherogenic
coefficient
Unit.
0-3
4.18
TG
mmol/l
0-2.37
0.86
GGTP
U/L
11-63
18.8
ALT
U/L
8.4-53.5
39.3
AST
U/L
7-39.7
19
total protein
g/l
63-87
72
As part of an in-depth medical examination consulted:
• Surgeon - healthy
• Neurologist - Initial manifestations of cerebrovascular insufficiency in the form of scattered neurological symptoms and pseudoneurotic syndrome.
• Optometrist - myopia in 3.0 D, hypertensive angiopathy of the retina in both eyes.
• Traumatologist - left-sided scoliosis of the first degree, osteochondrosis of the thoracic spine without dysfunction. Shoulder periarthritis.
• Dentist - needs oral hygiene (36, 37, 45, 47).
The goals of hospitalization have been achieved - the "target level" of blood pressure has been reached - 120-130 / 70-85 mm Hg.
Discharged in a satisfactory condition under the supervision of the doctors of the unit
Recommended:
39. Supervision of the doctor of the unit in accordance with DM-1.
40. Sanitation of the oral cavity in a planned manner in the clinic of the unit.
41. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
42. Limit the consumption of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
43. Continue taking:
a. Tab. Lozap 50 mg ½ tab. in the morning all the time.
b. Tab. Vinpocetine 0.005 - 1 tab 3 times a day for 1 month.
c. Caps. Movalis 0.015 – 1 capsule in the morning for 3 weeks
d. Ointment Voltaren - lubricate the area of the left shoulder 2 times a day for 3 weeks.
44. If conservative therapy of humeroscapular periarthritis is ineffective for 3 weeks, routinely perform MRI of the left shoulder joint, re-examination of the traumatologist of the clinic of Military Traumatology and Orthopedics of the Military Medical Academy with the results of
MRI
Form
12_Un
. St. Petersburg, Suvorovsky pr., 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY No. ARCHIVE No. _________
Surname, name, patronymic: born in 1929
He was on inpatient treatment (in the day hospital mode)
in the hospital therapy clinic
Total days of treatment were 8
The final diagnosis was established. ICD code I.24
Diagnosis:
Main: ischemic heart disease. Progressive angina pectoris from 01.11.2010. with stabilization at the level of 3 FC from 12.11.2010. Atherosclerosis of the aorta and coronary arteries Atherosclerotic and post-infarction (of unknown age) cardiosclerosis.
Complications of the underlying disease: Blockade of the anterior branch of the left leg of the bundle of His. Paroxysmal form of atrial fibrillation, without exacerbation. NK stage 2B, CHF 3 FC
Concomitant: Hypertension stage III. (The risk of CVD is extremely high). Diabetes mellitus of the second type, moderate degree, is compensated. Diabetic neuropathy of the lower extremities of the sensory type. Alimentary-constitutional obesity of the 2nd degree, stable phase. Fatty hepatosis without impaired liver function. Dyscirculatory encephalopathy II st. mixed (atherosclerotic, hypertensive, dibetic) genesis. Diffuse nephroangiosclerosis of mixed (atherosclerotic, hypertensive, diabetic) genesis. Microalbuminuria. Chronic pyelonephritis in the acute phase. Chronic kidney disease stage 3. HPN - stage 1a. Focal pneumofibrosis C1-C2 of the right lung. Chronic pancreatitis without exacerbation.
A disability certificate was not issued.
Ability to work restored
Total exposure dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicization, disability, _____ disability group, degree of disability _______________________________, other _____________________________________________
Outcome: discharged on improvement, discharged on recovery, transferred to another medical institution (what) ____________________, transferred to rehabilitation treatment (where) _______________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a medical
examination
.
Complaints: pressing and constricting pain behind the sternum, shortness of breath, mainly of an inspiratory nature, arising from slight physical exertion (walking 50-70 m or climbing 10 steps), stopped by rest for 5 minutes. or taking nitroglycerin; increase in blood pressure up to 180/125 mm. rt. Art., accompanied by a dull headache without a clear localization; discomfort in the left half of the chest against the background of a feeling of interruptions in the work of the heart, moderate general weakness, increased fatigue; memory loss.
Anamnesis of the disease: For a long time suffers from ischemic disease and hypertension, type 2 diabetes mellitus. Repeatedly underwent inpatient treatment in various hospitals of the city. The last hospitalization was in March 2010 in the 26th hospital in St. Petersburg with a diagnosis of progressive angina pectoris (medical documentation not provided). Regularly takes: amlodipine 10+5 mg/day, sotalol 80+40 mg/day, hypothiazide 25 mg/day, diroton 5 mg in the evening, cordarone 100 mg/day, preductal 2+2 tab/day, diabetone MV 30 mg in the morning and siofor 500 mg in the evening. Against the background of ongoing therapy, hemodynamics is stable at the "target" level of blood pressure 130-140/60-70 mm Hg, pulse 56-66 per minute. Over the past 2 weeks, she began to occasionally notice paroxysms of a feeling of palpitations with interruptions in the work of the heart that occur acutely against the background of relative well-being, lasting up to 6 hours, stopping on their own or after taking 400 mg of cordarone. During the last 10 days, she began to notice the occurrence of angina attacks with previously tolerated physical exertion, which required the use of nitroglycerin more often than usual. Given the ineffectiveness of self-administered therapy, she called an ambulance team, which was hospitalized in the ICU of the hospital therapy clinic.
As a child, she suffered from tuberculosis, complicated by pleurisy, in the region of the upper lobe of the right lung in childhood. Withdrawn from the dispensary.
Objective status: general condition of moderate severity, due to signs of instability of the coronary blood flow., heart rate 72 per minute, no deficit, rhythmic pulse, auscultatory heart sounds are muffled, the borders of the heart are moderately expanded to the left, blood pressure 130/80 mm Hg, in lungs breathing is vesicular, "stagnant" wheezing in the lower lobe of the right lung; the abdomen is soft, painless on palpation, tapping on the lumbar region is painless on both sides. Pastosity of the shins, moderate swelling of the ankle joints, feet
As a result of the treatment: regimen, diet No. 10, metabolic therapy (polarizing mixture: NaCl 0.9% -200.0, Sol.KCl 5% -20.0, Sol.MgSO4 25% -10.0, Sol.Insulini 4ED -N3), diuretics (furosemide 40 mg IV once, hypothiazide 25 mg No. 2), amlodipine 15 mg / day, ACE inhibitors (Enalapril 5 mg in the evening), Aspicor 100 mg in the morning, Sotalol 120 mg / day, feeling improved , coronary blood flow is stabilized, manifestations of heart failure are stopped, blood pressure is stabilized at the target level (120-135/80-90 mm Hg).
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuc., *109/l
Ht,
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
12.11.10
138
4.44
6.5
41.0
25
287
3
1
38
8
2
48
18.11.10
140
4.59
7.5
42.4
30
361
5
24
5
2
64
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
12.11
sl.mut
1015
light yellow
5.5
no
no
no
no
no
no
0-1
no
3-5-7
0-0-1
Reberg's test dated 15.11.10. - blood creatinine 0.09 mmol / l (0.044-0.132); urine creatinine - 7.92 mmol / l (5.3-17.6), diuresis in 1 min - 0.5 ml (0.75-1.0), glomerular filtration 44 ml (70-120), tubular reabsorption - 98.9 (97-99%), diuresis per day 710 ml (without stimulation).
Nechiporenko test from 11/13/2010. – leukocytes 5.25×106/l, erythrocytes 2.0×106/l
Zimnitsky's test from 11/17/2010. – daily diuresis 1250ml (580/670ml), bw 1010-1015
Urinalysis for microalbuminemia. 69.4 mg/l (N up to 25 mg/l)
Coprogram dated 11/15/2010 – without features
Safety factors [HBsAg, Anti-HCV (Core-n NS3-p NS4-n; Core-n NS4-p NS5-n), AT-HIV 1 and 2; Microreaction with cardiolipin antigen (RW)] from 11.11.2010. - negative.
Lipoproteins from 11/12/2010:
Alpha 21.35% range (13.00-44.00)
Pre Beta 22.36% range (6.90-42.50)
Beta 56.29% range (30.30-62, 70)
Analysis of daily fluctuations in blood glucose levels from November 12, 2010:
08:00 - 6.4 mmol / l,
10:00 - 9.6 mmol / l,
12:00 - 7.2 mmol / l.
Biochemical blood test:
Name
Unit. rev.
Norm
12.11.10
18.11.10
Creatinine
mmol/l
53-124
72.4
80.0
Na
mmol/l
130-150
145.0
144.6
K
mmol/l.
3.5-5.1
4.3
4.78
serum iron
mmol/l
10.5-25
10.1
Cl
mmol/l
98.0-107.0
115.2
CS
mmol/l
3.7-6
5 .31
TG
mmol/l
0-2.37
1.26
HDL
U
0.60-1.2
0.58
ALT
U/L
8.4-53.5
30.9
AST
U/L
7-39.7
20.5
Quick prothrombin
%
70-130
90
Glucose
mmol/l
3.90-6.20
5.53
CPK
U/l
10-160
95, 6
Fibrinogen
g/l
2.0-4.0
4.82
total protein
g/l
63-87
72.8
total bilirubin
mmol/l
6.8-26
14.0
Results of instrumental studies:
ECHO-KG No. 998 dated 11/17/2010: Aorta: diameter 33 mm, sealed, aortic valve opening 16 mm, ascending Ao 30 mm, MZHP-12mm, ZS-12mm, KDRLZh-56mm, KSRLZh-38mm, PV-55% , FU-29%, LP-41×50×60mm, PP-46mm, KDRPZH-28×4mm, LA=22mm, E/A=0.81. Symmetrical eccentric LV myocardial hypertrophy. The kinetics is not broken. Dilatation of the LA cavity. The aorta is sealed. Fibrous annulus AK, MK, their valves are sealed. The blood flow is laminar. LV diastolic dysfunction. Applied regurgitation on MK, TK. Pulmonary blood flow is not changed. The pericardium is not changed.
ECG #2334 dated 11/18/2010. Sinus rhythm. A sharp deviation of the e.o.s. to the left. Blockade of the anterior superior branch of the left leg of the bundle of His. Intra-atrial blockade Ι degree. Left ventricular hypertrophy. Cicatricial changes in the anterior septal region. Violation of repolarization processes in the region of the posterior wall.
X-ray of the chest organs No. 3033 dated 11/19/2010: Conclusion: On the plain radiograph of the chest cavity organs in the right lung in the C1-2 projection there are dense focal shadows, massive pleural layers in the projection of the upper lobe of the right lung. The roots of the lung are fibrously changed. Calcified paratracheal lymph nodes on the right. The diaphragm is flattened, sinuses are not fully disclosed. The heart is not enlarged. The aorta is compacted and deployed.
Ultrasound examination No. 1358 dated 11/15/2010: The liver is enlarged, the right lobe is 13.4 cm, the left lobe is 7.4 cm, the contours are even, the structure is homogeneous, the echogenicity is increased, the vascular pattern is depleted, the vessels are not dilated, the portal vein is 8 mm (H<13 mm), hepatic veins are normal, intrahepatic bile ducts are not dilated. There are no volumetric formations. The gallbladder was removed (after cholecystectomy). Common bile duct 4-5 mm. The pancreas is not clearly located; the contours are not clear, not even, the head is 27 mm, the body is 26 mm, the tail is 28 mm, echogenicity is increased, the structure is homogeneous, the Wirsung duct is not dilated, there are no volumetric formations. The kidneys are of normal size (right 11.5×4.5 cm, left 11×5 cm), the location is typical, mobile, fibrous contours, the parenchyma of the right kidney is homogeneous 12 mm thickened to 22 mm in the upper pole. The left kidney parenchyma is not homogeneous 13 mm-7-14 mm calcification in the parenchyma 7 mm. The pyelocaliceal region is not expanded. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 9.0×3.8 cm, the structure is homogeneous. Conclusion: Diffuse changes in the echostructure of the liver (hepatosis), pancreas (lipomatosis) condition after cholecystectomy.
The goals of hospitalization were achieved - coronary blood flow was stabilized, manifestations of heart failure were stopped, blood pressure was stabilized at the target level (120-135/80-90 mm Hg). working ability is restored.
Discharged in a satisfactory condition under the supervision of doctors at the clinic at the place of residence
Recommended:
45. Supervision by a cardiologist, endocrinologist.
46. Control study of general urine analysis after 1 month. Glucose control (on an empty stomach) once a week.
47. Observe the drinking regime of 1-1.5 l / day; restriction of salt intake (no more than 3 g per day), hypoglycemic diet.
48. Limit the consumption of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes).
49. Continue taking:
a. Tab. Amlodipine 10 mg - 1 tablet in the morning and ½ tablet in the evening continuously.
b. Tab. Enalapril 10 mg - ½ tablet in the evening constantly.
c. Tab. Hypothiazide 50 mg - 1 tablet 1 time per week.
d. Tab. Thrombo ASS 0.1 - 1 tablet in the morning constantly.
e. Tab. Sotahexal 80 mg - 1 tablet in the morning and ½ tablet in the evening constantly.
f. Tab. Diabeton MB 30 mg - 1 tablet daily in the morning.
g. Tab. Metformin (Siofor) 500 mg - 1 tablet in the evening constantly.
h. Tab. Nitroxoline 50 mg - 2 tablets 4 times a day for 30 days.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr., 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY № ARCHIVE №_________
Surname, name, patronymic: born in 1960 (50 years old),
was hospitalized (in the day hospital mode)
in the hospital therapy clinic
Total days of treatment 8
The final diagnosis was established ICD code I.45
Diagnosis
Atherosclerosis of the aorta and coronary arteries, atherosclerotic and myocardial cardiosclerosis. Dissociation of the atrioventricular node into 2 channels. Paroxysm of reciprocal av-nodal tachycardia (PRAVUT) from 05/09/2011, complicated by arrhythmogenic collapse, was stopped by EIT on 05/09/2011. Mitral valve insufficiency of the first degree. CHF 2A st, 2 FC.
Hypertensive disease of the second stage (Risk of CVE 4).
Systemic lupus erythematosus, chronic progressive course with damage to the skin (Raynaud's syndrome, ecchymosis), joints (arthralgia, osteoporosis of small joints of the hands), myocardium (myocarditis cardiosclerosis), kidneys (secondary nephropathy of autoimmune origin, chronic kidney disease stage 2 (GFR according to MDRD 62 ml / min / 1.73 m2), CRF-0), lungs (diffuse pneumofibrosis, emphysema), nervous system (ataxia, dysarthria, headaches, mnestic disorders), lymphadenopathy, active phase with a moderate (II) degree of activity, FNS- I, DN-0.
Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of unexpressed bilateral pyramidal-cerebellar insufficiency and moderately pronounced astheno-neurotic syndrome.
Widespread osteochondrosis of the spine with moderate pain syndrome in the stage of unstable remission.
Initial cataract, simple myopic astigmatism of the direct type, hypertensive angiopathy of the retina in both eyes.
Subserous uterine myoma of small size, cicatricial deformity of the cervix, bilateral fibrocystic mastopathy.
Secondary partial adentia. Chronic compensated tonsillitis. Lateral pharyngitis.
Condition after posterior crurorrhaphy and fundoplication. gastroptosis.
Chronic iron deficiency anemia of mild severity.
A disability certificate was not issued.
Ability to work restored
Total radiation dose 5.72 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity
, disability, established _____ disability group, degree of disability _______________________________, other _____________________________________________ where) _________________________________________________________________________
Examined by MSEC: yes (no) (group 3 disability, degree of disability ______________) _______________________________________________________________
Complaints at admission: pronounced palpitations, "lump in the throat", pronounced weakness, pressing pain in the region of the heart, pain in the shoulder, knee and small joints of the hands, their stiffness in the morning for 2 hours, swelling of the face in the morning, internal discomfort, itching of the skin of the face, episodic sharp chilliness in the fingers and toes; nausea when taking medications, heaviness in the epigastric region when eating; weight loss within 4 months by 10 kg.
Disease history:
She fell ill acutely in November 2005, when, against the background of relative well-being, severe morning stiffness, soreness, redness and swelling appeared in the area of small joints of both hands, shoulder, elbow and knee joints, fever up to 400C, sweating, severe general weakness, and rapid fatigue. On November 14, she was examined by a general practitioner, and a course of anti-inflammatory therapy (diclofenac retard, prednisone 30 mg/day) was prescribed, which resulted in a significant improvement in her state of health. She underwent inpatient treatment at military unit 25515 with a diagnosis of rheumatoid arthritis, seropositive, articular form. She received cytostatic therapy, mini-pulse therapy with methylprednisolone, movalis, physiotherapy with a positive effect. In the future, against the background of outpatient cytostatic therapy (methotrexate 7.5 mg/week, prednisolone 10 mg/day), pain, heaviness in the epigastrium, left and right hypochondria appeared, and therefore in May 2006 she independently refused to take medications. Against the background of refusal of treatment, the pain in the joints intensified, pains in the right elbow joint joined. She resumed taking medications again without a positive effect.
26.06.06 was hospitalized in the rheumatology department of the NLMK Medical Unit, where she was diagnosed with systemic lupus erythematosus for the first time. Received treatment: methotrexate 10 mg/week, prednisolone 20 mg/day, movalis, chimes, pentoxifylline, physiotherapy with a positive effect. However, against the background of the constant intake of these drugs, at the end of October 2006, pain in the joints increased again, hyperemia of the back of the nose and cheeks, itching of the skin of the face, swelling on the face and hands, periodic pain behind the sternum and in the left half of the chest, palpitations, shortness of breath with slight physical exertion, general weakness, sore throat, pain in the lumbar region during physical exertion.
In 2008, 2009, she underwent inpatient treatment using efferent therapy methods for repeated exacerbations of systemic lupus erythematosus with a moderate effect.
Over the past three years, he has been noted an increase in blood pressure up to 170/110 mmHg, accompanied by dizziness, nausea, and palpitations. From the same time - unsteadiness when walking, numbness in the fingers of the upper limbs.
In May 2010, she underwent inpatient treatment for progressive angina pectoris. Over the next year, there were attacks of stable angina, characteristic of level 2 FC. Occasionally noted attacks of palpitations, mainly at night, lasting up to 20 minutes, stopped on their own.
Episodic pain in the epigastric region notes for ten years, was treated independently, taking a large number of antisecretory and antacid drugs, with a temporary positive effect. On December 22, 2010, laparoscopic surgery was performed to eliminate the incarceration of the paraesophageal hernia (laparoscopic posterior crurorrhaphy, Nissen-Rosetti fundoplication. K 44.9).
At the time of hospitalization, he regularly takes: Prednisone 5 mg - 2 tab. in the morning with breakfast until 9 am - all the time; Methotrexate 2.5 mg - 1 tab. 3 times a week (Saturday morning and evening 1 tab., Sunday morning 1 tab.) - constantly; Sorbifer durules - 1 capsule in the morning; Movalis - 1 suppository in the morning with exacerbation of the articular syndrome; Concor-core - 1 tab. in the morning.
Real deterioration: on May 9, 2011, at about 9 am, I woke up from pressing pain in the left side of my chest, pronounced palpitations, and significant general weakness. Independently took the entire list of medications taken without effect. Given the ineffectiveness of self-therapy, she called an ambulance team, which was taken to the hospital therapy clinic for diagnosis and treatment with a diagnosis of "first-time detected paroxysm of atrial fibrillation."
Objective status at admission: Height 164 cm, body weight at admission 64 kg. The general condition is severe, due to signs of electrical instability of the myocardium, arrhythmogenic shock. The position is passive. Satisfactory nutrition: BMI 24.4 kg/m2. The skin in the "décolleté" area is hyperpigmented, ecchymosis on the skin of the face, chest, abdomen, and extremities. Peripheral (submandibular, maxillary, cervical and axillary) lymph nodes are moderately enlarged, painless on palpation, not soldered to surrounding tissues. Movement in the joints is not limited, in the ankle, knee and small joints of the hands are moderately painful, edematous. On palpation of the radial arteries, the pulse is non-synchronous, the same on both hands, rhythmic, with a frequency of 158 beats. per minute, weak filling, uniform, weak tension, the vascular wall is palpated outside the pulse wave. The monitor registers supraventricular tachycardia with a heart rate of 158/min. SatO2=92%. Blood pressure: on the right shoulder - 80/60, on the left shoulder - 80/60 mm Hg. Art. Limits of relative cardiac dullness: right and upper are normal; left - on the left mid-clavicular line. The heart sounds are deaf, over the apex of the heart the 1st tone is weakened, systolic murmur at the apex. The respiratory rate is 24 per minute. On auscultation over the lungs, breathing is hard, multiple congestive rales are heard in the lower lobes of both lungs. The abdomen is soft and painless. The size of the liver according to Kurlov is 10x9x7 cm. Tapping in the lumbar region is painless. left - on the left mid-clavicular line. The heart sounds are deaf, over the apex of the heart the 1st tone is weakened, systolic murmur at the apex. The respiratory rate is 24 per minute. On auscultation over the lungs, breathing is hard, multiple congestive rales are heard in the lower lobes of both lungs. The abdomen is soft and painless. The size of the liver according to Kurlov is 10x9x7 cm. Tapping in the lumbar region is painless. left - on the left mid-clavicular line. The heart sounds are deaf, over the apex of the heart the 1st tone is weakened, systolic murmur at the apex. The respiratory rate is 24 per minute. On auscultation over the lungs, breathing is hard, multiple congestive rales are heard in the lower lobes of both lungs. The abdomen is soft and painless. The size of the liver according to Kurlov is 10x9x7 cm. Tapping in the lumbar region is painless.
As a result of the treatment: According to vital indications at 11:45 09.05.2011, taking into account the significant hemodynamic significance of tachycardia paroxysm, transthoracic electrical cardioversion was performed - sinus rhythm was restored.
Regime, diet No. 10, metabolic, hypotensive, antianginal, antiarrhythmic, vascular therapy, cytostatics, glucocorticosteroids, health improved, heart rate stabilized, manifestations of heart failure stopped, blood pressure stabilized at the target level (120-135 / 80-90 mmHg. Art.).
The results of laboratory studies in dynamics:
General clinical analysis of blood:
Date
Hb, units.
Er., *1012/l
MCV
fl
Rt
‰ Leuc
., *109/l
Ht
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
10.05
118
5.35
74
5
5.5
39.8
27
302
4
45
7
2
42
Anisopoikilocytosis-1, hypochromia - 1
16/05
109
4.67
75
6
5.6
35
20
258
1
41
5
4
49
Anisopoikilocytosis-1, hypochromia-1
Biochemical blood test:
Name
Unit. rev.
Norm
12.05
Name
Unit. rev.
Norm
12.05
Creatinine
mmol/l
53-124
80
CS
mmol/l
3.7-7
5.75
Urea
mol/l
3-8.4
6.8
TG
mmol/l
0-2.37
PTI
%
70-120
101
T3
nmol/l
1.3-3.1
1.26
Fibrinogen
g/l
2.0-4.0
4.43
T4
nmol/l
66-181
1.56
Total protein
g/l
63-87
79
TSH
uIU/l
0.27-4.2
Glucose
mmol/l
4.2-6.4
4.97
AT to TPO
U/ml
up to 60
47.4
Albumin
g/l
30-55
42.60
AT to TG
U/ml
up to 60
29.8
Vol. bilirubin
µmol/l
6.8-26
7.5
Cl
mmol/l
95-108
111
ALT
U/L
8.4-53.5
18
Na
mmol/l
130-150
148
AST
U/L
7-50.0
14
K
mmol/l .
4-6
4.29
ALP
U/l
45-129
75
Fe (serum)
mmol/l
10.5-25.0
7.17
CPK
U/l
36-160
26
CPK-MB
U/l
0.0-25.0
Safety factors [ HBsAg, Anti-HCV (Core-n NS3-p NS4-n; Core-n NS4-p NS5-n), HIV AT 1 and 2; Microreaction with cardiolipin antigen (RW)] from 10.05.2011. - negative.
Complete
urinalysis
date
_
PH
Protein
sugar
Ley in p / z
Er. in p/z
Epit.
Salts
Slime
18.05.10
1025
clear
6.0
no
no
-
no
no
no
-
Reberg's test dated 12.05.11. - blood creatinine 0.08 mmol / l (0.044-0.132); urine creatinine - 10.55 mmol / l (5.3-17.6), diuresis in 1 min - 0.8 ml (0.75-1.0), glomerular filtration 105.5 ml (70-120), tubular reabsorption - 99% (97-99%), diuresis per day 1160 ml.
Nechiporenko test from 05/11/2011. – leukocytes 1.0×106/l, erythrocytes 0.5×106/
l – daily diuresis 1160 ml (630/530 ml), bw 1014-1022
Results of instrumental studies:
ECG No. 455 on admission dated 09.05.2011 (before EIT): Supraventricular tachycardia with a frequency of 160 bpm, normal EOS (α=650), local violation of intraventricular conduction in the posterior diaphragmatic region of the left ventricle.
ECG No. 456 (after EIT) dated May 09, 2011: Sinus rhythm with a frequency of 64 bpm, horizontal EOS (α=300), local disturbance of intraventricular conduction in the posterior diaphragmatic region, left ventricular hypertrophy.
ECHO-KG dated May 10, 2011: MZHP-9.0mm, ZS-9.0mm, KDRLZh-45mm, KSRLZh-30mm, FV-66%, FU-33%, UO-78ml, LP-33×34×40mm , PP-31×40mm, RV-24mm, E/A=0.7 LV myocardial mass 143 g, IMM 85.1 g/m2, myocardium is not thickened. The kinetics is not broken. The cavities are free, not dilated, the free leaflets of the mitral valve are thickened, there are no vegetations, the rest of the valves are not changed, on the mitral valve regurgitation stage I, on the tricuspid valve I stage. Pulmonary blood flow is not changed. Diastolic dysfunction of the left ventricle of the rigid type. The aorta is sealed. The pericardium is intact.
Transesophageal EPS No. 49 dated May 10, 2011: initially sinus rhythm with an average RR = 713 msec, VSAP 106 msec, VVFSU 793 msec, KVVFSU 80 msec, Wenckebach point 200/min, dissociation of atrioventricular conduction into 2 channels – ERP of β-path 330 ms, α-path 280 ms.
Test with a six-minute walk from 05/14/2011: 490m
Ultrasound of the abdominal organs No. 720 dated May 16, 2011: the liver is not enlarged, the right lobe: 13 cm; left 7×6cm, smooth contours, homogeneous structure, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein 12 mm, hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder is irregularly shaped (with an inflection in the neck area), dimensions 7×2.5 cm, smooth contours, walls 2 mm, stones are not visualized. The pancreas is located clearly 21x11x20mm, homogeneous structure, contours are clear, even, the structure is homogeneous, echogenicity is increased; Wirsung's duct is not dilated. Kidneys of normal size (right 11.5×4.5 cm, left 11×5 cm), normal location, with smooth contours, homogeneous parenchyma 14 mm thick on the right, 10-16 mm on the left; cavity systems are not expanded. The spleen is not enlarged, size 9, 5×4cm. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: diffuse changes in the pancreas, signs of chronic pyelonephritis.
X-ray of the chest organs in the direct and left lateral projection No. 1386 dated 05/10/2011: Conclusion: The lung fields are emphysematous, without fresh focal and infiltrative changes, the pulmonary pattern with fine mesh deformation due to diffuse pneumofibrosis. The roots are structural, no free fluid was found in the pleural cavity. The diaphragm is flattened. The heart is moderately expanded in diameter to the left due to the left ventricle, the aorta is compacted and deployed.
Radiography of the stomach No. 51 dated May 16, 2011: the esophagus is freely passable for barium suspension, its walls are elastic, mucosal folds can be traced throughout, in the lower third they are somewhat thinned. The cardia does not close completely. The stomach is hypotonic, lowered (its bottom is at the level of S1. The fornix of the stomach and the cardial section are located in the abdominal cavity. Condition after posterior crurorrhaphy and fundoplication. The walls of the stomach are elastic in all sections. The relief of the mucosa is not changed. Peristalsis is of medium depth. the loop of the duodenum is usually located.When examined after 24 hours, the contrast agent unevenly fills the loops of the colon.Most of them are in the ascending section.Gaustras are uneven, deep, spastic.Conclusion: Condition after posterior crurorrhaphy and fundoplication. gastroptosis.
On spondylograms of the thoracic spine in 2 projections dated May 16, 2011: physiological kyphosis is enhanced. Osteochondrosis of Th6-7 Th7-8 Th8-9 Th9-10 motor segments with a decrease in the height of the discs, compaction of the endplates and small marginal exophytes in the anterior sections at the same levels.
Monitor observation of ECG and blood pressure according to Holter (against the background of antihypertensive and antiarrhythmic therapy) ID: L5CO2 dated May 13, 2011: during the observation period, sinus rhythm was recorded with a heart rate of 50 to 141 per 1 minute, the decrease in heart rate at night was adequate. Average heart rate 71/77/58 in 1 minute. Registered single polytopic supraventricular extrasystoles (total 16), periodically group. When performing the planned load, the heart rate reached 141 and 132 in 1 minute, while subjectively noted palpitations, shortness of breath, weakness in the legs, ischemic changes in the ST segment were not detected. Mean systolic blood pressure during the day and mean diastolic blood pressure in the daytime, their variability is within acceptable limits, mean systolic blood pressure at night is characteristic of mild labile hypertension. At night, systolic and diastolic blood pressure decrease insufficiently (nondipper). There is an increase in the rate of morning rise in diastolic blood pressure. Episodes of hypotension were not registered.
The patient has signs of disability. Needs social security measures.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition.
A temporary disability certificate was not issued.
The goals of hospitalization were partially achieved - it needs planned hospitalization in the department of surgical arrhythmology in order to perform endocardial EPS with RFA of the slow channel of the atrioventricular node [class 1 (B) of indications of Recommendations ACC / AHA / HRS 2008, VNOA 2009].
Recommended:
187. Outpatient observation of a rheumatologist, cardiologist.
188. Annual inpatient treatment in a specialized hospital.
189. Sanatorium-and-spa treatment once a year, profile - treatment of rheumatological diseases, period - autumn, spring.
190. Consultation of an arrhythmologist-surgeon in order to resolve the issue of conducting endocardial EPS with RFA of the slow channel of the atrioventricular node [class 1 (B) indications of the Recommendations ACC / ANA / HRS 2008, VNOA 2009]
191. Dispensary observation:
a. Frequency of observations by a rheumatologist, cardiologist: - 4 times a year.
b. Examination by an ENT doctor, gynecologist, ophthalmologist, gastroenterologist - 2 times a year;
c. clinical blood test (with counting of platelets and reticulocytes), urinalysis - 6 times a year; when changing the dose of cytostatic drugs - monthly control;
d. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - at least 2 times a year;
e. x-ray (fluorography) of the chest organs 2 times a year; x-ray of the joints - according to indications;
f. a blood test for the content of antinuclear factor and antibodies to double-stranded DNA and the level of complement C3 and C4 - 3 times a year and during exacerbation.
g. Echocardiography - 2 times a year;
192. Change in lifestyle:
a. Exclusion of wearing corsets, bandages, tight belts
b. Exclusion of weight lifting more than 4-5 kg, physical exercises associated with overstrain of the abdominal muscles (including yoga classes)
193. Changing the regimen and nature of nutrition:
a. Avoid overeating, snacking, eating at night
b. Exclude from the diet drinks containing caffeine (coffee, strong tea, Coca-Cola), chocolate, products containing mint and pepper, citrus fruits, tomatoes, cabbage, legumes, onions, garlic, fried foods.
c. Do not use alcoholic drinks, carbonated mineral water.
d. Limit consumption of butter and margarine
e. After eating, take a 30-minute walk.
194. Continue taking:
a. Prednisolone 5mg - 5 tab. in the morning with breakfast (drink with kissel, low-fat yogurt) until 9 am - 4 weeks, then a gradual decrease in the dose to a maintenance dose (7.5 mg) under the supervision of a rheumatologist at the place of residence
b. Plaquenil - 1 tab. in the morning - all the time
c. Wobenzym - 5 tablets × 3 times a day × a month, then 3 tablets × 3 times a day - at least 6 months.
d. Ca-D3-Nycomed-forte - 1 tab. in the evening daily
e. Ferrum Lek - 1 capsule 3 times a day with meals for 3 months, then 1 capsule in the morning.
f. Movalis - 1 suppository in the morning for 4 weeks, then - with an exacerbation of the articular syndrome.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER (TRANSFER) EPICRISIS CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1984
He was on inpatient treatment in the intensive care unit of the hospital therapy clinic
. He left the Military Medical Academy on "___" _____________ 2011.
In total, 3 days of treatment were carried out .
The final diagnosis was established. ICD code
Diagnosis:
Main disease: Sepsis, severe course.
Community-acquired viral-bacterial bilateral focal polysegmental confluent pneumonia, severe,
Complications: infectious-toxic shock of the 2nd degree, stopped medically on 04.03.11.
Bilateral parapneumonic pleurisy, ARF -2 degrees.
Infectious-toxic myocarditis, moderate HF 2 tbsp.,
Infectious-toxic hepatonephropathy, complicated by prerenal acute renal failure from 03/01/11, stopped by medication on 03/02/11.
Infectious-toxic pancreatitis, secondary diabetes mellitus of moderate severity
Secondary immunodeficiency.
Background disease Bronchial asthma, atopic form.
Concomitant disease: Common psoriasis, winter-spring form, exacerbation
Total radiation dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicization, disability, _____ disability group, degree of disability _______________________________, other ____________________________
Outcome: discharged on improvement, discharged on recovery, transferred to the clinic of infectious diseases of the Military Medical Academy.
On admission:
Complaints: severe general weakness; cough with a small amount of yellow discharge; severe general weakness, fatigue; intermittent chills, sweating; intermittent pain in the left hypochondrium with a deep breath.
Anamnesis of the disease He considers himself ill since February 18, 2011, when, against the background of complete well-being, he noted weakness, malaise, body aches, fever to febrile values (39.0 ° C), dry cough. He did not apply for medical help, he independently took NSAIDs, antiviral agents (ingaverin). Over the next 6 days, it increased slightlyst, fatigue, chills, increased sweating, body aches, cough with a small amount of sputum appeared from time to time. 24.02. and on February 25, 2011, he felt better, noted a decrease in body temperature to subfebrile numbers, and went to work. From the middle of the day on February 25, 2011, weakness, chills resumed, an increase in body temperature up to 39.00C was again noted, and the general state of health worsened. In the future, the complaints described above intensified, a sharp weakness appeared, making it difficult to move around the room. On March 2, 2011, an ambulance was taken to the HT clinic for urgent indications, at the prehospital stage, due to the identified severe hypotension, 400 ml of Quadrosol solution, 16 mg of Dexamethasone solution were intravenously administered.
Over the past 30 years, he has been suffering from bronchial asthma (atopic form), constantly taking Seretide 25 mcg / 125 mcg PDA. Asthmatic status in 2006. In the 1990s, psoriasis was diagnosed.
Objective status: Height 182 cm, body weight at admission 86 kg,
The condition is extremely serious, unstable. Consciousness is clear (SHG=14 points). The position is passive. The skin is pale, cold, elasticity is not changed. The skin of the lips is pale pink. Acrocyanosis. On the skin of the legs, thighs hyperemic papules with peeling up to 4 cm in diameter (psoriasis). On the radial arteries, a threadlike pulse is palpable, the same on both hands, rhythmic, with a frequency of 118 per minute, weak filling and tension. Arterial pressure: 60/- mm. rt. Art. On auscultation, the heart sounds are muffled, rhythmic, the first tone at the apex is sharply weakened. The chest is of the correct form, symmetrical. The respiratory rate when breathing atmospheric air is 32 per minute, shallow breathing. With comparative percussion, dullness of percussion sound is determined in the projection of the lower loli of the lungs. Auscultation over the lungs on both sides is determined by hard breathing; over all fields of the lungs on both sides, foci of multiple moist sonorous small bubbling rales are heard. SatO2 without inhalation of humidified oxygen 78-82%, with inhalation - 88%. The edge of the liver protrudes from under the costal arch by 3 cm, soft-elastic consistency, sharp, somewhat painful on palpation. The spleen is not palpable. Ragosa's symptom is positive.
As a result of the treatment:
• IVL with PEEP within 3 hours from the moment of admission,
• inotropic support for 2.5 days (maximum dose of dopamine 10 µg/kg×day), removed from inotropic support at 23:30 on 04.03.11 .HELL when transferring = / mmHg
• continuous mask oxygen therapy,
• complex metabolic and detoxification therapy (neoton 4g/day, cytoflavin 10 ml/day, mildronate 10 ml/day, calcium gluconate (correction of significant hypocalcemia), ascorbic acid),
• avelox 400 mg 1 r/day,
• Invanz 1.0×1 time per day,
• Tamiflu 0.075, 1 tab 2 r/day,
• Berotek (Berodual), Lazolvan inhalation through a nebulizer,
• Linex 2 caps. 3 r / day,
• Erespal 0.08 1 tab. 2 times a day,
• Ascoril - 1 tbsp. spoon 3 times a day,
• Prednisolone 60 mg×4 times a day intravenously (from 04.03.11, the dose was reduced to 30 mg×4 times a day intravenously), there was an improvement in the general condition.
The right subclavian vein was catheterized on March 2, 2011.
At present, he is oxygen-dependent (when breathing atmospheric air, Sat O2 = 88%!)
Results of instrumental studies:
X-ray of the chest organs on March 2, 2011: bilateral polysegmental infiltration of the pulmonary pattern with increased pattern of the pleura .
ECG 02; 03.02; 03/04/2011: sinus rhythm with a heart rate of 118 per minute, horizontal EOS, left ventricular hypertrophy. Subsequently, a decrease in heart rate is noted.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Thrombus.
*109/l
MCH
ESR, mm/h
E
%
B
%
Lf
%
M
%
Metamyel
%
Miel
%
Pia
%
Xia
%
02.03.11
131
4.2
3.4
242
31.0
60
-
-
5
1
1
41
52
03.03. 11
137
4.4
12.3
281
30.9
60
0
-
1
1
1
40
57
04.03.11
132
4.2
14.6
287
31.0
66
0
-
4
3
1
4
89
Biochemical blood test: Urinalysis
Name
Unit of measure.
Norm
01/02/11
03/03/11
03/04/11
Indicator
03/02/11
03/03/11
Creatinine
Mkmol/l
53-124
310
240
200
Color
Yellow
Yellow
Total protein
g/l
64.0-83.0
54.2
61.5
55.7
Clarity
Clear
Haze
Glucose
mmol/l
4.2-6.4
5.8
8.9
12.9
Specific. weight
1015
1015
Potassium
mmol/l
3.4-4.5
4.1
4.2
3.5
Reaction
5.0
5.0
Sodium
mmol/l
130-150
138.8
142.9
140.4
Protein (g/ l)
0.3
0.1
Urea
mmol/l
2.5-6.4
23.1
22.2
24.2
Sugar
No
No
Calcium
mmol/l
2.1-2.5
1.75
1.9
2.06
Urobilin
No
No
Creatine kinase
U/l
Up to 190
33.0
Leukocytes in p/sp
7-8
2-4
Erythr. in p/sp
4-5
100-150
Erythr. vysch. in p / sp
-
No
Epit. cells
10-15
General analysis of sputum on 03/04/2011: brown-yellow color, viscous consistency, mucopurulent character, squamous epithelium 0-2 in p / c, ciliated 0-3 in p / c, alveolar 0-5 in p / c, atypical cells were not found, leukocytes up to 30-50 in p / c, erythrocytes 0-40-20 in p / c, eosinophils 0, neutrophils 80%, staphylococci in moderate amounts.
ECHO-KG (in the ward) 03/02/2011: LV 57/42 mm, EF 47%, FU 24%, VR 76 ml, IVS=ZS=9 mm, Ao 30 mm, VosAO 27 mm, LA 33 mm, RV 24 mm, PP 38 mm. Dilatation of the LV cavity, total myocardial hypokinesia. The aorta is not changed. The pericardium is unchanged.
KShchS
(
arterial
blood on the background of inhalation
of
100
%
oxygen
)
03/03/11
08:11
pH
7.3-7.4
7.426
7.407
7.403
7.427
7.433
pCO2
32.0-45.0 mmHg
26.6
28.1
30.4
32.0
32.2
pO2
75.0-100 mmHg
60.1
64.9
77.4
96.0
102
K
3.4-4.5 mmol/L
3.5
3.5
4.1
3.8
3.6
Na
130-150 mmol/L
136
133
133
135
237
Ca
1.15-1.3 mmol/L
0.85
0.94
0.7
1.02
0.76
Cl
95-110 mmol/L
103
105
103
106
102
Glu
4.2-6.4 mmol/L
5.8
8.6
8.4
7.1
7.7
BE
mmol/L
-6.4
-6.5
- 5.3
-2.9
-2.5
RT-PCR 03/04/2011: influenza A (H1N1) virus - positive reaction.
On 04.03.2011, the patient was consulted by telephone ZNK on the KR of the Clinic for Infectious Diseases by Associate Professor Yurkaev I.M., Acting PNK for LR Major Shakhmanov D.M.
In connection with the identification of a pandemic strain of influenza A (H1N1) according to epidemiological indications to the patient for further treatment transfer to the clinic of infectious diseases of the VMA is indicated.
The patient is transportable by resuscitation sanitary transport, accompanied by an anesthesiologist-resuscitator.
Recommended:
2. Continuation of treatment at the Clinic for Infectious Diseases of the Military Medical Academy
With patients transferred:
8. Invanz - 6 bottles (obtained from pharmacy No. 2)
9. Avelox - 1 bottle (obtained from pharmacy No. 2)
10. Neoton - 5 packs (20g)
11. Ascoril - 1 bottle (started)
12. Tamiflu - 3 tablets
13. Lazolvan in solution - 1 bottle (started)
14. Erespal - 5 tablets (received from pharmacy No. 2)
Form 12_Un.VmedA-2010 GT
MILITARY MEDICAL ACADEMY
DISCLAIMER REPORT CASE
HISTORY No.
Surname, name, patronymic: born in 1962
He was examined and treated in the clinic of hospital therapy of the Military Medical Academy on a day hospital
Total days of treatment 7
The final diagnosis was established Code ICD_E-11.1_
Diagnosis:
Main disease: Diabetes mellitus type 2, moderate degree, compensation.
Concomitant diseases: Ischemic heart disease. Angina pectoris II functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis. Hypertensive disease stage II (arterial hypertension of the 2nd degree, the risk of developing cardiovascular disorders is very high). Chronic hepatitis B. Obesity III degree, alimentary-constitutional origin.
Certificate of incapacity for work: No.
Clinical outcome (underline): recovery, improvement, no change, chronicity, disability
Outcome: discharged due to improvement
Admission complaints: moderate weakness, sweating, thirst, dry mouth, shortness of breath and discomfort in the left half of the chest with moderate physical exertion, periodically headaches mainly in the occipital region, weight gain.
History of the disease: in 2006, during inpatient examination and treatment, type 2 diabetes mellitus was first detected. The level of sugar in the blood measures independently when absolutely necessary with the Aku Chek glucometer. The patient has been suffering from ischemic heart disease and hypertension for a long time since 2000. He was repeatedly hospitalized in various clinics of the Military Medical Academy. The last hospitalization in the HT clinic was from 18.01 to 03.02.2010. He did not take antihypertensive and hypoglycemic drugs. Over the past year, he has noted an increase in blood pressure rises, an increase in the severity of headaches.
Present worsening: during the last week he noted an increase in blood glucose levels up to 20 mmol / l (measured independently). In this connection, he turned to the GT clinic and was hospitalized.
Objective status at admission: general condition of moderate severity, due to decompensation of diabetes mellitus, the manifestation of which is diabetic ketosis. Hypersthenic constitution. Increased nutrition. Lymph nodes are not enlarged. Heart rate 88 per minute, no deficit, rhythmic pulse, satisfactory properties. On auscultation, the heart sounds are muffled, the emphasis of the second tone is on the aorta, BP is 120/80 mm Hg, there is vesicular breathing in the lungs, no wheezing. the abdomen is soft, painless on palpation, the liver is along the edge of the costal arch, effleurage along the lumbar region is painless on both sides.
The following treatment was carried out: parenterally: glucose (5%-200 ml/day), MgSO4 (25%-5 ml/day), KCl (5%-30 ml/day), Humulin (12 U/day) . Inside: aspirin 100 mg/day, galvusmet 150/1500 mg/day, enalapril 5 mg/day, verapamil 120 mg/day.
As a result of the treatment, the state of health improved, blood glucose was within acceptable limits, cardiac pain syndrome did not recur, exercise tolerance was satisfactory, blood pressure was within normal values.
The results of instrumental studies:
ECG on December 23, 2011: heart rate - 100 per minute. Moderate sinus tachycardia. The horizontal position of the electrical axis of the heart to the left. Hypertrophy of the left heart. Violation of repolarization processes in the region of the posterior wall.
ECHOCARDIOGRAPHY 20.12.2011 № 47 Aorta: d=29 mm; Aortic valve: opening 21 mm; Left atrium: 40 mm; Mitral valve: S>4 cm2; left ventricle: KSR 33 mm, KDR 50 mm, FU 33%; Ejection fraction (Teicholz)=61%; Posterior wall: diast 11.2 mm, interventricular septum: diast 11.2 mm. Pulmonary artery: 19 mm; Right atrium: 37 mm; Right ventricle: KDR 27 mm, anterior wall: diast <5 mm. Conclusion: Initial manifestations of aortic atherosclerosis. Diastolic dysfunction of the left ventricle. Left ventricular hypertrophy.
24-hour ECG monitoring on December 13, 2011: during the observation period, sinus rhythm was recorded with a heart rate of 64 to 138 per minute. During wakefulness, tachycardia was recorded with an average hourly heart rate of 94 to 122 per minute. The decrease in heart rate at night is adequate. Average heart rate 96 (N to 85)/103/77 per minute. Registered single supraventricular extrasystoles (total 95), periodically paired. When performing the planned load (staircase test, 55 and 56 steps), the heart rate reached 116 and 125 per minute, the patient noted shortness of breath, palpitations. Ischemic changes in the ST segment were not detected.
X-ray of the chest organs No. 84 08.12.11: no pathological changes were detected on the survey chest X-ray.
Results of laboratory researches:
Date
Hb, g/l.
Er., *1012/l
Leuk., 109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
26.12
169
5.10
7.3
33.1
12
1
0
26
6
5
61
Biochemical blood test: Urinalysis:
Name
Unit.
Norm
26.12.11
Indicator
23.12.2011
AST
U/l
11-50
34.0
Color
Yellow
Glucose
mmol/l
3.9-6.2
11.45
Clarity
Clear
Urea
mmol/l
2.5-6.4
3.3
Specific. weight
1010
Creatinine
Mmol/l
0.05-0.12
0.09
Reaction
5.0
Total bilirubin
Mkmol/l
6.8-26
21.1
Protein (g/l)
Traces
Total protein
G/l
63-87
71
Sugar
5.5 mmol/l
ALT
U/l
11-50
26 .0
Ketones
No
LDL
U/l
360-650
700
Urobilin
No
Cholesterol
mmol/l
3.7-6.0
8.12
Leukocytes in p/zr
0-2
K
Mmol/l
3.5-5.1
4.09
Erythrocytes
0-2
Na
Mmol/l
136-145
135.9
Salts
In large amount.
Mucus
+
Urinalysis according to Nechiporenko dated December 20, 2011: leuk-1.25x106 / l .; erythr-0.25 x106/l
Blood coagulation system from 26.12.11. prothrombin-127
%
,
fibrinogen
4.78
g
/
l
,
INR
0.90
Blood
glucose
Blood
glucose
7.0
6.6
6.3
6.5
6.5
10.1
10-00
7.2
12-00
9.2
6.6
15-00
11.1
10.1
8.1
10.6
6.4
6.6
20-00
8.6
7.2
7.6
7.3
Discharged in a satisfactory condition under the supervision of the endocrinologist of the polyclinic at the place of residence.
Employment has been restored. Discharged for work, return to work on 12/29/2011
.
Recommended:
1. Observation of an endocrinologist, a cardiologist.
2. Diet with restriction of easily digestible carbohydrates, animal fats, table salt and liquid.
3. Aspirin 0.5 g ¼ tab x 1 time per day, for a long time.
4. Enalapril 5 mg x1 once a day, long-term;
5. Verapamil 40 mg 1 tab x 3 times a day, for a long time;
6. Galvus Met 50/1000 mg 1 tab x 2 times a day, for a long time;
Form 12 -2010
DISCLAIMER CASE
HISTORY №
Surname, name, patronymic: born in 1967
Was on examination and treatment in the clinic
during the period. In total, 12 days of treatment were carried out
. The final diagnosis was established. ICD code_E-11.1_
Diagnosis: Type 1 diabetes mellitus. Individual target HbA1c<7.0%. Diabetic ketosis from 07/29/2013. Diabetic retinopathy of the first degree in both eyes. Nephropathy of mixed (diabetic, hypertensive, atherosclerotic) genesis, microalbuminuric form, progressive stage. Chronic kidney disease stage 3, chronic renal failure stage 1a. Diabetic symmetrical distal sensory polyneuropathy. Coronary artery disease. Angina pectoris of the third functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis with arrhythmias of the type of frequent ventricular extrasystoles. Hypertensive disease stage II (arterial hypertension 3→1 degree, the risk of developing cardiovascular complications is very high). Chronic heart failure stage 2A, 3→2 functional class. Encephalopathy of mixed (dyscirculatory, hypertonic, dysmetabolic) genesis in the form of bilateral cerebellar symptoms, rare transient disorders of cerebral circulation. Obesity III degree, alimentary-constitutional genesis, stable course. Asymmetric transitional vertebra (sacralization of the fifth lumbar vertebra); non-occlusion of the arches of the sacrum. Chronic gastroduodenitis with rare exacerbations. Fatty hepatosis of the first degree without dysfunction. alimentary-constitutional genesis, stable course. Asymmetric transitional vertebra (sacralization of the fifth lumbar vertebra); non-occlusion of the arches of the sacrum. Chronic gastroduodenitis with rare exacerbations. Fatty hepatosis of the first degree without dysfunction. alimentary-constitutional genesis, stable course. Asymmetric transitional vertebra (sacralization of the fifth lumbar vertebra); non-occlusion of the arches of the sacrum. Chronic gastroduodenitis with rare exacerbations. Fatty hepatosis of the first degree without dysfunction.
Certificate of incapacity for work: No.
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability
Outcome: discharged due to improvement
Complaints at admission: moderate severe general weakness, sweating, thirst, dry mouth, shortness of breath and discomfort in the left half of the chest cell with moderate physical exertion, periodically headaches mainly in the occipital region against the background of an increase in blood pressure to 180/115 mm Hg, weight gain.
Anamnesis of the disease: considers himself ill since 1999, when he first noted the appearance of a headache against the background of an increase in blood pressure to 160/110 mm Hg. Not treated. In 2003, during a hospital examination, hypertension of the second stage was diagnosed. The maximum figures for blood pressure are 220/120 mm Hg. He took enalapril, amlodipine with a temporary positive effect. Since 2008, the disease has acquired a crisis character with an episode of transient ischemic attack in the LSMA pool (November 30, 2010). Significant lability of blood pressure levels (130-220/80-120 mm Hg) over the past 5 years required frequent correction of antihypertensive therapy in stationary conditions with an increase in the doses of drugs taken (currently taking co-exforge 10/160/12, 5 mg, arterial hypertension at the level of mild arterial hypertension). Since 2007 began to notice episodes of palpitations, interruptions in the work of the heart. In 2009, a rhythm disorder was diagnosed according to the type of frequent ventricular extrasystole, against the background of taking antiarrhythmic drugs, extrasystole is less pronounced. Pain in the region of the heart during physical, psycho-emotional stress has been noted since 2007. Coronary heart disease has been diagnosed on a stationary basis, periodically taking kardiket, nitrospray. Since 2003, he has been experiencing an increase in blood glucose levels; he was hospitalized with type 2 diabetes mellitus; he took sorbifer without effect. Since 2010, he has been taking Siofor 850 mg 2 times a day, Protofan 36 units in the morning and 38 units in the evening, which allowed him to maintain a normal level of glycemia throughout the year. Over the past year, he began to notice an increase in blood glucose levels up to 15-16 mmol/l, he did not seek medical help. Independently increased the dose of Siofor taken to 1000 mg 2 times a day with little effect. An increase in microalbumin in the urine since 2007, at the same time, diabetic nephropathy was diagnosed. Increase in body weight for more than 20 years, during the last 3 years the weight is stable. Pain in the spine during physical exertion since 1997. He was treated on an outpatient and inpatient basis with a short-term positive effect. Pain in the epigastric region with an error in the diet since 1994, chronically diagnosed gastroduodenitis on an outpatient basis, occasionally taking Almagel, omeprazole with a positive effect. In May 2009, he was dismissed from the Armed Forces of the Russian Federation for health reasons. Real deterioration: during the last three months, when, against the background of errors in the diet, he began to notice an increase in blood glucose levels up to 20 mmol / l (measured independently),
Objective status at admission: general condition of moderate severity, due to decompensation of diabetes mellitus, the manifestation of which is diabetic ketosis. Hypersthenic constitution. Increased nutrition (BMI 40kg/m2). Lymph nodes are not enlarged. Heart rate 88 per minute, no deficit, rhythmic pulse, satisfactory properties. On auscultation, the heart sounds are muffled, the emphasis of the second tone is on the aorta, BP is 160/95 mm Hg, there is vesicular breathing in the lungs, no wheezing. The abdomen is soft, painless on palpation, the liver is along the edge of the costal arch, effleurage along the lumbar region is painless on both sides. Edema of the lower third of the legs and feet.
Treatment was carried out: parenterally: after stopping ketosis in the ICU according to the standard scheme with the transition to the scheme Protofan HB 40 IU in the morning and 50 IU in the evening, Actrapid 40 IU before meals. Inside: aspirin 100 mg/day, galvusmet 150/1500 mg/day, Co-exforge 10/160/12.5.
As a result of the treatment, the state of health improved, blood glucose was within acceptable limits, cardiac pain syndrome did not recur, exercise tolerance was satisfactory, blood pressure was within normal values.
Results of instrumental studies:
ECG 29.07.2013:. Sinus rhythm with a heart rate of 76 per minute. Deviation of the electrical axis of the heart to the left. Hypertrophy of the left heart. Violation of repolarization processes in the region of the posterior wall.
ECHOCG 07/30/2013 Aorta 29 mm; Aortic valve: opening 21 mm; Left atrium: 43 mm; Mitral valve: S>4 cm2; left ventricle: CFR 42 mm, CDR 57 mm, Ejection fraction (Teicholz) 54%; e/a 0.69; posterior wall: diast 12 mm, interventricular septum: diast 12 mm. Pulmonary artery: 22 mm; Right atrium: 43 mm; Right ventricle: KDR 27 mm, anterior wall: diast <5 mm. Conclusion: the aorta is sealed. Diastolic dysfunction of the left ventricle. Left ventricular hypertrophy. Slight dilatation of the left chambers of the heart.
24-hour ECG monitoring on 08/03/2013: during the observation period, sinus rhythm was recorded with a heart rate of 64 to 138 per minute. During wakefulness, the heart rate is from 64 to 122 per minute. The decrease in heart rate at night is adequate. Average heart rate 76/83/77 per minute. Frequent polytopic ventricular extrasystoles (895 in total), periodically paired, at 18:55 a single episode of unstable VT was registered (6 complexes). When performing the planned load (staircase test, 55 and 56 steps), the heart rate reached 116 and 125 per minute, the patient noted significant shortness of breath, palpitations. ST depression of the ischemic type was recorded against the background of physical activity, a total of 5 episodes, with a total duration of 42 minutes.
Daily monitoring of blood pressure 05.08.2013 (against the background of therapy): mild stable arterial hypertension is recorded during the entire observation period with single rises in blood pressure (max. 182/124 mm Hg). Mean BP during the day 146/97 mmHg, mean BP at night 141/94 mmHg.
X-ray of the chest organs on August 08, 2013: on a survey radiograph in the lungs without infiltrative changes, the aorta was thickened.
Radiography of the lumbar spine on August 08, 2013: left-sided sacralization L5, spina bifida of the sacrum.
Ultrasound of the OBP from 08/07/2013: signs of steatohepatosis of the first degree, diffuse changes in the pancreas.
MRI of the brain on 08/06/2013: MRI-signs of dyscirculatory encephalopathy, moderately expressed substitutive external hydrocephalus.
Results of laboratory researches:
Date
Hb, g/l.
Er., *1012/l
Leuk., 109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
29.07.13
169
5.60
7.3
33.1
4
1
0
26
6
5
61
07/30/13
155
5.1
6.8
32.1
8
1
27
4
2
66
08/07/13
Biochemical analysis of blood: Analysis of urine:
Name
Unit of measure.
Norm
30.07.13
Indicator
29.07.2013
08.08.2013
AST
U/l
11-50
34.0
Color Yellow
Yellow
Glucose
mmol/l
3.9-6.2
15.5
Transparency
Clear
Clear
Urea
mmol/l
2.5-6.4
3.3
Specific
. weight
1035
1015
Creatinine
mmol/l
0.05-0.12
0.12
Reaction
5.0
5.5
Total bilirubin
µmol/l
6.8-26
21.1
Protein (g/l)
No
trace
Total protein
G/l
63-87
71
Sugar
10.5 mmol/l
no
ALT
U/l
11-50
26.0
Ketones
++
-
LDL
U/l
360-650
700
Urobilin
No
No
Cholesterol
Mmol/l
3.7-6.0
7.12
Leukocytes in p/s
2-4
0-2
K
Mmol/l
3.5-5.1
3.62
Erythrocytes
0-2
0-2
Na
mmol/l
136-145
135.9 Oxalate
salts
+.
-
HbA1c
%
<6.5%.
10.2
Mucus
+
+
Urinalysis for microalbumin 08/30/2013: positive. (+++)
Urinalysis according to Nechiporenko dated 08.08.2013: leuk-1.25x106/l.; erythr-0.25 x106/l
Blood coagulation system from 26.12.11. prothrombin
-
127
%
,
fibrinogen
4.78
g
/
l
,
INR
0.90
Blood
glucose
Blood
glucose
Time
_
_
_
7.1
10-00
7.2
12-00
9.2
6.6
15-00
11.1
10.1
8.1
10.6
6.4
6.6
20-00
8.6
7.2
7.6
7.3
Endocrinologist's consultation: The patient has decompensated diabetes mellitus. Diagnosis: Type 1 diabetes mellitus. Individual target HbA1c<7.0%. Diabetic ketosis from 07/29/2013. Diabetic retinopathy of the first degree in both eyes. Nephropathy of mixed (diabetic, hypertensive, atherosclerotic) genesis, microalbuminuric form, progressive stage. Chronic kidney disease stage 3, chronic renal failure stage 1a. Diabetic symmetrical distal sensory polyneuropathy. Obesity III degree, alimentary-constitutional genesis, stable course. Recommended: Protofan HB 40 IU in the morning and 50 IU in the evening, Actrapid 40 IU before meals. Inside: galvusmet 150/1500 mg / day. Independent daily monitoring of glycemic levels, HbA1c levels (1 time / 3 months)
Discharged in a satisfactory condition under the supervision of an endocrinologist of the clinic at the place of residence.
Recommended:
1. Observation of an endocrinologist, a cardiologist.
2. Diet with restriction of easily digestible carbohydrates, animal fats, table salt and liquid.
3. Independent control of glycemic level, HbA1c level (1 time / 3 months)
4. Aspirin 0.5 g, ¼ tab x 1 time per day, for a long time.
5. Co-exforge 10/160/12.5 mg x1 once a day, for a long time;
6. Protofan HB 40 IU in the morning and 50 IU in the evening, for a long time;
7. Actrapid 40 IU before meals
8. Galvus Met 50/1000 mg 1 tab x 2 times a day, for a long time;
.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1978
She was on inpatient treatment in the clinic of hospital therapy
Total days of treatment 10
The final diagnosis was established
ICD Code I 10.0;
Diagnosis:
Hypertensive disease of the second stage (drug normotension, the risk of cardiovascular complications is "medium") without signs of heart failure.
Rarely recurrent neuroreflex syncope. Simple fainting from 10/18/2013
Acute bronchitis complicated by an episode of hemoptysis on 10/25/2013.
Deviation of the nasal septum without persistent obstruction of nasal breathing. Vasomotor rhinitis
Cholelithiasis stage III. Chronic calculous cholecystitis without exacerbation.
Chronic gastritis without exacerbation
Android obesity of the 2nd degree, stable phase.
Kippelfeld anomaly, C2-C3 retrolisthesis. Osteochondrosis of the cervical and thoracic spine with muscular-tonic syndrome.
Certificate of incapacity for work: not issued
Total radiation dose 0.78 mSv
Clinical outcome: improvement.
Outcome: discharged.
Upon enrolment:
Complaints: discomfort in the lower part of the chest, general weakness, shortness of breath with previously tolerated physical exertion, cough with a moderate amount of discharge mixed with blood, episodic nausea, retching with streaks of blood.
History of present illness. In 2012, due to the frequent detection of high blood pressure, its lability, and headaches, he underwent inpatient treatment at the military field therapy clinic (a copy of the medical history No. 56606 is pasted into this medical history). During hospitalization, the patient was diagnosed with the second stage of hypertension (AH 2, CV risk 3), atherosclerosis of the aorta and coronary arteries, CHF 1 fc, chronic calculous cholecystitis, remission, osteochondrosis of the thoracic region with muscular tonic syndrome, obesity of the third degree. Regularly takes amlodipine, valsartan + hypothiazide, Plavix with a positive effect.
Over the past year, I began to notice the frequent appearance of discomfort in the lower part of the chest on both sides, more on the left. From the beginning of October, after physical exertion (ascent to the 5th floor), attacks of nausea, vomiting of bile with episodes of blood streaks in it appeared, and general weakness began to increase. On October 18, 2013, after physical exertion (6-hour service), a sharp weakness developed, blackout in the eyes, followed by a short-term loss of consciousness. As he fell, he hit the corner of the table with his spatula. After this episode, there was a significant weakness, a cough with a bloody discharge (did not occur during the last three days). The presence of seizures denies. According to urgent indications, he was hospitalized in the city clinical hospital No. 40 (Sestroretsk), where, according to the patient, pulmonary embolism was ruled out and this condition was explained by the presence of an anomaly of the cervical vertebrae (copies of the examination results, including the result of a CT scan of the head and chest, are pasted into the present medical history, the discharge summary is not presented). Considering that his state of health does not allow him to properly perform his duties, he turned to the hospital therapy clinic, where, after examination, he was hospitalized to the clinic for further diagnosis and treatment.
As a result of the treatment: regimen, diet No. 10, antiplatelet, antihypertensive, diuretic, metabolic, cardioprotective, mucolytic, antibacterial therapy, the state of health improved. The maximum possible compensation of the functions of internal organs and systems has been achieved.
Results of instrumental studies:
ECG dated October 24, 2013: sinus rhythm with heart rate of 73/min Normal position of the EOS. Incomplete blockade of the right leg of the bundle of His. The predominance of the potentials of the left ventricle. Violation of repolarization processes in the region of the lower wall.
Spirometry dated 25.10.2013 The coefficient of bronchodilation was 6.77%, which is regarded as the physiological variability of the bronchial lumen.
FGDS dated 20.28.13: Cardia insufficiency. Superficial gastritis with atrophy. Duodenogastric reflux. Secondary duodenitis. Papillitis.
Angiography of the chest dated 11/13/2013: CT data for a neoplasm of the chest organs were not obtained. defects in contrasting vessels, AVMs in the scanning area were not detected. In the basal parts of the left lung, there is a single pleurodiaphragmatic adhesion.
Results of laboratory tests
Complete blood count
Date
10/25/2013
Hb, g/l.
143
Erythrocytes *1012/l
4.05
Leukocytes *109/l
7.2
Myelocytes
-
ESR, mm/h
8
Eosinophils %
0
Basophils %
1
Lymphocytes %
27
Monocytes %
15
Stab %
3
Segmented %
55
Urinalysis
Date
25.10.2013
Color
Yellow
Clarity
Transparent
Density
1030
pH
5.5
Protein (g/l)
neg.
Leukocytes
3-4-5-
Erythrocytes
0-1-2
Glucose
neg.
slime
2
bacteria
1
Biochemical blood test from 25.10.2013.
Name
Unit
Norm
Urea
mmol/l
2.5-6.4
3.6
Glucose
mmol/l
4.2-6.4
6.16
Creatinine
mmol/l
0.05-0.12
0.08
Potassium
mmol/l
3.50-5.10
3.81
ALT
U/l
11.0-50.0
55
APTT
U/l
8-63
23.6
Prothrombin
%
70-130
99
Fibrinogen
Mg/dl
200-400
3.64
C-reactive protein
mmol/l
0-5.0
13.4
Consultation of a pulmonologist: Currently, there are no convincing data for the pathology of the respiratory system.
ENT consultation dated 20/25/2013: Deviation of the nasal septum without persistent difficulty in nasal breathing. Vasomotor rhinitis.
Treatment goals have been achieved. In a satisfactory condition, he is discharged to the polyclinic at the place of residence under the supervision of specialist doctors.
Recommended:
50. Observation by a cardiologist at a polyclinic.
51. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
52. Limit the consumption of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium.
53. Continue taking:
a. Tab. Valz H 80/12.5 mg 1 tablet in the morning continuously.
b. Tab. Amlodipine 5mg - 1 tablet daily in the morning.
c. Tab. Thrombo ACC 0.05 1 tablet in the morning constantly.
d. Tab
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCUSSION REPORT CASE
HISTORY No. ARCHIVE No. _________
Last name, first name, patronymic: born in 1938.
Was hospitalized at the hospital therapy clinic
Total number of days of treatment 1
Final diagnosis established ICD Code I 69.3
Diagnosis:
cerebrovascular disease. Dyscirculatory encephalopathy 111 st. mixed genesis (atherosclerotic, post-stroke (stroke stroke in the LSMA pool from 1991), hypertensive) in the form of dysarthria, right-sided upper hemiparesis, right-sided hemihypoesthesia. Cryptogenic temporal lobe epilepsy with rare simple paroxysmal seizures. Meningioma of the left frontal lobe.
Acute oral poisoning with barbiturates of moderate severity from 01/19/2014.
Coronary artery disease. Stable angina pectoris 11I functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and post-infarction (1995) cardiosclerosis with rhythm disturbance as a paroxysmal form of atrial fibrillation (without exacerbation).
Hypertensive disease of the third stage (AH - 1, risk 4) Chronic heart failure stage 11a, 111 functional class
Secondary nephropathy of mixed genesis (atherosclerotic, hypertensive) genesis. Chronic pyelonephritis, remission. Cysts of the left kidney. Chronic kidney disease C2Ax stage. Acute urinary tract infection (urinary catheter 20-21.01.2014).
operated thyroid gland. Total strumectomy (1996, 2010) for recurrent follicular tumor of the thyroid gland Clinical hypothyroidism.
Sensorimotor hearing loss. Chronic atrophic pharyngitis. Absence of the gallbladder (2002).
Chronic viral hepatitis C with a minimal degree of activity.
Consolidated fracture of the right femoral neck, osteosynthesis (2010)
Widespread osteochondrosis of the spine.
Primary age-related cataract, AMD, dry form.
A disability certificate was not issued. Total radiation dose 0 mSv
Clinical outcome (underline): recovery, improvement,
Outcome: discharged on improvement, discharged on recovery.
On admission:
Complaints of weakness, nausea, vomiting, dizziness, local pain in the left side of the chest.
The real worsening of the state of health came on the afternoon of 10/19/2014, when, while taking nitrospray for pain in the left side of the chest, the patient lost consciousness (the duration of the syncope is unknown). The patient refused the hospitalization offered by the emergency medical service team. Regularly takes phenobarbital for epilepsy (dose in the last day is unknown). On the morning of January 20, 2014 there was nausea, vomiting. Social transport delivered to the hospital therapy clinic VMedA. In the course of the survey, no convincing data were obtained for acute coronary syndrome (chest pain the day before and taking nitrospray for this reason) (chest pain was regarded as thoracalgia of non-cardiac origin). Loss of consciousness the day before, most likely due to orthostatic hypotension while taking nitrospray. Attention is drawn to the pronounced cerebral symptoms. The main severity of the condition at the time of hospitalization on 20.01.2014. caused cerebral symptoms, within which a differential diagnostic search was carried out between acute cerebrovascular accident in the vertebrobasilar basin and poisoning (overdose) of antiepileptic drugs (phenobarbital). Taking into account the obtained MRI data (according to sito), the results of a toxicological blood test for barbiturates, the patient had toxic encephalopathy due to an overdose of barbiturates. In order to conduct detoxification therapy, the patient was urgently transferred, in agreement with the leadership of the department of military field therapy, to a specialized toxicological department of resuscitation and intensive care of the VPT clinic, where complex detoxification therapy was carried out. According to the stabilization of the state on 21.01.2014. at 18:30 she was again admitted to the hospital therapy clinic by transfer from the ICU. In the course of the examination, it was found that diseases of the internal organs are of a compensated nature and do not require additional correction of the therapy. Dominant in the picture of the disease is the pathology of the central nervous system, which does not require urgent medical intervention and the patient can undergo further treatment on an outpatient basis. that diseases of the internal organs are compensated and do not require additional correction of the therapy. Dominant in the picture of the disease is the pathology of the central nervous system, which does not require urgent medical intervention and the patient can undergo further treatment on an outpatient basis. that diseases of the internal organs are compensated and do not require additional correction of the therapy. Dominant in the picture of the disease is the pathology of the central nervous system, which does not require urgent medical intervention and the patient can undergo further treatment on an outpatient basis.
Epidemiological history: tuberculosis, syphilis denies, sexually transmitted diseases. Contact with infectious and febrile patients denies. Hepatitis C since 2010 (according to the patient).
Insurance history: Pensioner. Does not work. There is no need to apply for a disability certificate.
Laboratory results:
General clinical blood test (attached): Hb
date
, units.
Er., *1012/l
Leuc., *109/l
Rt,
‰
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
20.01
132
4.34
5.1
28
301
6
29
7
8
50
22.01
133
4.44
3.9
16.2
31
274
2
1
27
7
7
58
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol /l
Salts
Mucus
Acetone
M / o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
22.01
clear
1030
yellow
5.0
0.3
no
no
2
traces
3
2-5
no
up to 100
1-2
Biochemical blood test on January 22, 2013: glucose, urea, creatinine, total protein, potassium, sodium, chlorine are normal.
Biochemical blood test and test for cardiospecific enzymes (myoglobin, troponin T, CPK-MB) dated January 20 and 22, 2014. - are negative.
Blood test for barbiturates 20.01.2014 12:20 - positive.
The results of instrumental studies:
On the ECG dated 01/20/2014. recorded sinus rhythm with a heart rate of 56 in 1 minute, indirect signs of left ventricular hypertrophy, diffuse repolarization disorders. 22.01.2014 - without dynamics
ECHO-KG from 01/22/2014: the walls of the aorta and the leaflets of the aortic valve are sealed. Concentric left ventricular myocardial hypertrophy (IVH=ZS=11.2 mm, LVMI 113g/m2). The cavities of the heart are not dilated, free. The LV systolic function is reduced (EF35%, LV 44.3/32.3 mm). Hypokinesia of the middle and basal segments of the lower wall. Diastolic dysfunction of the rigid type. Minimal mitral and tricuspid regurgitation. Slight increase in pulmonary pressure. Pericardium without features.
MRI - from 01/20/2014. on hands.
Recommended:
43. Observation of a therapist, a neurologist at the place of residence.
44. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
45. Limit the consumption of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium.
46. Monitor the level of TSH and fT4 in the blood, followed by a consultation with an endocrinologist.
47. Routine Consultations
a. neurosurgeon (MRI - meningioma of the frontal lobes),
b. epileptologist (selection of antiepileptic therapy)
c. endocrinologist (total strumectomy - selection of therapy)
48. Continue taking:
a. Tab. Prestans 10/5 mg 1 tablet 1 time per day continuously.
b. Tab. Bisoprolol 5 mg - 1/4 tablet in the morning constantly.
c. Tab. Thrombo ACC 0.05 1 tablet in the morning constantly.
d. Tab. Veroshpiron 25 mg 1 tablet 2 times a day continuously.
e. Tab. Kanefron 1 tablet 3 times a day for 1 month
f. Tab. Norfloxacin 0.4 - 1 tablet 2 times a day for 10 days
g. Tab. Phenobarbital 0.1 - 1 tablet 3 times a day (Dose adjustment after consultation with an epileptologist)
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. (812) 577-11-35
Discharge summary No.
born in 1973 (36 years old),
was examined and treated in the clinic of hospital therapy
with a diagnosis of
Hypertensive disease of the first stage (AH-2, the risk of CVE is moderate). NK-0
Obesity of the third degree, alimentary-constitutional genesis, stable phase. Fatty hepatosis without impaired liver function. Chronic recurrent pancreatitis with impaired exocrine function in the phase of incomplete remission. Autoimmune thyroiditis, euthyroidism. Osteochondrosis of the lumbar without exacerbation. Initial signs of deforming arthrosis of both knee joints. Toxicoderma.
She was admitted to the clinic in a planned manner with complaints of a severe dull aching headache without a clear localization, an increase in blood pressure to 165/100 mm Hg, a rash on the body, pain in the knee joints during prolonged walking.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht, %
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
06.07.
155
5.22
6.3
47.3
8
318
6
1
30
5
1
57
22.07
153
4.8
5.8
5
1
37
8
1
53
General analysis of urine and feces from 22.07.10 without pathological changes.
Safety factors (anti-HCV, HBsAg, F-50, RW) from 07/19/2010 - negative
Biochemical blood test:
Name
Unit rev.
Norm
06.07
Creatinine
mmol/l
53-124
70
urea
mmol/l
2.5-6.4
4.1
sodium
mmol/l
136-145
142.7
chlorine
mmol/l
98-107
108.7
Potassium
mmol/l.
3.5-5.1
4.22
Sa
mmol/l
2.1-2.55
2.29
glucose
mmol/l
3.9-6.2
5.95
total protein
mmol/l
64-83
78.1
T3
nmol/l
1.3-3.1
1.59
Т4
nmol/l
66-181
95.02
TSH
uIU/l
0.27-4.2
3.43
cortisol
nmol/l
221-690
403.6
ALT
U/L
8.4-53.5
60.2
AST
U/L
7-39.7
25.5
GGTP
U/ L
7-63
28.9
CS
mmol/l
3.7-7
7.9
TG
mmol/l
0-2.37
2.34 Vol
. bilirubin
µmol/l
6.8-26
7.9
amylase
U/L
28-100
45.2
C-reactive protein
mg/l
3-10
2.5
B-lipoproteins
units
350-650
1400
Results of instrumental studies:
ECG in dynamics from 05.072.2010, sinus rhythm with a heart rate of 68/min, horizontal EOS. 07/16/2010 - without negative dynamics.
Ultrasound examination of the abdominal cavity and thyroid gland from 07/12/2010. in the left lobe of the thyroid gland, a hypoechoic node with a diameter of 5 mm is located; revealed signs of fatty hepatosis, chronic pancreatitis.
Ultrasound examination of the pelvic organs dated 07/13/2010 - no pathological changes were detected.
EchoCG from 14.07.2010. Aorta 30 mm, aortic ring 24 mm, asc. aorta 29 mm, opening of the aortic valve 19.4 mm, LA 40 mm, CRLV 29 mm, CRLV 43 mm, fr. reproach. 32%, fr. select 61%, AP 10 mm IVS 10 mm, E/A=1.7, PP 38mm, RV 24mm; the myocardium of the left ventricle is not thickened, the cavities are not expanded. The aorta is not changed. The valves are intact, laminar blood flow, valvular regurgitation on PC. The pericardium is unchanged, there is no pericardial effusion.
X-ray of the chest organs dated 07/08/2010. In the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is horizontal. The aorta is not changed.
On spondylograms of the lumbar spine from 08.07.2010. - physiological lordosis is straightened, the height of the discs is not reduced. Small exophytes are determined in the anterior-lateral sections of L4-L5 outside the plane of the disks - the initial manifestations of spondylosis.
On radiographs of the knee joints standing from 23.07.2010. - there is sclerosis of the articular areas in the medial condyles of both tibias. The height of the menisci in these lower extremities is symmetrically reduced (compared to the lateral menisci).
Consulted by a dermatologist - toxicodermia, recommendations were given
. Treatment was carried out: regimen, diet, enalapril, ACC thrombosis, desensitizing, sedative, polyenzymatic therapy.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
6. Observation of a general practitioner at a polyclinic at the place of residence.
7. Continue the course of treatment in a day hospital
8. Optimization of the regime of work, rest, nutrition.
9. Control ultrasound of the abdominal organs of the thyroid gland after 2 months
10. Continue taking:
• Enalapril 0.01 ½ tab.2 r/d. constantly
• Thrombo ASS 0.1 1 tab. 1 r / d after breakfast
• Mildronate 0.25 ½ capsules 2 r / d (after breakfast and lunch) - 2 weeks
• Omeprazole 0.02 1 capsule at night for 2 weeks.
• Motilium 0.01 1 capsule 3 times a day - 2 weeks.
• Suprastin 0.025 - 1 tablet at night for 1 week
Form 12_Uni.VmedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1991
He was on inpatient treatment (in the day hospital mode)
in the hospital therapy clinic
Total days of treatment were 7
The final diagnosis was established ICD code
Diagnosis: HEALTHY.
A disability certificate was not issued.
Ability to work restored
Total exposure dose 0.52 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, established _____ disability group, degree of disability _______________________________, other _____________________________________________
Outcome: discharged on improvement, discharged on recovery, transferred to another medical institution (what) ____________________, transferred to rehabilitation treatment (where) _______________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a
medical
examination
.
Anamnesis of the disease: During a planned medical examination during ECG recording, an incomplete blockade of the right bundle branch block was noted, which was the reason for performing an ECHO-KG (developmental anomaly - an additional chord in the cavity of the left ventricle) and daily ECG monitoring (27 episodes of supraventricular tachycardia were detected). Episodes of SVT were the basis for this hospitalization. The patient himself feels healthy, interruptions in the work of the heart, palpitations, episodes of loss of consciousness denies.
Objective status: Height 169 cm, body weight at admission 75 kg. BMI=25.6kg/m2. The general condition is satisfactory. The position is active. The physique is correct, corresponds to age and sex. Normosthenic constitution. Satisfactory nutrition. Peripheral lymph nodes are not enlarged. The pulse is synchronous, the same on both hands, rhythmic, with a frequency of 65 beats. per minute, satisfactory filling, uniform, tense, the vascular wall is palpated outside the pulse wave. Blood pressure: on the right shoulder - 120/80, on the left shoulder - 120/85 mm Hg. Art. The boundaries of relative cardiac dullness were not changed. The width of the vascular bundle does not extend beyond the edges of the sternum. The number of heartbeats corresponds to the pulse. Heart sounds are clear, pure, their ratio is not changed, there are no noises. The respiratory rate is 14 per minute, the respiratory movements are rhythmic, both halves of the chest evenly participate in the act of breathing. On auscultation over the lungs, breathing is vesicular, rales are not heard. The abdomen is not enlarged, the correct form, symmetrical, evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch.
Treatment: regimen, diet
Results of instrumental studies:
ECG No. 234 dated April 15, 2013: sinus rhythm with a frequency of 55 per 1 minute, horizontal EOS. Syndrome of early repolarization of the ventricles, Incomplete blockade of the right leg of the bundle of His.
ECHO-KG from 27.03.13: MZHP-8mm, ZS-7mm, KDRLV-49mm, KSRLZh-33mm, Vlzh=114/43 ml, EF-62%, FU-34%, UO-71 ml, LP- 29×51m, PP-46mm, RV-32mm, E/A=2.03 Myocardium is not thickened. The kinetics is not broken. The cavities are not dilated, free in visible areas. Aorta, valves, pericardium are not changed. False notochord in the cavity of the left ventricle. Systolic and diastolic functions are not disturbed. Regurgitation attached to the TC. Pulmonary blood flow is not changed. The pericardium is intact.
PE-EPI No. 7/8 dated April 15, 2013: initially, a stable sinus rhythm with a heart rate of 60/min is recorded. VSAP 60 ms, VVFSU 1233 ms, KVVFSU 301 ms, TV 190/min, ERPav 400 ms. After the introduction of atropine (0.02 mg / kg), ERPav 320 ms (FRP 375 ms), TB 190 / min. With a speeding, programmed ECS, single, paired and three extrastimuli failed to start a paroxysm of tachyarrhythmia.
VEM2 dated April 18, 2013: The test is negative. A submaximal heart rate was achieved, no ischemic changes were detected. Tolerance is high. The reaction of blood pressure to the load according to the normotonic type. The recovery period is adequate.
Plain radiograph of the chest No. 1354 dated April 18, 2013: in the lungs without focal and infiltrative changes. The heart is not enlarged.
Results of laboratory researches:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
Rt,
‰
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
16.04
143
4.93
7.4
12
7
339
4
26
9
1
60
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M / o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
16.04
clear
1025
yellow
5.5
no
no
no
no
no
no
2-4
no
0-2
no
_ – without features
Biochemical analysis of blood:
Name
Unit. rev.
Norm
16.04
Creatinine
mmol/l
53-124
100
urea
mmol/l
2.5-6.4
8.4
Potassium
mmol/l.
3.5-5.1
4.27
glucose
mmol/l
3.9-6.3
5.68
fibrinogen
g/l
2.0-4.0
1.82
C-reactive protein
unit
0-6
0
KFK
units
15-150
180
KFK-MB
units
0-55
24
cholesterol
mmol/l
3.5-5.5
3.25
ALT
U/L
8.4-53.5
15
AST
U/L
7-39.7
19
The goals of hospitalization have been achieved - organic pathology of the cardiovascular system has been excluded. The existing morphological and functional changes (additional chord in the cavity of the left ventricle, signs of autonomic dysfunction of atrioventricular conduction, incomplete blockade of the right bundle branch block) do not affect the functional state of the patient and are considered within the framework of the physiological norm.
Discharged in a satisfactory condition.
MILITARY MEDICAL ACADEMY Form 12_Uni.VMedA-2011
Discharge Epicrisis CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic 1933 b.
Was on inpatient treatment in the clinic of hospital therapy
Total days of treatment 8
The final diagnosis was established ICD code _I 20.0
DIAGNOSIS:
Primary disease: Ischemic heart disease. Angina pectoris of the third functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis with rhythm disturbance as a permanent form of atrial fibrillation, tachysystolic variant. Hypertensive disease of the second stage (arterial hypertension of the second degree, the risk of CVE is very high)
Complications of the underlying disease: Chronic heart failure of the second B stage, the third functional class.
Concomitant diseases: Dyscirculatory encephalopathy of the second stage, mixed genesis. Chronic non-calculous cholecystitis in remission. Chronic biliary-dependent pancreatitis in remission. Steatohepatosis. Chronic gastritis in remission. Urolithiasis disease. Chronic bilateral pyelonephritis in remission. Chronic renal failure 0. Primary gout, metabolic type. Chronic gouty arthritis of the I-IV metatarsophalangeal joints of both feet in remission. Functional insufficiency of the joints of the first degree. Chronic catarrhal non-obstructive bronchitis in remission. Emphysema, diffuse pneumofibrosis. Respiratory failure of the first degree. Obesity of the third degree. Degenerative-dystrophic disease of the spine. Chronic vertebrogenic cervical sciatica,
Certificate of incapacity for work: not issued
Total exposure dose _____0.6 mSv ____
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, _____ disability group, degree of limitation
Outcome: discharged due to improvement
Complaints: compressive pain behind the sternum during exercise of moderate intensity, passing at rest after 5-15 minutes from the moment of termination of the load, inspiratory dyspnea during exercise of low intensity, decreased tolerance to previously tolerated physical activity, weakness, swelling of the feet and legs; episodes of palpitations; on recurrent diffuse headache, general weakness with an increase in blood pressure to 165/110 mm Hg. Art., aching pain on the back of the neck when turning the head.
As a result of the treatment: regimen, diet N10, T. Bisoprolol 2.5 mg/day, T. Digoxin 0.125 mg/day, T. Veroshpiron 25 mg/day, T. Allopuroinol 100 mg/day, T. Furosemide 20 mg/day, T. Thrombo ASS 100 mg/day, there is a positive trend: blood pressure is stabilized and meets the target values. The pain syndrome did not recur. Hemodynamic parameters are stable. He notes an increase in working capacity, an increase in tolerance to physical activity. Discharged in a satisfactory condition under the supervision of medical specialists of the clinic. Therapy for the outpatient stage of treatment was selected, recommendations were given.
Results of instrumental studies:
ECG dated April 16, 2013: atrial fibrillation rhythm, normosystolic form. A sharp deviation of the electrical axis of the heart. Dlocade of the anterior branch of the left bundle of His bundle.
FLG UGP dated April 18, 2013: pulmonary fields are moderately emphysematous. The pulmonary pattern is reinforced and deformed due to diffuse pneumofibrosis. The roots of the lungs are structurally heavy. The sinuses are free. The heart is dilated in both directions. The aorta is compacted, elongated, deployed.
X-ray of the cervical, thoracic, lumbar spine dated April 17, 2013: signs of osteochondrosis C4-5, C5-6, C6-7 motor segments with posterior osteophytes at the C5-C6 level. Arthrosis of the intervertebral joints C5-6, C6-7..
Ultrasound of the OBP dated April 18, 2013: the liver is enlarged, the right lobe is 17.6 cm, the left lobe is 9.6 cm, the contours are even, the structure is homogeneous, the echogenicity is increased, the vascular pattern is depleted, the vessels are not dilated, the portal vein is normal, intrahepatic bile moves are not expanded. The gallbladder is of the correct form, dimensions 5.8x2.8 cm, the contours are even, the walls are 4 mm, there are no calculi. The pancreas is located not clearly 17.3x13.0x12.0 mm, the structure is heterogeneous, the echogenicity is increased, the Wirsung duct is 2 mm. Kidneys: typical right location, normal mobility, smooth contours, dimensions 12.1x5 cm, heterogeneous parenchyma 18.0 mm. CHLS is not expanded, microliths. The left one is typically located, the mobility is normal, the contours are even, the dimensions are 12.9x5.7 cm, the parenchyma is heterogeneous 14 (mm). CHLS is not expanded, microliths. No pathological formations were found in the projection of the adrenal glands. The spleen is not enlarged 11.2x4.7, the structure is homogeneous. Conclusion: diffuse changes in the liver according to the type of fatty hepatosis, diffuse changes in the pancreas. Thinning of the parenchyma of the left kidney. Microliths..
Echocardiography dated 21.04.2013:
Result, mm
Norm, mm
Aorta
At the level of AC
23
22-36
Valve opening
18.2
15-26
Left atrium
Anteroposterior size
58.7
25-40
Left ventricle
DFR
49.5
≤ 36
KDR
60, 6
≤ 55
Posterior wall thickness (diast.)
12.6
Interventricular septal thickness (l)
12.6
Right ventricle
EVA
≤ 30
Anterior wall
6.5
≤ 5
Right atrium
Transverse dimension
47.8
29-46
Longitudinal dimension
62.1
34-49
Pulmonary artery
At the valve
37.3
12-23
Indicator
Result
Norm
FU, %
18
28-41
EF, %
37
≥55
Ve/
Va
1.0-2.2 leaflets of the mitral and aortic valves of a degenerative-dystrophic nature. Concentric hypertrophy of the left ventricle. Severe dilatation of all chambers of the heart. The cavities of the heart are free. Mitral and tricuspid regurgitation of the 2nd degree, pulmonary regurgitation of the 1st degree. The systolic function of the left ventricle is reduced (total myocardial hypokinesia). Pulmonary hypertension 1 degree. Pericardium without features.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Tr. *109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
17.04
149
4.93
5.5
217
30.2
35
3
-
25
3
6
63
Urinalysis (automatic processing):
Date
U.weight
Reak
Protein
Sah
Ket.
Lei
Er.neiz
Urobil
17.04
1015
5.5
-
-
-
0-2
-
3.2
Biochemical analysis of blood:
Name
Unit of measure.
Norm
17.04
O. protein
g/l
64-83
74
Glucose
mmol/l
4.2-6.4
5.94
Creatinine
mmol/l
0.05-0.12
0.13
Potassium
mmol/l
3.4-4.5
5.22
Calcium
mmol/l
2.1-2.55
Sodium
mmol/l
130-150
142.5
Cholesterol
mmol/l
3.7-6.0
5.59
Total bilirubin
µmol/l
6.3-26
19.2
Direct bilirubin
µmol/l
6.2
Urea
mmol/l
1.9-2.5
6.4
AST
U/l
11-50
22
ALT
U/ l
11-50
13
GGTP
U/l
CPK
LDL
Triglycerides
0-2.37
1.59
HDL
T4 vol.
Nmol/l
0.89-1.76
CRP
up to 5.5
18.1
glycated Hv
%
6.94
PSA
Ng/ml
Up to 4
1.89
Coagulogram dated April 17, 2013: prothrombin 88%, fibrinogen 4.23 g/l, INR 1.07;
Analysis for HBsAg, anti-HCV, RW, F-50 04/19/2013: negative.
Coprogram dated April 17, 2013: normal consistency, neutral mucus reaction - 0, blood - 0, digested muscle fibers 2, undigested longitudinal striation 2, transverse striation 1, vegetable fiber: digested 0, undigested 2, starch grains: intracellular 0 , extracellular 1, iodophilic flora 2, neutral fat 0, fatty acids 2, soaps 1; leukocytes 0; Erythrocytes 0. I/g were not found.
Discharged in a satisfactory condition under the supervision of specialists of the clinic.
Recommended:
17. Observation of a therapist, endocrinologist, neurologist, cardiologist, rheumatologist, gastroenterologist.
18. MRI of the head and neck, followed by a consultation with a neurologist.
19. Control of b / x blood after 3 months (AST, ALT, o. bilirubin, o. cholesterol, lipidogram, glycated hemoglobin) with subsequent consultation of a therapist.
20. Normalization of the regime of work and rest. Exclude the use of animal fats, easily digestible carbohydrates, alcohol, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet. exercise therapy.
21. Observe the water regime (fluid balance), daily monitoring of blood pressure and heart rate.
22. Continue taking:
1. T. Bisoprolol 5 mg 1/2 tab. 1 time after lunch
2. T. Digoxin 0.25 mg 1/2 tab. 1 time per day after breakfast except Saturday and Sunday
3. T. Veroshpiron 25 mg 1 tab. 1 time per day before breakfast.
4. T. Thrombo ACC 100 mg 1 tab. 1 time per day after lunch.
5. T. Allopurinol 100 mg 1 tab. 1 time per day after lunch.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1973
Was on inpatient treatment (in the day hospital mode)
in the clinic of hospital therapy
Total number of days of treatment 24
The final diagnosis was established ICD Code I 13.9
Diagnosis:
Hypertension stage II (low blood pressure arterial hypertension 2, the risk of cardiovascular complications is "very high").
Coronary artery disease. Stable angina 1 functional class. Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis.
Chronic heart failure stage 1 1 functional class.
Primary gout is a mixed variant. Acute gouty arthritis with damage to the I metatarsophalangeal joint of the left foot in the phase of fading exacerbation. FTS I.
Android obesity II degree (BMI 36.2 kg/m2), essential, stable phase. Fatty hepatosis with a slight violation of liver function. Dysfunction of the sphincter of Oddi with a spastic component.
Diabetes mellitus of the second type, moderate severity, subcompensation.
Small-nodular hyperplasia of the left adrenal gland.
Secondary nephropathy of mixed (atherosclerotic, hypertensive, diabetic) genesis. Urolithiasis disease. Stone of the right kidney. Chronic latent pyelonephritis without exacerbation. Chronic kidney disease stage II (GFR 73 ml / min / 1.73 m2 according to the MDRD formula), microalbuminuria.
Initial manifestations of cerebrovascular insufficiency in the form of scattered neurological symptoms, astheno-neurotic syndrome.
Degenerative-dystrophic disease of the spine. Osteochondrosis, spondylosis of the lumbar. Chronic discogenic lumbar sciatica with L4-L5 radicular syndrome on the left in remission.
A disability certificate was not issued.
Ability to work restored
Total exposure dose 2.66 mSv
Clinical outcome: improvement
Outcome: discharged due to improvement
Conclusion VVK (VLK): discharged to the unit without medical examination.
On admission:
Complaints: increased blood pressure up to 180/140 mm. rt. Art., accompanied by a dull headache without a clear localization; memory loss; violation
History of present illness. Episodic headaches against the background of an increase in blood pressure have been a concern since 2000. In 2002, he was diagnosed with hypertension. Repeatedly passed inpatient treatment in the clinics of the Academy (VPT, Nervous diseases). Due to the ineffectiveness of the therapy, the appearance of edema and pain in the left foot, in 2007 he was examined inpatiently at the Clinic of Faculty Therapy of the Military Medical Academy, where he was diagnosed with an advanced metabolic syndrome ("Primary gout mixed variant. Acute gouty arthritis with damage to the first metatarsophalangeal joint of the left foot. Secondary osteoarthritis of the shoulder and knee joints FNS I. Hypertension stage II (AH 2, CVC risk 4) Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis without signs of heart failure. Type 2 diabetes mellitus, a sporadic variant, first identified. Obesity II degree, essential, stable phase. Diffuse non-toxic goiter of the 2nd degree, clinical euthyroidism. Fatty hepatosis 1 degree. Chronic discogenic radiculopathy with L4-L5 radicular syndrome on the left, with pain and muscular-tonic syndrome in remission). Since the same time, pronounced diffuse repolarization disorders have been detected on the ECG. In the future, against the background of constant neuropsychic overstrain, he noted an increase in the level of blood pressure, mainly diastolic, the appearance of edema of the legs and feet. In order to stabilize the condition, various combinations of drugs were used on an outpatient basis: Tarka, Prestarium, Arifon-retard, Amlodipine, Cordaflex... However, all combinations were effective only for a short time after their appointment, further there was a re-increase in the level of diastolic blood pressure. He regularly took allopurinol 1-2 times a year for prophylactic purposes. Over the past year, against the background of constant neuropsychic overwork, he began to fall asleep with difficulty, independently used Morozov's drops, gradually increasing their dose to 5-10 ml before bedtime. With an increase in the level of diastolic blood pressure over 130 mm Hg. (during the first days of January 2012) began to notice pronounced pressing pains behind the sternum, independently took nitroglycerin with a positive effect. Over the past year, against the background of constant neuropsychic overwork, he began to fall asleep with difficulty, independently used Morozov's drops, gradually increasing their dose to 5-10 ml before bedtime. With an increase in the level of diastolic blood pressure over 130 mm Hg. (during the first days of January 2012) began to notice pronounced pressing pains behind the sternum, independently took nitroglycerin with a positive effect. Over the past year, against the background of constant neuropsychic overwork, he began to fall asleep with difficulty, independently used Morozov's drops, gradually increasing their dose to 5-10 ml before bedtime. With an increase in the level of diastolic blood pressure over 130 mm Hg. (during the first days of January 2012) began to notice pronounced pressing pains behind the sternum, independently took nitroglycerin with a positive effect.
Follows a strict hypoglycemic diet. Currently regularly taking Rasilez 300 mg 1 time / day (against this background, the level of blood pressure = 140/110 mm Hg), Thrombo ACC 0.1 / day, Glibomet 400 / 2.5 1 time per day (glucose level blood against this background with self-control 7.0-7.6 mmol/l); and in view of the exacerbation of gouty arthritis of the first metatarsophalangeal joint of the left foot since January 28 - allopurinol 100 mg/day, meloxicam 15 mg/day.
He was admitted to the clinic of hospital therapy as planned to correct the therapy and diagnose the cause of the increase in blood pressure and the genesis of thoracalgia.
Objectively Height 176 cm, body weight at admission 112 kg. BMI=36.2kg/m2. The general condition of moderate severity, stable, is due to the detailed picture of subcompensated metabolic syndrome. Hypersthenic constitution. Increased nutrition. Pastosity of the feet and legs to the middle third. The thyroid gland is not visually determined, the isthmus and the upper poles of the lobes are palpable, mobile when swallowing, not soldered to the surrounding tissues. On palpation of the radial arteries, the pulse is asynchronous, the same on both hands, arrhythmic, with a frequency of 62 beats. per minute, increased filling, uniform, tense, the vascular wall is palpated outside the pulse wave. Blood pressure: on the right shoulder - 160/110, on the left shoulder - 160/110 mm Hg. Art. The boundaries of relative cardiac dullness are extended to the left. Heart sounds are muffled short systolic murmur at the apex, accent of the second tone on the aorta. The respiratory rate is 18 per minute, the respiratory movements are rhythmic, both halves of the chest are evenly involved in the act of breathing. On auscultation of the lungs, there are no vesicular rales. Tongue wet, pink. The abdomen is enlarged in size due to the subcutaneous fat layer, the correct shape, symmetrical, evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*8*7 cm. The spleen is not palpable. Ragosa's symptom is negative. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. both halves of the chest evenly participate in the act of breathing. On auscultation of the lungs, there are no vesicular rales. Tongue wet, pink. The abdomen is enlarged in size due to the subcutaneous fat layer, the correct shape, symmetrical, evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*8*7 cm. The spleen is not palpable. Ragosa's symptom is negative. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. both halves of the chest evenly participate in the act of breathing. On auscultation of the lungs, there are no vesicular rales. Tongue wet, pink. The abdomen is enlarged in size due to the subcutaneous fat layer, the correct shape, symmetrical, evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*8*7 cm. The spleen is not palpable. Ragosa's symptom is negative. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*8*7 cm. The spleen is not palpable. Ragosa's symptom is negative. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless. evenly participates in the act of breathing, soft, painless. The edge of the liver does not protrude from under the edge of the costal arch, soft-elastic consistency, sharp, painless on palpation. The size of the liver according to Kurlov is 10*8*7 cm. The spleen is not palpable. Ragosa's symptom is negative. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless.
As a result of the treatment: regimen, diet No. 9, Metabolic therapy (polarizing mixture: Sol. NaCl 0.9% -200.0, Sol.KCl 5% -30.0, Sol.MgSO4 25% -10.0 -N2), Solution Diclofenac 3 ml / day / m No. 2, Solution. Sibazon 0.5%-2ml, solution Movalis 1%-5 ml / day No. 2, T. Glibomet 400/25 mg / day, T. Aspirin 125 mg / day, T. Atorvastatin 20 mg / day, T. Allopurinol 100 mg / day, T. Losartan 50 mg / day → Losartan 100 mg / day → T. Lorista 150 mg / day, Caps. Phosphogliv 4 caps/day, T. Cordipin 60 mg/day → T. Amlodipine 10 mg/day, T. Indapamide 1.5 mg/day, health improved, blood pressure stabilized at the level of "mild" hypertension (140-145/90-105 mm .rt.st.).
After assessing the level of ACTH, plasma renin activity, aldosterone (with a test: infusion of 1200 ml / 4 hours of 0.9% NaCl solution), daily excretion of cortisol: Amlodipine 5 mg in the morning, Veroshpiron 25 mg 3 times a day, the blood pressure level stabilized at 140 /90 mmHg
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
01.02.12
153
5.16
6.7
50
3
209
1
45
10
8
36
15.02.12
173
5.23
8.3
53
5
226
37
9
4
50
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epithelium Profit center in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
02/01/12
clear
1030
yellow
5.5
0.3
no
urates
1
no
no
1-2
no
0-2
1-5
microalbumin in urine 50.5 mg/l (norm: up to 25 mg/l)
17.02.12
clear
1025
yellow.
6.0
no
no
no
0
no
no
0-2
-
0-2
-
15.02.12
Zimnitsky's test - daily diuresis 1280 ml (750/530 ml), specific weight 1024-1027
Biochemical blood test:
Name
Unit of measure.
Norm
02/02/2012
02/07/12
02/15/12 02/20/12
Creatinine
µmol
/l
53-124
80
80
urea
mmol/l
2.5-6.4
5.6
4.7
Potassium
mmol/l.
3.5-5.1
3.81
4.34
glucose
mmol/l
3.9-6.3
5.64
total protein
g/l
63-87
64
Cholesterol
mmol/l
3.7-6.0
6.4
4.95
AST
U/l
11.0-50.0
81
ALT
U/l
11.0-50.0
70
GGTP
U/l
8-63
271
26
CPK
U/l
10-160
442
258
67
CPK-MB
U /l
0-25
22.4
HDL
U/l
120-216
228
amylase
U/l
30-118
50
TSH
μIU/ml
0.23-3.4
2.6
T4
nmol/l
53-158
103
alkaline phosphatase
U/l
45-129
59
bilirubin
mmol/l
6 .8-26
17.7
uric acid
µmol/l
15-420
393
Prothrombin
%
70-130
104
Fibrinogen
g/l
2.0-4.0
3.92
ACTH
pg/ml
<46
8.3
Aldosterone (9:00 )
pg/ml
10-105
172.9
Aldosterone (13:00)
(after infusion of 1200 ml/4h 0.9% NaCl)
pg/ml
10-105
63.6
Cortisol (9:00)
nmol/l
138-690
301
Cortisol ( 21:00)
nmol/l
70-345
39.2
Renin (direct)
μIU/ml
2.8-39.9 (lying down)
11.4
Angiotensin I (9:00)
ng/ml/hour
0.5-1 ,9
0.44
Analysis of daily fluctuations in blood glucose levels February 3, 2012: February 15,
2012:
08:00 – 6.6 mmol/l, 08:00 – 7.3 mmol/l,
10:00 – 8.9 mmol / l, 10:00 - 9.8 mmol / l
12:00 - 5.1 mmol / l. 12:00 - 10.7 mmol / l.
Safety factors [Anti-HCV (Core-n NS3-p NS4-n; Core-n NS4-p NS5-n), AT-HIV 1 and 2; Microreaction with cardiolipin antigen (RW)] from 02.02.12. - negative. HBsAg detected (31.01.12) Control HBsAg (07.02.12) - negative, PCR in hepatitis B virus (07.02.12) - negative
Lipidogram 01.02.2012: α 14.20% (13.00-44.00), β 41.71% (6.9-42.20); β 44.09% (30.30-62.70).
Results of instrumental studies:
X-ray of the chest, lumbar spine, knee and shoulder joints, feet (D=2.24 mSv) No. 482 dated 02/01/2012:
➢ On the chest radiograph in the lungs without focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is expanded in diameter to the left, the aorta is sealed.
➢ On the spondylograms of the lumbar spine in 2 projections, physiological lordosis is smoothed out, scalariform retrolisthesis with displacement of the vertebral bodies L2, L3, L4 posteriorly by 0.4 cm, 0.5 cm, 0.7 cm, respectively. Osteochondrosis of the L4-L5 motor segment with an uneven decrease in the height of the disc, compaction of the end plates and a marginal exophyte of 0.1 cm in the anterior section of the L5 in the projection of the disc.
➢ On radiographs of the knee joint in 2 projections and both shoulder joints, no bone changes were found.
➢ No bony changes were found on radiographs of the feet.
Computed tomography of the abdomen dated February 6, 2012: hepatomegaly, diffuse decrease in liver density. Small-scale hyperplasia of the left adrenal gland. Radiopaque calculus of the right kidney. Lymphoadeonopathy of intra-abdominal lymph nodes.
Magnetic resonance imaging of the lumbosacral spine, MR myelography dated February 6, 2012. MR picture of degenerative-dystrophic changes in the lumbosacral spine (osteochondrosis, spondylosis) with impaired statics. Herniated discs L4-L5, L5-S1 up to 4 mm.
Magnetic resonance imaging of the head with a targeted study of the chiasmal-sellar region dated February 17, 2012: MRI data for the presence of volumetric pathological formations of the pituitary gland were not obtained. MR picture of moderately severe dyscirculatory encephalopathy.
Ultrasound of the abdominal organs No. 298 dated February 1, 2011: the liver is enlarged, the right lobe: 16 cm; left 8.7 cm, smooth contours, homogeneous structure, increased echogenicity; the vascular pattern is depleted, the intrahepatic vessels are not dilated; portal vein 10 mm, hepatic veins 8 mm (up to 10 mm). Intrahepatic bile ducts are not dilated. The gallbladder of the correct form, 5.7 × 2.4 cm, the contours are even, the walls are 4-6 mm, unevenly thickened, calculi and polyps are not visualized, the common bile duct is 0.3 cm. The pancreas is clearly located, the head is 20.0 cm , the body is 18.3 cm, the contours are clear, even, the structure is heterogeneous, the echogenicity is moderately increased; Wirsung's duct is not dilated. Kidneys of normal size (right 10 × 6.0 cm, left 10.6 × 6.0 cm), normal location, with smooth contours, homogeneous parenchyma 16-18 mm thick, cavity systems are not expanded. The spleen is 9.3×4.7 cm in size, not enlarged. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: diffuse changes in the liver according to the type of fatty hepatosis.
DUHG 02/27/2012: Sphincter of Oddi dysfunction with spastic component
Ultrasound of the thyroid gland 02/01/2012: the gland is located typically, symmetrical, not enlarged. Right lobe 14.0×15.2×51.0 mm. Left lobe 16.0×13.3×47.0 mm. Isthmus 4 mm. The total volume is 11.1 ml. The contours are fuzzy, uneven, the structure is heterogeneous, increased echogenicity. Volumetric formations are not located, the blood flow is slightly increased. Regional lymph nodes are not changed. Conclusion: diffuse changes in the thyroid gland.
EchoCG on February 1, 2012: aorta 36 mm, aortic valve dilatation 18 mm, LA 49x50x50 mm, mitral valve S>4 cm2, leaflets sealed, CRLV 38 mm, CRLV 60 mm, EF 60%, FU 33%, PSLV 11 mm , MZHP 11 mm, LA 24 mm, PP 52x52 mm, KDRPZH 25 mm, E/A=1.28. Dilatation of the atrial cavities, left ventricle. No zones of local disturbance of kinetics were revealed. Moderate fibrosis of the IVS. The aorta, fibrous rings of the aortic and mitral valves are sealed. The valves have not been changed. The blood flow is laminar. Diastolic dysfunction 2 (pseudo-normal) type. Applied regurgitation of the mitral and tricuspid valves. The pericardium is not changed, there is no effusion.
ECG No. 425 dated February 15, 2012: atrial rhythm with a heart rate of 62/min, EOS is normal. Partial violation of intraventricular conduction. Left ventricular hypertrophy. Violation of repolarization in the anterior-lateral region
of the left ventricle Consulted by a neurologist on 02.02.2012, the diagnosis was made: Initial manifestations of cerebrovascular insufficiency in the form of scattered neurological symptoms, astheno-neurotic syndrome, chronic discogenic lumbar sciatica with L4-L5 radicular syndrome on the left, remission.
The goals of hospitalization have been achieved - the "target level" of blood pressure has been reached, the ability to work has been restored.
Discharged in a satisfactory condition.
Recommended:
54. Observation of the doctor of the unit according to DM-1 with the involvement of a cardiologist, neurologist, endocrinologist.
55. Control dynamic ultrasonic cholecystography after 1 month
56. Control of AST, ALT, CPK, GGTP, lipidograms after 1 month
57. Keep drinking regimen 1-1.5 l/day; restriction of the use of table salt (no more than 3 g per day).
58. Limit the consumption of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes).
59. Continue regular medication:
a. Tab. Eplerenone 50 mg 1 tablet daily in the morning.
b. Tab. Amlodipine 5 mg - 1 tablet daily in the morning.
c. Tab. Losartan 100 mg - 1 tablet daily in the morning.
d. Tab. Glibomet 400/2.5 mg - 1 tablet daily in the morning.
e. Tab. Atorvastatin 10 mg - 1 tablet in the evening continuously.
60. Continue course medication:
a. Tab. Duspatalin (Odeston) 0.4 1 tablet 15 minutes before breakfast and dinner 10 days
b. Caps. Urdoksa 0.25 - 2 capsules 2 times a
day
for
1
month (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1986
He was treated in the clinic of hospital therapy in day hospital mode
Total days of treatment 6
The final diagnosis was established by ICD Code K 26.7
Diagnosis:
Duodenal ulcer, often relapsing course, phase of unstable remission, cicatricial deformity of the duodenal bulb without impaired evacuation function. Chronic gastroduodenitis, exacerbation.
Alimentary-constitutional obesity of the 1st degree, android type, stable stage. Complex astigmatism of the right eye.
A disability certificate was not issued.
Ability to work restored
Total radiation dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no change, chronicity
, disability, established _____ disability group, degree of disability _______________________________, other _______________________________________ where)_____________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a medical
examination
.
Complaints of episodic pain in the epigastric region of a aching nature, decreasing after eating, aggravated on an empty stomach (hungry pain) and at night, heartburn, nausea, general weakness.
Anamnesis of the present disease (Anamnesis morbi):
Periodic aching pain in the epigastric region and heartburn after an error in nutrition has been noted since 2006, he did not seek medical help. FEGDS in 2007 verified chronic gastritis in the acute stage, was treated on an outpatient basis, took antacids with temporary improvement. In the future, abdominal pain syndrome recurred after errors in nutrition with a frequency of 2-3 times a year. He treated himself, took almagel with a good effect. Over the past year, abdominal pain has intensified and become more frequent.
On October 11, 2011, FEGDS revealed multiple (two) ulcers of the duodenal bulb. He was treated permanently in the clinic of faculty therapy for newly diagnosed peptic ulcer. On the background of the therapy, scarring of ulcerative defects was achieved. In the future, he took antacid drugs for relapses of abdominal pain syndrome with temporary improvement. Deterioration of well-being a month after discharge, when, after a nutritional error, aching pains in the epigastric region, heartburn, "night" pains recurred, he took Almagel, Omez with little effect. On November 16, 2011, FEGDS revealed an ulcer of the duodenal bulb. In this connection, he underwent inpatient treatment at the FT clinic from 22.11 to 12.12.2011.
Within a month after discharge, he felt satisfactorily, however, with a slight error in the diet, he noted the appearance of heartburn, sour eructation, which forced him to increase the dose of antacids taken on his own, and had a negative effect on the performance of official duties. He was hospitalized in a planned manner for a day hospital in order to diagnose the state of the gastrointestinal tract and correct the therapy.
Objective status:
The general condition is relatively satisfactory. Consciousness is clear. The position is active. Emotionally calm, there are no gross focal symptoms. No sensory disturbances were found. Correct physique, increased nutrition. There are no developmental defects or visible bodily injuries. Skin and mucous membranes of normal color, without rashes. Peripheral lymph nodes are not enlarged. The pulse on the radial arteries is 76 per minute, the same on both arms, satisfactory filling, not tense. The vascular wall outside the pulse wave is not palpable. BP - 130/90 mm Hg. The limits of relative cardiac dullness were within the normal range. Auscultation of the heart tones are clear, rhythmic. The pulse on the arteries of both feet is the same, satisfactory filling. The superficial veins of the lower extremities are not visible. The chest is correct, there are no deformations, evenly participates in the act of breathing Respiratory rate - 16 / min. With percussion of the lungs, a clear pulmonary sound is determined, which is the same at symmetrical points of the chest. The borders of the lungs are within the normal range. On auscultation, vesicular breathing is carried out evenly over the entire surface. There are no wheezes. The mucous membrane of the mouth is pink. The tongue is coated with white. Zev is not hyperemic. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. With percussion of the lungs, a clear pulmonary sound is determined, which is the same at symmetrical points of the chest. The borders of the lungs are within the normal range. On auscultation, vesicular breathing is carried out evenly over the entire surface. There are no wheezes. The mucous membrane of the mouth is pink. The tongue is coated with white. Zev is not hyperemic. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. With percussion of the lungs, a clear pulmonary sound is determined, which is the same at symmetrical points of the chest. The borders of the lungs are within the normal range. On auscultation, vesicular breathing is carried out evenly over the entire surface. There are no wheezes. The mucous membrane of the mouth is pink. The tongue is coated with white. Zev is not hyperemic. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. The borders of the lungs are within the normal range. On auscultation, vesicular breathing is carried out evenly over the entire surface. There are no wheezes. The mucous membrane of the mouth is pink. The tongue is coated with white. Zev is not hyperemic. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. The borders of the lungs are within the normal range. On auscultation, vesicular breathing is carried out evenly over the entire surface. There are no wheezes. The mucous membrane of the mouth is pink. The tongue is coated with white. Zev is not hyperemic. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged. The abdomen is symmetrical. On palpation, soft, painful in the epigastric region. Symptoms of peritoneal irritation are negative. The liver does not protrude from under the edge of the costal arch. The dimensions of the liver according to M.G. Kurlov: 13x9x8 cm. The spleen is not enlarged. In the supine and standing position, the kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged.
As a result of the treatment: regimen, diet No. 1, de-nol, omeprazole, almagel, the state of health improved.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., 109/l
MSN
ESR, mm/h
Lf, %
M, %
E, %
P/I, %
S/I, %
19.01
154
5.75
9.6
26.7
8
25
9
58
6
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M / o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
19.01
clear
1030
yellow
5.5
no
no
no
2
no
no
2-4
no
1-2
0-2
Biochemical blood test:
Name
Unit of measure.
Norm
19.01.2012
Cholesterol
Mmol/l
3.7-6.0
2.49
Total protein
G/l
63.0-87.0
77
AST
U/l
11.0-50.0
28
total bilirubin
mmol/l
6.8-26
13.2
glucose
mmol/l
3.9-6.2
5.49
C- RP
mg/l
3-10
9.42
Sialic acids
mol/l
1.9-2, 5
2.1
fibrinogen
g/l
2.0-4.0
4.13
PTI
%
70-110
105
alkaline phosphatase
U/l
36-129
109
GGTP
U/l
11-63
103
Results of instrumental studies:
ECG dated 17.01.2012 g.: sinus rhythm with a frequency of 76 per 1 minute, EOS is normal.
Ultrasound of the abdominal organs from 01/23/2012: the liver is not enlarged, the right lobe: 11.8 cm; left 6.5 cm, smooth contours, homogeneous structure, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein 8 mm, hepatic veins 7 mm (up to 10 mm). Intrahepatic bile ducts are not dilated. The gallbladder of the correct form, 5.6×1.3 cm, the walls are even 2 mm, stones are not visualized. The pancreas is located indistinctly, not enlarged, the contours are indistinct, even, the structure is homogeneous, echogenicity is average; Wirsung's duct is not dilated (2mm). Kidneys of normal size (right 11.2×4.7 cm, left 11.3×4.3 cm), normal location, with even contours, homogeneous parenchyma 15-19 mm thick, cavitary systems are not expanded. The spleen is 9.8×4.9 cm, not enlarged. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: moderate flatulence.
Plain radiograph of the chest No. 389 dated January 23, 2012: in the lungs without focal and infiltrative changes. The heart is not enlarged.
FGDS on 01/19/2012: The esophagus is passable, 42 cm from the upper incisors. Z-line at the level of the abdominal region is indistinct. The erosions were completely epithelialized. The mucosa in the distal section is somewhat hyperemic, edematous. The socket of the cardia does not close completely, there is a reflux of the contents of the stomach into the esophagus. In the stomach, folds of the usual caliber straighten out during insufflation. The mucosa is moderately hyperemic in the area of the body, in the antrum there are multiple, millet-like bulges (whitish). The pylorus does not close completely. The duodenal bulb is deformed due to a strengthened red linear scar. There is a whitish linear scar on the posterior-lateral wall. Conclusion: healed ulcer of the duodenal bulb. Moderately expressed cicatricial and ulcerative deformity of the duodenal bulb. Chronic gastritis with focal atrophy of the antrum (follicular-nodular antrum-gastritis). Distal catarrhal reflux esophagitis.
Recommended:
49. Observation of the doctor of the department according to DM-1
50. Limit the consumption of animal fats, fried and spicy foods, increase the amount of vegetable fiber, vegetable fats, products in the diet.
51. Continue taking:
e. Caps. Omeprazole 0.02 1 capsule in the evening for 2 weeks.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1949
She was hospitalized at the hospital therapy clinic
In total, 10 days of treatment were carried out
. ICD Code M 17.9 MES 381020
Diagnosis:
Secondary nephropathy of mixed (atherosclerotic, hypertensive, nephritic) genesis. Chronic bilateral pyelonephritis, exacerbation phase. Cysts of the right kidney. Chronic kidney disease stage 4 (GFR 24 ml/h). Proteinuria. Chronic renal failure stage 1a. Neoplasm of both adrenal glands.
Arterial hypertension of mixed (essential, renoparenchymal) genesis of III degree → drug normotension, the risk of CVE is "very high".
Coronary artery disease. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis complicated by paroxysmal atrial fibrillation (without exacerbation).
Heart failure II functional class 2a stage.
Bronchial asthma of mixed genesis (infection-dependent, primary altered bronchial reactivity) of moderate course, remission without respiratory failure.
Fixed hiatal hernia. Chronic atrophic gastritis, erosive bulbitis, exacerbation.
Alimentary-constitutional obesity of the 2nd degree (BMI-37.6 kg/m2), stable course.
Certificate of incapacity for work: not issued
Total radiation dose 1.4 mSv
Clinical outcome: improvement.
Outcome: discharged.
Upon enrolment:
Complaints: frequent bouts of palpitations, increased blood pressure up to 190/150 mm Hg, episodic attacks of suffocation accompanied by wheezing, coughing with white bloody discharge, pain in the right hypochondrium and epigastric region with errors in diet.
History of present illness. She suffered from chronic bronchitis for a long time. in 2011, the disease acquired a protracted course with frequent attacks of dyspnea, which prevented active seeking medical help. Bronchial asthma was verified on a stationary basis, adequate therapy was selected for outpatient admission (Seretide-multidisc 50/250 1 dose 1 time per day and berodual 2 doses 2 times a day). In the same year, she was operated on for urolithiasis on both sides, the stones were removed. In the postoperative period, she began to notice a significant increase in blood pressure, mainly due to diastolic blood pressure, palpitations, weakness, and her weight began to progressively increase (over the past 2 years, body weight has been stable). Takes diltiazem without visible effect.
As a result of the treatment: regimen, diet No. 7, Seretide-multidisc, Berodual, Acecardol, Amlodipine, Omeprazole, Furosemide, Ciprofloxacin, the state of health improved.
The patient was consulted by Professor Barsukov A.V. It has been determined that at present the course of concomitant diseases is of the maximum possible compensated character. The severity of the condition and the prognosis determine the functional state of the excretory function of the kidneys and the existing neoplasms of the adrenal glands, which make a significant contribution to the maintenance of arterial hypertension, cardiac arrhythmias, and lesions of the upper gastrointestinal tract. Despite the convincing effect of the prescribed therapy, it is recommended that the patient undergo an additional examination on an outpatient basis in order to determine the functional state of the adrenal glands, perform a blood test for catecholamines, plasma renin activity, aldosterone levels (after discontinuation of drugs that affect the RAAS system for 14 days) followed by a consultation nephrologist.
Results of instrumental studies:
ECG on September 18, 2013: heart rate 83 per minute. Sinus rhythm. Horizontal position of the electrical axis of the heart. Left ventricular hypertrophy. Violation of repolarization processes in the area of the anterior wall and apex.
Echocardiography 23.09.2013: NORMAL
PARAMETERS
NORMAL
PARAMETERS
Diameter
of the aortic root
-
20-37 mm
ERD of the left ventricle
37.7
38-56 mm
Opening of the leaflets of the aortic valve
21.1
more than 15 mm EFR of the
left ventricle
27.4
22-38 mm
Antero-posterior size of the left atrium
25
39.2 -40 mm
Anterior wall thickness of the right ventricle
6.0
less than 5 mm
Transverse left atrium
39.8
25-45 mm
Left ventricular ejection fraction
55
more than 55%
Longitudinal dimension of the left atrium
51.7
29-53 mm
Longitudinal dimension of the right atrium
46.2
Interventricular septal thickness
13.3
7-11 mm
Transverse dimension of the right atrium
37.1
34-49 mm
Thickness of the posterior wall of the left ventricle
12.6
7-11 mm
ECR of the right ventricle
37.7
Less than 30 mm
Systolic pressure in the pulmonary artery
28
to 30 mm Hg
Pulmonary trunk diameter
-
12-23 mm
LVMI, g/m2
92
Less than 109/124 LVMI
, g
198
Less than 141/183
Echocardiography: Sinus rhythm. The walls of the aorta are sealed. The leaflets of the aortic valve are sealed and calcified. Concentric remodeling of the left ventricle. The cavities of the heart are not dilated, free. The systolic function of the left ventricle is preserved. Restrictive type diastolic dysfunction of the left ventricle. LV contractility (global and local) is not broken. Mitral regurgitation 1 degree. Pericardium - without features.
Holter blood pressure monitoring on September 24, 2013: mean systolic blood pressure during the day and mean diastolic blood pressure during the daytime were within the normal range, mean diastolic blood pressure at night is characteristic of mild labile hypertension. At night, systolic and diastolic blood pressure decrease insufficiently (nondipper). The variability of systolic and diastolic blood pressure during the day is within the acceptable range. Episodes of hypotension were not registered. There is an increase in the rate of morning rise in systolic blood pressure.
Holter monitoring of the ECG on September 20, 2013: During the observation, sinus rhythm was recorded with a heart rate of 49 to 97 per minute. The decrease in heart rate at night is insufficient. Average heart rate 58/63/53 per minute. Registered single supraventricular extrasystoles (total 123), periodically paired, group. When performing the planned load (staircase test 72 and 96 steps), the heart rate reached 78 and 97 per minute. Ischemic changes in the ST segment were not detected.
Spirometry on September 23, 2013: VC 46%, FVC 48%, FEV1 40%. Violation of FVL according to the mixed type III degree (sharp).
Spirometry (test with salbutamol) on September 23, 2013: VC 61%, FVC 61%, FEV1 49%. ROf expiration 22.55%. The test with salbutamol is positive (the coefficient of bronchodilation was 22.55%).
Ultrasound examination of the abdominal cavity and thyroid gland on September 20, 2013: the liver is not enlarged, the right lobe is 16.0 cm, the left lobe is 9.9 cm, echogenicity is increased, the vascular pattern is depleted, choledochus is 4 mm. The gallbladder is irregular in shape, an inflection in the area of the body. Dimensions: length 5.6cm, diameter 3.1cm, smooth contours, wall 3mm, not changed. The pancreas is located indistinctly, the dimensions are: the head is 19.5 mm, the body is 17.2 mm, the contours are fuzzy, uneven, the structure is heterogeneous with signs of lipomatosis, the Wirsung duct is not dilated, 2 mm. The spleen is not enlarged, dimensions: length 10.0 cm, thickness 5.6 mm, homogeneous structure. Kidneys: irregular contours. Right kidney: length 11.0 cm, width 5.7 cm, homogeneous parenchyma 16.0 mm, PCL moderately dilated, grossly deformed. Hyperechoic inclusions 65 x 45 mm, 26 x 23 are visualized in the upper pole of the kidney. 2 mm with partitions. In the area of the sinus, the calculus is 19.5 mm in diameter. Left kidney: length 10 cm, width 5.0 cm, homogeneous parenchyma 15.5 mm, PCL is sealed. In the area of the adrenal gland, no changes are visualized. The thyroid gland is not enlarged, the contours are fuzzy, uneven, the structure is heterogeneous, the isthmus is 5 mm. Right lobe: width 23.0cm, thickness 22.7cm, length 43.4cm, volume 12.0cm3. Left lobe: width 29.1cm, thickness 33.4cm, length 52.0cm, volume 26.4cm3. Vtot. 138.4. Diffuse mass formations are not visualized. The blood flow is moderately increased. Regional lymph nodes are not changed. Conclusion: Diffuse changes in the liver according to the type of fatty hepatosis. Pancreatic lipomatosis. ICD. Cysts of the right kidney. Hyperplasia of the thyroid gland. CHLS is sealed. In the area of the adrenal gland, no changes are visualized. The thyroid gland is not enlarged, the contours are fuzzy, uneven, the structure is heterogeneous, the isthmus is 5 mm. Right lobe: width 23.0cm, thickness 22.7cm, length 43.4cm, volume 12.0cm3. Left lobe: width 29.1cm, thickness 33.4cm, length 52.0cm, volume 26.4cm3. Vtot. 138.4. Diffuse mass formations are not visualized. The blood flow is moderately increased. Regional lymph nodes are not changed. Conclusion: Diffuse changes in the liver according to the type of fatty hepatosis. Pancreatic lipomatosis. ICD. Cysts of the right kidney. Hyperplasia of the thyroid gland. CHLS is sealed. In the area of the adrenal gland, no changes are visualized. The thyroid gland is not enlarged, the contours are fuzzy, uneven, the structure is heterogeneous, the isthmus is 5 mm. Right lobe: width 23.0cm, thickness 22.7cm, length 43.4cm, volume 12.0cm3. Left lobe: width 29.1cm, thickness 33.4cm, length 52.0cm, volume 26.4cm3. Vtot. 138.4. Diffuse mass formations are not visualized. The blood flow is moderately increased. Regional lymph nodes are not changed. Conclusion: Diffuse changes in the liver according to the type of fatty hepatosis. Pancreatic lipomatosis. ICD. Cysts of the right kidney. Hyperplasia of the thyroid gland. 1cm, thickness 33.4cm, length 52.0cm, volume 26.4cm3. Vtot. 138.4. Diffuse mass formations are not visualized. The blood flow is moderately increased. Regional lymph nodes are not changed. Conclusion: Diffuse changes in the liver according to the type of fatty hepatosis. Pancreatic lipomatosis. ICD. Cysts of the right kidney. Hyperplasia of the thyroid gland. 1cm, thickness 33.4cm, length 52.0cm, volume 26.4cm3. Vtot. 138.4. Diffuse mass formations are not visualized. The blood flow is moderately increased. Regional lymph nodes are not changed. Conclusion: Diffuse changes in the liver according to the type of fatty hepatosis. Pancreatic lipomatosis. ICD. Cysts of the right kidney. Hyperplasia of the thyroid gland.
Fibrogastroduodenoscopy on 09/19/2013: the esophagus is passable, 38 cm from the upper incisors. G line at the level of 35 cm from the upper incisors, a symptom of "two cardias" is noted, a fixed fixed hernia of the pi of the esophageal opening of the diaphragm is not excluded. In the mid/gr and v/gr sections of the esophagus, there are single veins in the form of tubercles of a bluish hue with a diameter of 0.2 to 0.4 cm. In the stomach, folds of the usual caliber are straightened out during insufflation. The mucosa is moderately hypertrophied with areas of atrophy. The pylorus does not close completely, there is a reflux of duodenal contents with prolapse of the mucosa of the pyloric canal. There are multiple petechial erosions in the duodenal bulb. Conclusion: "Ectopic varix" of the upper esophagus. Fixed hiatal hernia. Chronic focal atrophic gastritis. Duodenogastric reflux with hypermotor dyskinesia. Erosive bulbitis.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/L
Leuc., *109/L
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
Tr, 109/L
19.09
128
4.44
4.0
28.9
12
0
-
43
5
1
52
229
General
urine
analysis
(
automatic
processing
)
:
Date
Urobil
Bacteria
19.09
1015
6.5
0.1
No
No
30-35-40
8-10-15
3.2
1
Biochemical blood test:
Name
Unit of measure.
Norm
19.09
27.09
Glucose
mmol/l
4.2-6.4
5.29
Creatinine
mmol/l
0.05-0.12
0.19
0.21
Urea
mmol/l
2.5-6.4
12.0
16.3
Cholesterol
mmol/l
3.7-6.0
5.53
Potassium
mmol/l
3.50-5.10
5.28
4.76
sodium
mmol/l
136-145
145.0
ALT
U/l
11-50
23
AST
U/l
11-50
20
O. protein
g/l
63-87
68
Prothrombin
%
70-120
103
Fibrinogen
g
/
l
2.0-4.0
2.45
Unit.
Norm
20.09
Albumin
%
55.80..65.00
53.25
Alpha1
%
2.20..4.60
4.06
Alpha2
%
8.20..12.50
13.28
Beta
%
7.20..14.20
9.36
Gamma
%
11.50..18.60
20.05
Recommended:
52. Observation by a nephrologist at the place of residence.
53. Diet:
a. Limiting the intake of protein with food to up to 0.8-1 g / kg (up to 50-60 g per day), depending on the severity of renal failure. At the same time, 30 g should be a high-value protein, and only 10 g of protein per day should fall on the share of bread, cereals, potatoes and other vegetables. 30-40 g of complete protein. In general, the patient's menu is compiled within table No. 7. The following products are included in the patient's daily diet: meat (100-120 g), cottage cheese dishes, cereal dishes, semolina, rice, buckwheat, barley porridge. A potato and potato-egg diet is recommended. Particularly suitable due to the low protein content and at the same time high energy value are potato dishes (fritters, meatballs, grandmothers, fried potatoes, mashed potatoes, etc.), salads with sour cream, vinaigrettes with a significant amount (50-100 g) of vegetable oil. Tea or coffee can be acidified with lemon, put 2-3 tablespoons of sugar in a glass, it is recommended to use honey, jam, jam. Thus, the main composition of food is carbohydrates and fats and dosed - proteins. Calculating the daily amount of protein in the diet is a must. It is allowed to replace 1 egg with: cottage cheese - 40 g; meat - 35 g; fish - 50 g; milk - 160 g; cheese - 20 g; beef liver - 40 g.
Approximate diet:
• Breakfast: Soft-boiled egg + Rice porridge 60 g + Honey 50 g
• Lunch: Fresh cabbage soup 300 g + Fried fish with mashed potatoes 150 g + Apples
• Dinner: Mashed potatoes 300 g + Vegetable salad 200 g + Milk 200 d
Correction of water balance disorders: take enough liquid to maintain diuresis within 2-2.5 liters per day.
Correction of electrolyte imbalance: salt intake should be limited to 5-10 g per day
54. Perform in a planned manner:
a. Urinalysis for daily protein loss;
b. blood test for catecholamines, plasma renin activity, aldosterone level
55. Nephrologist's consultation with research results.
56. Continue taking:
• Amlodipine 5 mg - 1 tab. in the morning constantly;
• Allapenin 25 mg - 1 tab. 2 times a day;
• Furosemide 40 mg - ½ tab. in the morning;
• Seretide multidisk 50/250 1 dose 2 times a day
• Berodual - op 1 dose 2 times a day
• Omeprazole 20 mg - 1 capsule in the morning for 14 days.
Limiting the intake of protein with food to up to 0.8-1 g / kg (up to 50-60 g per day), depending on the severity of renal failure. At the same time, 30 g should be a high-value protein, and only 10 g of protein per day should fall on the share of bread, cereals, potatoes and other vegetables. 30-40 g of complete protein. In general, the patient's menu is compiled within table No. 7. The following products are included in the patient's daily diet: meat (100-120 g), cottage cheese dishes, cereal dishes, semolina, rice, buckwheat, barley porridge. A potato and potato-egg diet is recommended. Particularly suitable due to the low protein content and at the same time high energy value are potato dishes (fritters, meatballs, grandmothers, fried potatoes, mashed potatoes, etc.), salads with sour cream, vinaigrettes with a significant amount (50-100 g) of vegetable oil. Tea or coffee can be acidified with lemon, put 2-3 tablespoons of sugar in a glass, it is recommended to use honey, jam, jam. Thus, the main composition of food is carbohydrates and fats and dosed - proteins. Calculating the daily amount of protein in the diet is a must.
An approximate daily set of products (diet No. 7) per 50 g of protein in chronic renal failure
It is allowed to replace 1 egg with: cottage cheese - 40 g; meat - 35 g; fish - 50 g; milk - 160 g; cheese - 20 g; beef liver - 40 g.
Approximate diet:
• Breakfast: Soft-boiled egg + Rice porridge 60 g + Honey 50 g
• Lunch: Fresh cabbage soup 300 g + Fried fish with mashed potatoes 150 g + Apples
• Dinner: Mashed potatoes 300 g + Salad vegetable 200 g + Milk 200 g
Correction of water balance disorders: take enough liquid to maintain diuresis within 2-2.5 liters per day.
Correction of electrolyte imbalance: salt intake should be limited to 5-10 g per day
MILITARY MEDICAL ACADEMY Form 12_Uni.VMedA-2011
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic born in 1990
He was hospitalized at the clinic of hospital therapy
Total days of treatment were 7
The final diagnosis was established ICD code G 90.8
DIAGNOSIS:
Main disease: Neurocirculatory asthenia of the cardiac type with severe cardialgic syndrome without heart failure. Nutritional deficiencies.
Concomitant disease: Gastroesophageal reflux disease. Distal catarrhal reflux esophagitis. Superficial gastroduodenitis.
Certificate of incapacity for work: not issued
Total exposure dose _____0.6 mSv ____
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, disability group established, degree of limitation
Outcome: discharged due to improvement
Complaints: palpitations, pressing, stabbing pain in the heart area, irradiation under the left shoulder blade and into the left shoulder with moderate physical exertion, rise to the second floor), psycho-emotional stress, in the position on the left side, discomfort in the epigastrium when bending forward.
Disease history. Chronic diseases are denied. These symptoms began to bother about 2 weeks ago with a tendency to progression, did not take any medications. During the last 3 days, he notes an increase in shortness of breath, the appearance of pressing pain in the region of the heart, radiating under the left shoulder blade and shoulder, and palpitations. On May 27, 2013, he applied for medical help at the Central Clinical Hospital, was consulted by a cardiologist, hospitalization in the cardiology department was recommended.
For examination and treatment, he was admitted to the clinic of GT VMedA in a planned manner.
As a result of the treatment: regimen, diet N10, caps. Cardionate 1.0 g/day showed positive dynamics: the pain syndrome did not recur, hemodynamic parameters were at the level of normal values. Given the patient's lack of a history of cardiac pathology, episodes of pain syndrome should be considered within the framework of dysfunction of the autonomic nervous system.
Results of instrumental studies:
ECG dated May 28, 2013: Sinus rhythm with heart rate 72. EOS vertical position.
ECG control dated May 30, 2013: no dynamics.
FEGDS from 06/03/2013: distal catarrhal reflux esophagitis. Superficial gastroduodenitis.
FLG UGP dated May 29, 2013: no pathological changes.
VEM dated May 31, 2013: negative test.
24-hour ECG monitoring on May 30, 2013: sinus rhythm was recorded during the observation period. Heart rate from 47 to 118 per minute. The decrease in heart rate at night is adequate. Average heart rate 66/72/57 per minute. The following rhythm and conduction disturbances were registered: single supraventricular (2 in total) and ventricular extrasystoles (49 in total). When performing the planned load, the heart rate reached 118 and 113 per minute. Ischemic changes in the ST segment were not detected.
Echocardiography dated May 29, 2013:
Result, mm
Norm, mm
Aorta
At the level of AK
25.4
22-36
Valve opening
18.8
15-26
Left atrium
Anteroposterior size
28.2
25-40
Left ventricle
DSR
30.8
≤ 36
EC
47.4
≤ 55
Posterior wall thickness (diast.)
7.4
Interventricular septal thickness (l)
7.4
Right ventricle
EC
≤ 30
Anterior wall
4.2
≤ 5
Right atrium
Transverse dimension
34.6
29-46
Longitudinal dimension
34.6
34-49
Pulmonary artery
At the valve
12-23
Indicator
Result
Norm
FU, %
35
28-41
EF, %
64
≥55
Ve/Va
1.3
1.0-2.2
Conclusion: Large vessels of the heart without visible pathology. Normal geometry of the left ventricle. The cavities of the heart are not dilated, free. The systolic function of the left ventricle is preserved. Applied tricuspid regurgitation. Pericardium without features. Dopplerography revealed no pathology.
Laboratory results : Complete
urinalysis (automatic processing):
Date
U.weight
Reak
Protein
Sax
Ket.
Lei
Er.neiz
Urobil
29.05
1025
5.5
-
-
-
0-2
-
0.2
Clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
Tr. *109/l
MCH
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
29.05
141
5.39
3.4
194
26.2
5
-
1
42
6
1
43
31.05
146
5.64
4.8
222
25.8
4
4
-
52
7
1
36
Biochemical blood test:
Name
Unit.
Norm
29.05
O. protein
g/l
64-83
69
Glucose
mmol/l
4.2-6.4
4.93
Creatinine
mmol/l
0.05-0.12
0.1
Potassium
mmol/l
3.4-4.5
4.22
Calcium
mmol/l
2.1-2.55
Sodium
mmol/l
130-150
137.7
Cholesterol
mmol/l
3.7-6.0
3.71
Total bilirubin
mmol/l
6.3-26
21.9
Direct bilirubin
mmol/l
Urea
mmol/ l
1.9-2.5
5.5
AST
U/l
11-50
ALT
U/l
11-50
GGTP
U/l
CPK
100.4
CPK MB
AtTPO
less than 37
T3
1.25
T4
T4 St.
Nmol/l
0.89-1.76
TSH
0.35-5.5
2.18
glycated Hv
%
PSA
Ng/ml
Up to 4
0.78
Test for HBsAg, anti-HCV, RW, F-50 04/13/2013: negative.
Coagulogram dated April 13, 2013: fibrinogen 2.39 g/l
Coprogram dated April 13, 2013: mushy consistency, neutral mucus reaction - 0, blood - 0, digested muscle fibers 2, undigested longitudinal striation 2, transverse striation 1, vegetable fiber: digested 0, undigested 2, starch grains: intracellular 0 , extracellular 1, iodophilic flora 2, neutral fat 0, fatty acids 2, soaps 1; leukocytes 0; Erythrocytes 0. I/g were not found.
Discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
23. Observation, therapist, gastroenterologist.
24. Normalization of the regime of work and rest. Exclude the use of animal fats, easily digestible carbohydrates, alcohol, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet. exercise therapy.
25. Observe the water regime (fluid balance), daily monitoring of blood pressure and heart rate.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. d. 63, tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1961
Was on inpatient treatment (in day hospital mode)
in the clinic of hospital therapy
Total days of treatment 15
The final diagnosis was established ICD code I.10
Diagnosis:
Hypertensive disease of the second stage.
Coronary artery disease. Angina pectoris of the second functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis.
Heart failure of the first functional class.
Diabetes mellitus of the second type, moderate severity, compensated.
Intervertebral osteochondrosis, deforming spondylosis of the cervical, thoracic, lumbar, lumbar spondylarthrosis, right-sided first degree scoliosis of the thoracic regions with a slight dysfunction of the spine. Chronic discogenic radiculopathy from the fifth lumbar, first sacral roots on the right, remission, without impaired function of the lower extremities.
Dyscirculatory encephalopathy of the second stage of mixed genesis (post-traumatic (1996), atherosclerotic, hypertensive, dysmetabolic) in the form of external hydrocephalus, multiple vascular foci in both frontal lobes, left-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome.
Curvature of the nasal septum without persistent violation of nasal breathing. Vasomotor rhinosinusopathy.
Partial secondary adentia of the upper and lower jaws.
Alimentary obesity of the second degree, stable stage.
Diffuse-nodular euthyroid goiter of the first degree.
Diffuse pneumosclerosis without respiratory failure.
Secondary nephropathy of mixed origin (atherosclerotic, hypertensive, diabetic) without signs of renal failure
.
Ability to work restored
Total radiation dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity
, disability, established _____ disability group, degree of disability _______________________________, other _____________________________________________ where)_____________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a medical
examination
.
Complaints: headache, dizziness, pain in the region of the heart of a pressing nature during physical and psycho-emotional stress, fatigue, memory impairment, decreased performance, emotional lability, sleep disturbance, pain in the spine during physical exertion and prolonged work in a sitting position, the absence of several teeth upper and lower jaws, dry mouth, thirst, overweight.
Anamnesis of the disease: headache in the occipital region, increased blood pressure to 160/90-170/100 mm Hg. Art. worried since 1996, hospitalized diagnosed with hypertension of the first stage. Subsequently, with an increase in blood pressure, enalapril was occasionally taken. Over the past 10 years, notes a stable increase in blood pressure up to 160/100 mm Hg. Art., repeatedly developed a hypertensive crisis, hospitalized diagnosed with hypertension stage II, for permanent use assigned to ACE inhibitors, diuretics. Pressing pain in the region of the heart during physical and psycho-emotional stress over the past year, "on demand" independently took nitroglycerin, in the hospital diagnosed with coronary artery disease, angina pectoris FC 2.
According to the injury certificate of the commander of military unit 63174 dated October 22, 1996, No. 193, on October 15, 1996, while performing military service duties on the territory of the Chechen Republic, he followed the duty station in a GAZ-66 car, which collided with a ZIL-130 car , who fled the scene of an accident, hit his head on the metal rack of the cab, lost consciousness. He underwent inpatient treatment at military unit 63174 with a diagnosis of CBI, concussion. 11/04/1996 was examined by the military military commander at military unit 63174 with a causal relationship "Military injury". In the future, he began to notice the appearance of headache, dizziness at "working" values of blood pressure. Repeatedly underwent treatment with a diagnosis of "remote consequences of CBI".
Pain in the spine has been bothering me for ten years; in 2010, chronic radiculopathy of the L5 and S1 roots on the right was diagnosed as a hospital.
For 10 years, he has noted an increase in body weight, since 2010, body weight has been stable.
In 2010, ultrasound diagnosed a thyroid nodule without disturbing its function.
In 2010, hyperglycemia was detected, type II diabetes mellitus was diagnosed, normoglycemia is achieved with a constant intake of 500 mg of Siofor.
Repeatedly treated at the dentist, extraction of teeth was performed.
Sent to the VVK to determine the category of fitness for military service upon reaching the age limit for military service.
The present examination revealed a curvature of the nasal septum, diffuse pneumosclerosis.
Objective status: hypersthenic physique, overnutrition (BMI-35.1). Skin and visible mucous membranes of normal color. Absence of 14, 15, 17, 24, 25, 26, 27, 36, 46, 47 teeth. Peripheral lymph nodes and thyroid gland are not enlarged. Pastosity of legs and feet. Natural curves of the spine: flattening of the cervical and lumbar lordosis. On palpation, pain over the paravertebral points in the thoracic spine. The distance between the spinous process of the 7th cervical vertebra and the tubercle of the occipital bone increases by 3 cm when the head is tilted, and when the head is tilted back (extension) it decreases by 6 cm. The distance between the spinous processes of the 7th cervical and 1 sacral vertebrae increases by 7 cm when bending over normal posture and decreases by 4 cm when bending back. Lateral movements (tilts) of the body in the lumbar and thoracic regions are possible up to 200 from the vertical line. Movement in the joints of the limbs in full. Pulse 72 per minute, rhythmic. The right and upper borders of the heart are normal, the left - along the left mid-clavicular line. Heart sounds are muffled. BP 160/100-140/90 mmHg Art. Above the lungs there is a clear pulmonary sound, vesicular breathing. The abdomen is painless. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. The perianal region, with a digital examination - the rectum - without pathology. Psychoneurological status: there is a fixation on a change in one's state of health, the situational insistence is reduced, does not reach the level of depression. Emotional and vegetative reactions are unstable. The face is not symmetrical - the left nasolabial fold is smoothed. Weak convergence on both sides. The pharyngeal reflex is increased on both sides. Deep reflexes D>S (anisoreflexia), pathological carpal signs of Rossolimo, Hoffmann on the left. The muscle tone on the left is lowered, changed according to the cerebellar type. Adiadochokinesis. Hypermetry on the left. In the Romberg position, it deviates to the left. Hypesthesia of the radicular type in the projection of the fifth lumbar, first sacral roots on the right. The phenomenon of oral automatism. Visual acuity: OD=OS=1.0. The fundus of the eye: the arteries are narrowed, the veins are dilated, tortuous, the ratio a:b=1:2. IOP: 20/19 mmHg Art. ENT organs: the nasal septum is slightly curved to the right in the form of a cartilaginous ridge. Rumor: SR 6/6 m. The muscle tone on the left is lowered, changed according to the cerebellar type. Adiadochokinesis. Hypermetry on the left. In the Romberg position, it deviates to the left. Hypesthesia of the radicular type in the projection of the fifth lumbar, first sacral roots on the right. The phenomenon of oral automatism. Visual acuity: OD=OS=1.0. The fundus of the eye: the arteries are narrowed, the veins are dilated, tortuous, the ratio a:b=1:2. IOP: 20/19 mmHg Art. ENT organs: the nasal septum is slightly curved to the right in the form of a cartilaginous ridge. Rumor: SR 6/6 m. The muscle tone on the left is lowered, changed according to the cerebellar type. Adiadochokinesis. Hypermetry on the left. In the Romberg position, it deviates to the left. Hypesthesia of the radicular type in the projection of the fifth lumbar, first sacral roots on the right. The phenomenon of oral automatism. Visual acuity: OD=OS=1.0. The fundus of the eye: the arteries are narrowed, the veins are dilated, tortuous, the ratio a:b=1:2. IOP: 20/19 mmHg Art. ENT organs: the nasal septum is slightly curved to the right in the form of a cartilaginous ridge. Rumor: SR 6/6 m. the nasal septum is slightly curved to the right in the form of a cartilaginous ridge. Rumor: SR 6/6 m. the nasal septum is slightly curved to the right in the form of a cartilaginous ridge. Rumor: SR 6/6 m.
As a result of the treatment: regimen, diet No. 10, Metabolic therapy, diuretics (indapamide - 2.5 mg 1 time per day), ACE inhibitors (Enalapril 5 mg 2 times a day), Aspicor 100 mg in the morning, hypoglycemic agents (Metformin 500 mg 2 times a day), stugeron, celebrex, health improved, symptoms of heart failure stopped, blood pressure stabilized at the target level (130-135/80-90 mm Hg), headaches significantly decreased.
The results of laboratory and instrumental studies:
complete blood and urine analysis on 06/24/2011: ESR 26 mm/h, other indicators are normal.
Biochemical blood test on June 24, 2011: cholesterol 6.25 mmol/l, GGTP 85 U/L, ALT, AST, alkaline phosphatase, CPK, glucose, urea triglycerides, creatinine, amylase, electrolytes, total protein is normal.
Glycolized hemoglobin 06/24/2011: 6.6%.
HBs-Ag, anti-HCV, serological tests for syphilis, F-50 06/10/2011: negative. PSA 06/24/2011: normal.
ECG 06/22/2011: sinus bradycardia with a heart rate of 58 per minute, horizontal EOS, partial violation of intraventricular conduction. The predominance of the potentials of the left ventricle.
Ultrasound of 06/06/2011: the liver is not slightly enlarged, echogenicity is increased. Choledoch, portal vein, gallbladder, pancreas, kidneys, spleen without pathology.
Ultrasound of the small pelvis on June 24, 2011: the bladder is without pathology. The prostate gland (30x40x44 mm), the echostructure is homogeneous. There is no residual urine.
Ultrasound of the thyroid gland on 06/06/2011: the gland is located typically, enlarged. Right lobe 23x28x63 mm, volume 22 ml. Left lobe 20x21x61 mm, volume 13.5 ml. Isthmus 3 mm. The total volume is 35 ml. The contours are clear, even, the structure is heterogeneous, medium echogenicity. In the right lobe, there is an isoechoic nodule 15 mm in diameter, with a cystic central component without signs of increased blood flow.
EchoCG on 06/03/2011: aorta 31 mm, aortic valve dilatation 18 mm, LA 43x46x61 mm, mitral valve S>4 cm2, leaflets sealed, CRLV 35 mm, CRLV 56 mm, EF 58%, FU 29%, PSL 12 mm , MZHP 12 mm, LA 22 mm, PP 49x56 mm, KDRPZH 29 mm, E/A=0.86. Dilatation of the atrial cavities. atherosclerosis of the aorta. Symmetrical LV myocardial hypertrophy. LV diastolic dysfunction.
SM BP and ECG 06/08/2011: in the afternoon: cf. SBP 152 mmHg Art., max. SBP 189 mmHg st., min. SBP 117 mmHg st., cf. DBP 92 mm Hg avg., max. DBP 112 mm Hg st., min. DBP 71 mm Hg. st., at night: cf. SBP 147 mmHg Art., max. SBP 160 mmHg st., min. SBP 128 mmHg st., cf. DBP 87 mm Hg avg., max. DBP 99 mmHg st., min. DBP 69 mm Hg Art. Sinus rhythm was recorded with a heart rate of 51 to 132 per minute. At night, the decrease in heart rate is insufficient. Two supraventricular extrasystoles were registered. When performing the planned load, the heart rate reached 132 and 125 in 1 minute, while palpitations, shortness of breath, horizontal depression of the ST segment according to the ischemic type up to 2 mm were subjectively noted.
Radiography of the UCP on June 2, 2011: in the lungs without focal and infiltrative changes. The pulmonary pattern is reinforced and deformed due to diffuse pneumosclerosis. The roots of the lung structure. The sinuses are free. The heart is dilated to the left. The aorta is condensed and deployed.
Spondylography on 06/02/2011: physiological lordosis is straightened, C2 body is shifted posteriorly by 0.5 cm. The height of the intervertebral discs is reduced at the level of C4-5, C5-6, C6-7, the endplates are compacted, marginal bone growths in the anterior parts of the bodies C5,6,7 in the projection of the intervertebral discs and C4.5 outside the plane of the intervertebral discs in the form of a bracket. Right-sided scoliosis with an angle of deviation from the vertical axis of 70 (according to Chaklin) with the center of the arc at the level of Th3-7, torsion of the bodies Th3,4,5 to the left. The thoracic kyphosis is intensified. The height of the intervertebral discs is reduced at the level of Th5-6, Th6-7, Th7-8, the endplates are compacted, the marginal exophytes in the anterior parts of the bodies are Th5,6,7,8 0.1 cm in the projection of the intervertebral discs. Schmorl's hernia at the level of Th6-7, Th7-8. the height of the intervertebral discs at the level of L3-4, L4-5 is reduced, the endplates are compacted, marginal exophytes are 0,
EPI 06/29/2011: instability, increased exhaustion of attention come to the fore. Memory functions are moderately expressed. Thinking with moderately pronounced signs of a decrease in the level of the generalization process.
The goals of hospitalization were achieved - the "target level" of blood pressure - 120-130 / 70-85 mm Hg was reached, the cephalgic syndrome was reduced, the ability to work was restored.
Certified by VVK. On the basis of articles 43 b, 44 b, 24 b, 25 c, 13 b, 66 c columns III of the schedule of illnesses and TDT (annex to the Regulations on military medical examination, approved by Decree of the Government of the Russian Federation of February 25, 2003 No. 123)
B - limited fit for military service.
Discharged in a satisfactory condition under the supervision of doctors of the Central Committee for Children's Hospital of the Military Medical Academy
Recommended:
61. Observation of a cardiologist, neurologist, endocrinologist, gastroenterologist at a polyclinic at the place of residence;
62. Exercise therapy - constantly, swimming;
63. Spinal massage 10 sessions every 6 months;
64. Observe the drinking regime of 1-1.5 l / day; limiting the use of table salt (no more than 3 g per day), limiting easily digestible carbohydrates;
65. Limit the consumption of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium;
66. Periodic level control:
a. the level of glycemia on an empty stomach and 2 hours after a meal;
b. the level of glycosylated hemoglobin - 1 time in 3 months;
c. levels of TSH, St. T4 - 1 time in 6 months;
d. Ultrasound of the thyroid gland - 1 time in 6 months;
e. Examination by an ophthalmologist once a year.
67. Continue taking:
a. Tab. Lozap-plus 80 mg 1 tablet daily in the morning;
b. Tab. Thrombo ACC 0.05 1 tablet in the morning constantly;
c. Tab. Siofor 500 mg - 1 tablet at 22:00 constantly;
d. Tab. Cytoflavin - 2 tablets in the morning and in the afternoon for 1 month;
e. Tab. Stugeron - 1 tablet 3 times a day for 1 month;
f. Tab. Diacarb - 1 tablet in the morning (Monday, Wednesday, Friday) - 2 weeks.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
EXECUTIVE SUMMARY
CASE HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1972
He was hospitalized (in the day hospital mode)
in the clinic of hospital therapy
in the city.
In total, 20 days of treatment were carried out .
The final diagnosis was established. ICD code M 42.1
Diagnosis:
Uncovertebral arthrosis, intervertebral osteochondrosis of the cervical, thoracic and lumbar, deforming spondylosis of the lumbar, right-sided scoliosis of the first degree thoracic and non-fixed scoliosis of the second degree of the lumbar, with a slight dysfunction of the spine.
Hypertension of the first stage (borderline).
Alimentary-constitutional obesity of the first degree, stable stage.
Partial adentia of the upper and lower jaws
. No disability certificate was issued.
Ability to work restored
Total exposure dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicization, disability, _____ disability group, degree of disability _______________________________, other _____________________________________________
Outcome: discharged on improvement, discharged on recovery, transferred to another medical institution (what) ____________________, transferred to rehabilitation treatment (where) _____________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited military service, temporarily unfit for military service (it is necessary to provide sick leave for ____ days, it is necessary to provide an exemption for ___ days, unfit for military service, unfit for service in a military specialty, discharged to a unit without a medical examination.
Examined by MSEC: yes (no) (____ disability group, degree of disability ______________) _________________________________________________________
At admission:
Complaints about: periodic pain in the thoracic and lumbosacral spine at rest and during exercise, episodic headache, dizziness, overweight.
History of present illness: pain in the lumbosacral spine notes since 1998. On this occasion, he repeatedly underwent outpatient treatment with a temporary positive effect. In 2003, the initial manifestations of osteochondrosis of the thoracic and lumbar spine were diagnosed on an outpatient basis. According to the words, a headache against the background of psycho-emotional overstrain, accompanied by an increase in blood pressure to 150/90 mm Hg. Art. began to notice since 2011. He did not seek medical help, he was treated independently, he took captopril with a positive effect. During the present examination, hypertension of the first stage was diagnosed. He has been gaining weight since 1997. Since 2007, alimentary-constitutional obesity of the first degree has been diagnosed, since 2011, body weight has been stable.
Anamnesis of the patient's life: He grew and developed normally, did not lag behind his peers. Higher military education. Married. Material and living conditions are satisfactory.
Allergological history: intolerance to medicines, household, food, animal allergens was not noted.
Epid. History: Over the past 6 months, he has not traveled outside the city of St. Petersburg, he denies contact with patients with tuberculosis, malaria.
Past diseases, injuries, contusions, operations: acute respiratory infections; childhood infections.
Heredity: the mother has type 2 diabetes mellitus, varicose veins with trophic changes in the legs; father is obese.
Habits: smokes 20 cigarettes a day since 1991, drinks alcohol occasionally moderately.
Insurance history: lieutenant colonel of the Ministry of Defense of the Russian Federation, chief of staff of military unit 49719.
Objective examination data: normosthenic physique, overnutrition (BMI-29.0). Peripheral lymph nodes and thyroid gland are not enlarged. The line of the spinous processes is slightly deviated to the right in the thoracic region. Excessive tension of the paravertebral muscles in the region of the cervical, thoracic and lumbar spine is determined. Paravertebral points are painful in the projection C6-C7, L5-S1. Range of motion in the spine: the distance between the spinous process of the seventh cervical vertebra and the tubercle of the occipital bone increases by 3 cm when the head is tilted, and decreases by 6 cm when the head is tilted back (extension). The distance between the spinous processes of the seventh cervical and first sacral vertebrae increases when the spine is flexed 4 cm compared to normal posture and decreases by 4 cm when bending back, lateral movements (tilts) in the thoracic and lumbar spine are possible within 20 degrees on both sides of the vertical line. Pulse 62 per minute, rhythmic. The borders of the heart are normal. Heart sounds are muffled. BP 130-145/80-90 mmHg Art. NPV 16 min. Above the lungs a clear pulmonary sound. Respiration is vesicular. Absence of 12, 25, 27, 37 teeth. Chewing efficiency according to Agapov 90%. The language is clean. The abdomen is soft and painless. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology. Visual acuity: OD=OS=1.0. ENT organs endoscopically: no pathology. Rumor: SR 6/6 m. The borders of the heart are normal. Heart sounds are muffled. BP 130-145/80-90 mmHg Art. NPV 16 min. Above the lungs a clear pulmonary sound. Respiration is vesicular. Absence of 12, 25, 27, 37 teeth. Chewing efficiency according to Agapov 90%. The language is clean. The abdomen is soft and painless. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology. Visual acuity: OD=OS=1.0. ENT organs endoscopically: no pathology. Rumor: SR 6/6 m. The borders of the heart are normal. Heart sounds are muffled. BP 130-145/80-90 mmHg Art. NPV 16 min. Above the lungs a clear pulmonary sound. Respiration is vesicular. Absence of 12, 25, 27, 37 teeth. Chewing efficiency according to Agapov 90%. The language is clean. The abdomen is soft and painless. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology. Visual acuity: OD=OS=1.0. ENT organs endoscopically: no pathology. Rumor: SR 6/6 m. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology. Visual acuity: OD=OS=1.0. ENT organs endoscopically: no pathology. Rumor: SR 6/6 m. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology. Visual acuity: OD=OS=1.0. ENT organs endoscopically: no pathology. Rumor: SR 6/6 m.
As a result of the treatment: regimen, diet No. 10, ACE inhibitors (Enalapril 5 mg 2 times a day), Mildronate 500 mg 2 times a day, Aspicor 100 mg in the morning, health improved, blood pressure stabilized at the target level.
The results of laboratory and instrumental studies:
General analysis of blood and urine 10.10.2012: normal.
Biochemical blood test on September 18, 2012: total protein, calcium, potassium, sodium are normal.
Biochemical blood test on 03.10.2012: cholesterol 6.73 mmol/l, VLDL 0.4 mmol/l, o. bilirubin 26.5 mmol / l, glucose, creatinine, urea, uric acid, fibrinogen, prothrombin, PSA, LDL, triglycerides - the norm.
Serological tests for syphilis, F-50 19.09.2012 negative.
ECG 09/17/2012: sinus rhythm with a heart rate of 72 per minute. The horizontal position of the EOS.
Echocardiography on September 19, 2012: no pathology, LV CR 51 mm, EF 90%, FU 61%, LVL 8.9 mm, IVS 7.4 mm, LVMI 79 g/m2, LA 34 mm, PP 37 mm, CRPV 28 mm , E/A=1.9.
Ultrasound 04.10.2012: liver, gallbladder, pancreas, kidneys, spleen without pathology.
SM BP (on the background of therapy) 10/25/2012: in the afternoon: max. BP 153/101 mm Hg, mean BP 132/84 mm Hg. Art., at night: max. BP 120/77 mm Hg. Art., mean blood pressure 114/67 mm Hg. Art.
VEM on September 25, 2012: the test was terminated at 11 minutes at a load of 200 W due to the achievement of a submaximal heart rate of 151 per minute. The reaction of blood pressure according to the normotensive type. Ischemic changes were not detected. Tolerance to physical activity is high. the test is negative.
Radiography of the UCP on 09.10.2012: no pathology.
Spondylography 03.10.2012: In the thoracic region, an arcuate curvature of the spinal axis to the right (angle of 50 according to Chaklin) with a peak at the level of Th6, in the lumbar region to the right (angle of 120) with a peak at the level of L3 is determined. Physiological lumbar lordosis is enhanced. Reduced intervertebral disc height at the level of C2-C3, C5-C6, C6-C7, C7-Th1, Th5-Th6, Th6-Th7, Th9-Th10, L3-L4, L4-L5, L5-S1, moderately severe subchondral sclerosis endplates of the thoracic vertebrae, mild subchondral sclerosis of the endplates of the lumbar vertebrae. On the cranial endplate of the Th7 and Th8 vertebrae, there are small limited impressions with a sclerotic rim. Coracoid bone growths up to 1 mm in size, emanating from the anterior and lateral surfaces of L1-L2, L2-L3, L3-L4 vertebral bodies at the attachment sites of the anterior longitudinal and lateral ligaments. The apices of the semilunar processes are somewhat pointed.
MRI of the head on 03.10.2012: no pathology.
MRI of the lumbosacral spine on 03.10.2012: decrease in the intensity of the MR signal on T2-WI from the intervertebral discs of the lumbar spine, marginal bone sharpening along the endplates of the vertebral bodies. The MR signal from the bone marrow of the vertebral bodies is unevenly increased on T1 and T2-WI due to areas of fatty degeneration.
The goals of hospitalization have been achieved - the "target level" of blood pressure has been reached - 120-130 / 70-85 mm Hg.
Discharged in a satisfactory condition under the supervision of a doctor of the unit on
10/17/2012. certified by VVK:
on the basis of article 66 in columns III of the schedule of diseases and TDT (annex to the Regulations on military medical expertise, approved by Decree of the Government of the Russian Federation of February 25, 2003 No. 123)
B - fit for military service with minor restrictions.
Recommended:
68. Observation of the doctor of the unit according to DM-1.
69. Observe the drinking regimen 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
70. Limit the consumption of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
71. Continue taking:
a. Tab. Enalapril 10 mg ½ tab. 2 times a day all the time.
MILITARY MEDICAL ACADEMY Form 12_Uni.VMedA-2010 GT
DISCLAIMER EPICRISIS CASE
HISTORY No. ____,
Surname, name, patronymic_
He was hospitalized
in the hospital therapy clinic
Total days of treatment _22__
The final diagnosis was established ICD code_I 50.0_
Diagnosis:
Main: coronary artery disease. Stable angina pectoris III f.k. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (2004) cardiosclerosis. Secondary dilated cardiomyopathy. Congestive right-sided lower lobe pneumonia.
Complications of the underlying disease: Aneurysm of the apex of the left ventricle. Anasarca (edema, ascites, total right-sided hydrothorax). Cardiac asthma from 12/22/2010, stopped with medication on 12/23/2010. NC II B Art. CHF IVf.k. DN 2 tbsp.
Concomitant: Chronic viral hepatitis B, stage of cirrhosis. Hypertension III degree. (AH 1, risk IV). DEP 2 tbsp. mixed (atherosclerotic, hypertensive, dysmetabolic) genesis. Degenerative-dystrophic disease of the spine. Diabetes mellitus of the second type, decompensation. Chronic pyelonephritis, latent course. CKD 3 st (GFR=58 ml/min/1.73m2) CKD-1a st.
Disability certificate is not required
Work ability is not fully restored
Total radiation dose 59 mSv
Clinical outcome (underline): improvement
Outcome: discharged on improvement
Admission:
Complaints: increasing dyspnea of a mixed, mainly inspiratory nature, discomfort in the right side of the chest, paroxysmal cough without discharge, increasing weakness, decreased exercise tolerance.
Disease history. For a long time he suffers from coronary heart disease, hypertension. I have been drinking alcohol for a long time. In 2004, she suffered a massive myocardial infarction. 17.10.10 performed surgical treatment for bleeding (shock 2-3) from a chronic stomach ulcer. During the same hospitalization, decompensated diabetes mellitus was revealed. After discharge, she did not comply with the doctor's recommendations, she began to notice an increase in the volume of the abdomen. On this occasion, she was repeatedly hospitalized in the hospitals of the city, where complex treatment was performed with active diuretic therapy. The last hospitalization in the pulmonology department of City Hospital No. 26. After being discharged from the hospital, her condition deteriorated sharply. She was admitted to the hospital therapy clinic for urgent indications.
Objective status: general condition of moderate severity, edema of both legs to the hips, heart rate 60 per minute, no deficit, rhythmic pulse, auscultatory tones of the heart are muffled, the 1st tone is weakened above the apex of the heart, there is a rough systolic murmur at the apex, the boundaries of the heart are expanded , BP 115/70 mm Hg, hard breathing in the lungs, congestive rales in the lower lobe on the left, breathing is not heard on the right; the abdomen is enlarged due to the accumulation of free fluid, soft, painless on palpation, effleurage in the lumbar region is painless on both sides.
As a result of the treatment: regimen, diet No. 9, metabolic therapy (polarizing mixture: Sol.NaCl 0.9% -200.0, Sol.Asparcami 20 ml), vasodilators (Sol. Euphyllini 2.4% 10ml), inotropic therapy (Korglikon 0.06% 1.0 IV drip, Digoxin 0.00025 0.5 tab. in the morning), antibiotic therapy (Ciprofloxacin 0.5 1 tab. 2 times a day), diuretic therapy (Veroshpiron 0.025 tab. 1 tablet 4 times a day, Furosemide 1% 6.0 IV, Diuver 0.01 to 0.5 tablets 2 times a day, Hypothiazid 0.025 to 2 tablets in the morning), beta-adrenolytics (Betaloc-Zok 0, 05, 0.25 tab. 2 times a day), antithrombotic therapy (Aspicor 0.1, 1 tab. 1 time per day), punctures of the right pleural cavity (December 23, 24, 27, 9, 14 with evacuation of 2200 ml, 2500 ml, 2500 ml, 2550 ml straw-yellow liquid) feeling improved, shortness of breath decreased, cough regressed,edema in the legs and ascites disappeared, right-sided hydrothorax persisted, manifestations of heart failure decreased.
Taking into account the resistance of pathological exudation in the right pleural cavity to diuretic therapy and mechanical removal of fluid during pleural punctures, as well as taking into account the one-sidedness of the effusion (right pleural cavity), in further diagnosis, exclude a neoplasm of the right lung, mediastinum, and abdominal organs.
The results of instrumental studies:
ECG 23.12.2010, heart rate - 100 beats sinus rhythm, EOS to the right. Hypertrophy of the right ventricle. Widespread cicatricial changes in the anterior-septal, apical-lateral section of the left ventricle. Diffuse disorders of repolarization. Complete blockade of the right leg of the bundle of His.
ECG from 01/13/2011: sinus rhythm, heart rate 85 per minute. Violations of the processes of repolarization along the lower wall, rhythm disturbance in the form of frequent ventricular extrasystoles persist.
Ultrasound of the abdominal organs on December 27, 2011: no ascites. Flatulence. Diffuse changes in the echostructure of the liver (according to the type of hepatosis). Ultrasound signs of circulatory failure.
Ultrasound of the abdominal organs on 01/06/2011: compared to 12/27/2010 without dynamics. Hydrothorax on the right.
ECHO-KG from 01/11/2011:
PARAMETERS
Val.
NORMAL
PARAMETERS
Value
NORM
Aortic root diameter
27
20-37 mm
Left ventricular ERD
59
38-56 mm
Opening of the aortic valve leaflets
20
greater than 15 mm LV DFR
49
22-38 mm
Antero-posterior dimension of the left atrium
51
25-40 mm
Thickness of the free wall of the right ventricle
4
less
than 5 mm
Frontal dimension of the left atrium
49
25-45 mm
Ejection fraction of the left ventricle
36
more than 55%
Vertical dimension left atrial dimension
60
29-53 mm
Right atrial dimension
45
30-46
Interventricular septal thickness
10
7-11 mm
Right atrial vertical dimension
56
34-49 mm
Left ventricular posterior wall thickness
10
7-11 mm
ECR of the right ventricle, anteroposterior
45
Less than 30 mm
Systolic pressure in the LA
-
up to 30 mm Hg
Pulmonary trunk diameter
27
12-23 mm
During the study, frequent extrasystoles were observed. The wall of the aorta, the aortic crescents, the aortic valve ring are sealed. The mitral valve ring is calcified. The leaflets of the mitral valve are sealed, with small calcifications. Dilatation of all chambers of the heart. Expanded pulmonary artery. Eccentric myocardial hypertrophy of the left ventricle. The apex of the heart is not visualized. Akinesia of the interventricular septum, lateral wall, middle segment of the anterior wall. Hypokinesia of the rest of the myocardium. Global contractility is reduced. Type 3 diastolic dysfunction (rigid). Mitral tricuspid regurgitation of the 2nd degree. Aortic regurgitation 0-1 degree. Significant pulmonary hypertension (grade 2). Circular divergence of the sheets of the pericardium by 3-4 mm.
X-ray of the chest on December 23, 2010: subtotal hydrothorax of the right.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er
.
,
*
1012
/
l
Leuk
.
,
*
109
/
l
MCH
ESR
,
mm
/
h
_
_
_
_
_
_
_
_
12.01.
145
5.56
11.3
26.0
8
2
-
15
6
5
72
Biochemical blood test: Urinalysis:
Name
Unit of measure.
Norm
23.12
24.12
12.01
Index
24.12
Creatinine
Mkmol
/l
53-124
90
80
Color Yellow Dark
yellow
Cholesterol
Mole/l
3.7-6.0
3.6
Transparency
Clear
Haze
Triglycerides
Mole/l
0-2.37
Specific. Weight
1020
1.020
Total protein
G/l
63.0-87.0
71.6
67
Reaction
Neutr.
Neutr.
Calcium
Mole/L
2.1-2.5
Protein (g/L)
0.3
1.0
Potassium
Mole/L
3.5-5.1
5.08
4.85
Sugar
No
No
Glucose
Mole/L
4.2-6.4
11.54
12.91
10.51
Urobilin
16
33
Prothrombin
%
70-120
60
Leukocytes in p/s
1-3
0-3
Fibrinogen
Mg/dl
200-400
412
Erythr. unchanged in p/s
2-3
CPK
bacteria
U/l
10.0-160.0
56.5
38.5
Erythr. Vyschi. In p/s
Not
in terms of quantity
AST
U/l
11.0-50.0
23.6
31.5
Salts
No
ALT
U/l
11.0-50.0
18.1
20.6
Mucus
1
1
Total bilirubin
Mole/l
6.8-26.0
48.1
19.13
Urea mmol
/l
8.2
6.9
Analysis of the pleural fluid from 12/24/2011: 30 ml of lemon-yellow color, slightly turbid. Revolta test negative. Protein 3.0 g/l. Leukocytes 3.58*109/l, erythrocytes 8.73*109/l, mesothelial cells 4.0*109/l. Mesothelial cells with signs of dystrophic changes (pycnotic nuclei, partial lysis, with multiple cytoplasmic processes and reactive polymorphism (cricoid cells, cells with large nuclei in the form of small layers). Lymphocytes predominate 54%, neutrophils 41%, macrophages and histiocytes 5%
. blood for the presence of markers of viral hepatitis on December 24, 2010:
detected HBs-Ag Anti-HCV was not detected.
Discharged to the clinic at the place of residence. The ability to work was partially restored (significantly pronounced dysfunctions of the cardiovascular system continue to persist), he continues to get sick. Appearance at the clinic 01/15/2011.
Discharged in a satisfactory condition under the supervision of polyclinic doctors
Recommended:
26. Observation of a therapist, cardiologist, endocrinologist, hepatologist at the place of residence
27. Diet, normalization of work and rest. Avoid psycho-emotional stress. Limit salt and liquid intake. Control of blood pressure and heart rate. exercise therapy.
28. Performing computed tomography of the chest and abdomen in a planned manner at the place of residence to exclude a neoplastic process.
29. Consultation of cardiologists in the Federal Center. Almazov, tel. 702-37-06
30. Continue taking:
• Tab. Digoxin 0.00025 ½ tablet in the morning (except Saturday and Sunday)
• Tab. Betaloc-ZOK 0.05 ½ tablet 2 times a day continuously.
• Tab. Enalapril 0.01 ½ tablet 2 times a day continuously.
• Tab. Preductal MB 1 tablet 2 times a day for a month.
• Tab. Maninil 0.0035 1 tablet 2 times a day continuously.
• Tab. Hypothiazid 0.1 1 tablet daily in the morning.
• Tab. Furosemide 0.04 1 tablet on an empty stomach - in the presence of edema.
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
Discharge summary No.
born in 1982 (27 years),
was examined and treated in the clinic of hospital therapy
with a diagnosis
of arterial hypertension of the 2nd degree of unclear etiology (the risk of developing CVC is moderate) without signs of heart failure. Long-term consequences of stroke by hemorrhagic type (09.01.2009) in the form of scattered neurological symptoms, astheno-neurotic syndrome. Hypertensive type retinal
angiopathy On admission, he complained of an episodic increase in blood pressure up to 170/110 mm Hg, accompanied by dizziness, pressing headache without clear localization, and a feeling of discomfort in the left half of the chest.
He was admitted to the clinic for a fee in order to diagnose and select therapy for outpatient treatment.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/L
Leuk., *109/L
Ht, %
ESR, mm/h
Thrombus
*109/L
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
11.08
170
5.06
4.5
51.4
2
169
0
0
26
5
3
66
Biochemical analysis of blood:
Name
Unit. rev.
Norm
11.08
Creatinine
mmol / l
53-124
80
urea
mmol/l
2.5-6.4
2.6
glucose
mmol/l
3.9-6.2
5.14
chlorine
mmol/l
98-107
101.3
potassium
mmol/l
3.5- 5.1
4.26
sodium
mmol/l
136-145
140.5
T3
nmol/l
1.3-3.1
1.79
T4
nmol/l
66-181
75.77
TSH
uIU/l
0.27-4, 2
1.28
Quick prothrombin
%
80-130
112
Fibrinogen
g/l
2.0-4.0
3.47
cholesterol
mmol/l
3.7-7
5.74
triglycerides
mmol/l
0-2.37
0.66
Total protein
g/l
63-87
72.8 Vol
. bilirubin
µmol/l
6.8-26
18.1
ALT
U/L
8.4-53.5
288.1
AST
U/L
7-50.0
152.2
CPK
U/l
36-160
223.8
Creatinine clearance according to the Cockcroft formula- Gault = 129.5 ml/min.
GFR according to MDRD = 104.6 ml / min / 1.73 m2
General analysis of urine and feces from 11.08.2010. without pathological changes.
Results of instrumental studies:
X-ray of the chest organs No. 1635 (D = 0.26 mSv) dated 11.08.2010. In the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. Heart - left ventricular hypertrophy. The aorta is not changed.
Test with a six-minute walk from 08/12/2010. more than 800 m.
ECG No. 1767 dated 08/11/2010: sinus rhythm with a frequency of 64 beats per minute, horizontal EOS, the predominance of left ventricular potentials.
EchoCG from 12.08.2010. Aorta 33 mm, aortic ring 22 mm, asc. aorta 30 mm, opening of the aortic valve 23 mm, LA 34 mm, CRLV 35 mm, CRLV 50 mm, fr. reproach. 29%, fr. select 56%, AP 11 mm IVS 11 mm, E/A=1.38, PP 38mm, RV 24mm; the myocardium is at the upper limit of normal, the kinetics are not disturbed, the cavities are not dilated. Diastolic function is not disturbed. The aorta is not changed. The valves are intact, the blood flow is laminar, regurgitation on the TC 1 degree. The pericardium is unchanged, there is no pericardial effusion.
24-hour ECG monitoring from August 12, 2010: during the observation period, sinus rhythm was recorded with a heart rate of 53 to 138 per minute. The decrease in heart rate at night is adequate. Average heart rate 72/81/61 in 1 minute. Registered single ventricular extrasystole; single supraventricular extrasystoles (3 in total). When performing the planned load, the heart rate reached 138 per 1 minute, noted shortness of breath. Ischemic changes in the ST segment were not detected.
Ambulatory blood pressure monitoring dated August 12, 2010: daytime mean systolic BP is characteristic of mild stable hypertension, mean systolic BP at night and mean daytime diastolic BP are characteristic of moderate stable hypertension. At night, systolic and diastolic blood pressure decrease insufficiently (nondipper). The variability of systolic and diastolic blood pressure during the day is within the acceptable range. Episodes of hypotension were not registered. There is an increase in the magnitude and speed of the morning rise in diastolic blood pressure.
Ultrasound of the abdominal organs No. 951 dated August 11, 2010: no visible pathology.
Ultrasound of the thyroid gland from 11.08.2010: the contours are clear, even, the structure is homogeneous, echogenicity is increased; isthmus 3 mm, right lobe 18x19x60mm = 11cm3, left lobe 17x20x60mm = 10.5cm3 Optometrist's
consultation: retinal angiopathy of hypertensive type.
Neurologist's consultation: long-term consequences of stroke according to the hemorrhagic type (09.01.2009) in the form of scattered neurological symptoms, astheno-neurotic syndrome. In order to make a final conclusion, it needs additional examination.
Treatment: regimen, diet, polarizing mixture, furosemide, metoprolol, fosinopril, sedative therapy.
The goals of hospitalization were partially achieved (patient's refusal to continue treatment).
Discharged in a satisfactory condition under the supervision of a cardiologist of the clinic at the place of residence with recommendations.
A certificate of temporary incapacity for work was not issued.
Recommended:
6. Supervision by a cardiologist at a polyclinic at the place of residence.
7. Optimization of the mode of work, rest, nutrition.
8. Continue the examination on an outpatient basis, to do this:
a. MRI of the brain in normal and vascular mode;
b. Ultrasound of cerebral vessels;
c. Expanded coagulogram;
d. Renin of blood plasma (in the morning, on an empty stomach, after daily abstinence from physical activity);
e. Serum angiotensin-converting enzyme;
9. Repeated consultation of a neurologist and a cardiologist after performing the indicated laboratory and instrumental studies to make a final judgment on the patient's health status and correct the therapy.
10. Continue taking:
• Fosicard 20mg - 1 tablet in the morning constantly
• Thrombo ASS 0.05, 1 tab. 1 r / d after breakfast
• Mildronate 0.25 2 capsules 2 r / d (after breakfast and lunch) - 2 weeks.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1957 (52 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis: Seropositive rheumatoid arthritis (M.05.8), very early stage, III degree of activity, stage I, with systemic manifestations (myocardial dystrophy, mild secondary normoregenerative normoblastic anemia, right-sided exudative pleurisy), anti-CCP (+), FC I, FNS I. Symptomatic arterial hypertension (AH 1, CVE risk 3)
She was admitted to the clinic on a planned basis with complaints of palpitations, fever up to 38.8 ° C, swelling and stiffness of the small joints of the hands and feet, "flying" swelling and pain of the large joints of the legs .
Laboratory results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l
MSN,
pg
Rt,
‰
e, %
b, %
l, %
m, %
p %
s, %
ESR, mm/h
11.11.
98
3.06
10.4
630
32.1
6.9
1
19
7
5
68
70
13.11
101
3.55
8.5
824
28.4
6.6
1
30
5
2
62
70
25.11
122
4.29
13.5
593
28.6
6.2
25
7
1
69
40
Complete urinalysis
Date
Clear
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
11.11
clear
1.020 Yellow
5.5
-
-
-
-
-
-
-
-
-
-
Nechiporenko
test 11.11.09 L=0.75х106/l, E=2.0х106/l
Cal on I/g 11.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11
Total protein
G/l
63.0-87.0
77.5
Cholesterol
Mmol/l
3.7-6.0
5.17
Creatinine
Mmol/l
0.05-0.12
0.06
Glucose
Mmol/l
4.2-6.4
5, 54
Prothrombin
%
80-105
Fibrinogen
g/l
2-4
Potassium
Mmol/l
3.5-5.1
4.38
Calcium
Mmol/l
2.0-2.7
2.07
AST
U/l
11-50
23, 3
ALT
U/l
11-50
25.9
CPK
U/l
10-160
12.3
CEC
U
6-66
567
Beta-lipoproteins
AU 350-650
Serology
for HIV, hepatitis - negative.
* Detailed serology of rheumatoid arthritis (AKA, ACE, ACCP/anti-SSR, RF) 11/17/09.
* Antibodies to cyclic citrulline-containing peptide
- Result options
* <5 U/ml - no antibodies to CCP detected
* 5-50 U/ml - low concentration
* >50 U/ml - high concentration
- Result 56.9 U/ml
* Rheumatoid factor
- normal <1:20 (less than 25 IU/ml), result - 1:80 (100 IU/ml)
* Antikeratin antibodies
- normal <1:10 result <1:10
* Antiperinuclear factor
- normal <1:10 result <1:10
Blood test for antinuclear factor with immunoblot from 11/17/09.
on the hands soft tissue compaction is noted at the level of the metatarsophalangeal and interphalangeal joints, more pronounced on the right.
On the survey radiograph of the chest in the direct and right lateral projection from 11.11.09. No. 2613 (D=0.52 mSv): in the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, not expanded. The right dome of the diaphragm is slightly elevated. Encapsulated fluid in the right pleural cavity at the level of the costophrenic sinus. A small amount of fluid in the interlobar fissures. The heart is not dilated, the aorta is sealed.
On the control radiograph of the chest in the direct and right lateral projection from 11.11.09. No. 329 (D=0.52 mSv): no fluid was found in the right pleural cavity, in the lungs without focal and infiltrative changes.
On the radiograph of the left knee joint No. 2662 dated November 13, 2009. (D=0.02 mSv): no pathological changes were detected in 2 projections.
Ultrasound of the abdominal organs No. 1235 dated 11/16/2009: no pathological changes were detected
On ECG No. 2515 dated 11/10/09: sinus rhythm with a heart rate of 80/min. Normal position of the EOS. Partial violation of intraventricular conduction. Violation of repolarization in the region of the posterior wall, apex.
ECHO-KG No. 762 dated 10.11.09. Ao=30mm, ascending Ao=30mm, opening AC=16mm, LA=30mm, RA=32mm, RV=24mm, LV=47/27mm, IVS=10mm, AP=09mm, EF=74%, FU=43% , SV=75 ml, E/A=0.84 myocardium is not thickened, the kinetics is not disturbed, the cavities of the heart are not expanded, free. The aorta, fibrous rings of the aortic and mitral valves are sealed. The blood flow on the valves is laminar. Diastolic dysfunction of the rigid type. Applied regurgitation on the mitral valve. The pericardium is not changed.
Consulted by the rheumatologist of the clinic. Diagnosis was clarified, therapy was adjusted.
Treatment: regimen, diet, prednisolone, methotrexate, noliprel, calcium-D3-nycomed, cytoflavin, diclofenac, omeprazole, almagel, sedative and restorative therapy.
Against the background of the therapy, the patient's condition improved: He is discharged in a satisfactory condition under the supervision of a rheumatologist at the polyclinic.
Recommended:
195. Outpatient observation of a rheumatologist at the place of residence.
196. In case of resumption of pain syndrome or stiffness of the joints in the morning - a consultation with a rheumatologist with a decision on the correction of the therapy and the need for inpatient treatment.
197. Control of the general blood test after 1 month (then 1 time in 3 months)
198. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
199. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
200. Continue taking:
a. Noliprel - ½ tab 1 time per day (in the morning) constantly
b. Methotrexate 2.5 mg - 1 tablet on Monday evening, Tuesday morning and evening (total 7.5 mg / week) - constantly.
c. Prednisolone 5 mg - daily 4 tab. in the morning, 1 in the afternoon, with food, drinking kissel. In the absence of pain and stiffness in the joints, starting from December 5, reduce by 0.5 tablets every 4 days until a maintenance dose of 7.5 mg (1.5 tablets) is reached, then constantly 1.5 tablets in the morning.
d. Calcium D3-Nycomed - 1 tab. in the evening all the time.
e. Cytoflavin - 1 tab. 3 times a day for 1 month
f. Asparkam - 1 tab. 3 times a day from the 1st to the 10th of each month
XVII. DISCUSSION CASE
HISTORY №, ARCHIVE №_____,
Surname, name, patronymic
Date of birth 37 full years,
She was examined and treated in a day hospital at the clinic of hospital therapy of the Military Medical Academy
Total number of days of treatment
The
final
diagnosis was established by the ICD code []
.
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, ______________ group of disability, degree of disability ________________________________, other _____________________________________________
Outcome
: discharged, died, transferred to (another medical institution) (what) __________________ not formalized.
The total radiation dose during the stay in the hospital was (0)_________ per, mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, ______________ group of disability was established, degree of disability __________________________, other _____________________________________________.
Outcome: Discharged, died, transferred to (another medical institution) (what) ____________________
Examination at admission (including outpatient):
Examinations:
Complete blood count:
Date
Erit.
Hb g/l
Thrombos.
SOE
Lake.
E
P/poison
C/poison
Lymph
Mon
Hematocrit
March 4, 2014
5.08
15.3
210
13
4.8
2
1
62
27
6
45.1
Urinalysis:
Date
Rel. dense
pH
Protein
Acetone
Glucose
Leukocytes
Epithelium
Bacteria
mucus
Bilirubin
Urobilinogen
Erythrocytes
04.03.14g
1030
6.0
0.3
-
5.5
1-2-2
0-1-1
2
2
-
3.2
0-1-1
Biochemical analysis of blood ( glycated hemoglobin)
dated March 12, 2014 - 5.75%
Biochemical blood test (C-reactive protein)
from 05/05/2014 - 3.15
Thyroid hormone (TSH) from 12/16/2013 - 2.9 mIU / l (N- 0.3-4.0)
Blood test on F50, HbsAg, anti-HCV, RW from 12/11/2013: negative.
Biochemical blood test (fibrinogen) dated 03/04/2014 - 2.87 g / l
Fecal analysis No. 5 dated 03/04/2014 - without features
Biochemical blood test 03/04/14.
Indicators
Unit
Cholesterol
4.91
3.7-6.0
mmol.l
Triglycerides
1.72
0-2.37
mmol/l
HDL
1.45
0.78-2.33
mmol/l
LDL
2.67
1.9- 4.4
Rel. U
VLDL
0.79
0.6-1.2
Rel. UI Atherogenic
coefficient
2.39
0-3.0 Rel.
UI
ALT
23.0
11-50
g/l
AST
16.0
11-50
g/l
GGT
41
11-63
g/l
Urea
6.3
2.5-6.4
mmol/l
Glucose
5.70
3.90-6.20
mmol/l
Creatinine
0.11
0.05-0.12
mmol/l
Total protein
69
64-83
g/l
Chlorine
113.2
98.0-107.0
mmol/l
Potassium
4.38
3.50-5.10
mmol/l
Sodium
140.2
136.0-145.0
mmol/l
SK
97
10.0-160.0
g/l
SK
-MB
21.9
0-25
g/
l no evidence of neurological pathology was found at the time of examination.
Ophthalmologist (dated March 13, 2014): Healthy.
Otorhinolaryngologist (dated March 6, 2014):
Dentist (dated March 6, 2014):
Instrumental research methods:
Fluorography of the chest cavity and paranasal sinuses No. 0026 dated (03/06/2014) - Without focal and infiltrative changes. On the fluorography of the paranasal sinuses: their pneumotization is not reduced.
X-ray No. 190 dated March 14, 2014 - On the spondylograms of the cervical spine in 2 projections, the physiological lordosis is straightened, the C5 body is displaced posteriorly by 0.4 cm. Kimmerley anomaly. Osteochondrosis of C4-5, C5-6, C6-7 motor segments with a decrease in the height of the discs, compaction of the end plates and marginal bone growth of 0.1 cm in the posterior C5 and anterior C5-6 parts of the vertebral bodies in the projection of the discs.
No pathological changes were found on spondylograms of the thoracic spine in 2 projections.
The results of ECG Holter monitoring (dated February 20, 2014) - average heart rate during the day 82 bpm, at night 60 bpm. The decrease in heart rate at night is sufficient, the increase in heart rate in response to physical activity is adequate. Circadian index 1.4. Against the background of sinus rhythm with a heart rate of 51 to 140 bpm, registered:
1) ventricular extrasystole, total 1.
2) supraventricular extrasystole, total 401, according to the type in bigemia 37, according to the type of trigemenia 7, running supraventricular tachycardia 28.
Ischemic ST-T changes were not detected.
The results of daily monitoring of blood pressure No. 109 of 03/07/2014:
Daytime hours: cf. GARDEN - 131 mm Hg. Art. Max. GARDEN - 152 min. GARDEN - 108
cf. DBP - 82 mm Hg. Max. DBP - 101 min. DBP - 68
Night hours: cf. SBP - 108 mm Hg max SBP - 114 min. GARDEN - 95
cf. DBP - 65 mm Hg max DBP - 72 min. DAD - 56
Conclusion:
Mean systolic and diastolic blood pressure were within normal limits. At night, systolic blood pressure decreases adequately, diastolic blood pressure, at night, decreases excessively. The variability of systolic and diastolic blood pressure during the day is within the acceptable range. Episodes of hypertension were not registered. There is an increase in the rate of morning rise in systolic and diastolic blood pressure.
ECG dated 03.03.2014 No. 302: Moderate sinus bradycardia. Horizontal position E.O.S. Incomplete blockade of the right leg of the bundle of His. The predominance of the potentials of the left ventricle.
Echocardiography from 03/04/2014: Normal geometry of the left ventricle. The cavities of the heart are not dilated, free. The systolic and diastolic function of the left ventricle is preserved. The heart valves are intact. Pericardium without features.
Aorta and pulmonary artery
Value Norm
Left ventricle
LV EDR, mm 45.5 42-59
LV ECR, mm 26.1 20-36
TMZhP, mm 7.2 6-10
LV VC, mm 7.2 6-10
LP-34.7x31.9x38 .9
PZh-27.4x3.2
PP-36.9x38.4
Report on the test with physical activity (dated March 11, 2014): Functional class-1. The test is negative (submaximal heart rate has been achieved, no ischemic changes in the ST segment have been detected). Tolerance to physical activity is average (7.5 Met). BP response to exercise is normotensive. The recovery period for blood pressure and heart rate is adequate.
Ultrasound of the digestive organs: the liver is not enlarged, the right lobe is 16.0 cm, the left lobe is 7.0 cm. The contours are even, the structure is homogeneous, the echogenicity is moderately increased, the vascular pattern is preserved, the portal vein is 12 mm, the choledochus is 4 mm, the intrahepatic bile ducts are not dilated . Gallbladder: irregular shape, deformation in the body area, dimensions: length-5.5, diameter-2.0 cm, smooth contours, wall -3.0 mm. The pancreas is located clearly. The contours are clear, even. The head is 22.3 mm. body 19.8 mm, tail -17.5 mm. Echogenicity - increased moderately. The structure is homogeneous. Wirsung's duct is not dilated - 2.0 mm. The spleen is not enlarged, dimensions: length-8.8; thickness 5.5, homogeneous structure. Kidneys: typical location, smooth contours, right kidney 10.2x5.3 cm, parenchyma - homogeneous - 27.0 mm; PCS - not expanded, no calculi; left kidney: 10.5x6.0 cm, the parenchyma is homogeneous - 15.0 mm, microliths are not detected. Thyroid gland: not enlarged, clear, even contours, homogeneous structure, perthmus 4 mm, right lobe: width 15.5 cm, thickness 17.2 cm, length 43 cm, volume 6.0 cm3; left lobe: width 15.3 cm, thickness 17.0 cm, length 44.0 cm, volume 6.0 cm 3.
Conclusion: the handwriting is not clear(!).
At discharge: General condition is satisfactory. May be discharged under medical supervision. Recommendations are given.
Recommended:
• Supervision of the physician of the unit.
• Compliance with the regime of work and rest.
• Continue admission:
Form 12_Un.VMEDA-2011
MILITARY MEDICAL ACADEMY
DISCHARGE REPORT CASE
HISTORY No. ARCHIVE No. _________ Last name, first name, patronymic born in 1962.
He was treated in the day hospital mode in the clinic of hospital therapy
Total number of days of treatment was 16
The final diagnosis was established. ICD code _I 42.8
DIAGNOSIS:
Main disease: Arrhythmogenic dysplasia of the right ventricle. Implanted cardioverter-defibrillator (2009) Atherosclerosis of the aorta and coronary arteries. Large-focal myocarditis (1995) and atherosclerotic cardiosclerosis with persistent cardiac arrhythmias of the type of frequent ventricular extrasystole and paroxysmal polytopic ventricular tachycardia. Hypertensive disease of the second stage (arterial hypertension 3, the risk of CVE is very high).
Complications of the underlying disease: Chronic heart failure of the third functional class, stage I.
Background disease: Diabetes mellitus type 2. Diabetic symmetrical distal sensory polyneuropathy. Target HbA1c < 7.0%
Concomitant diseases: Diffuse-nodular goiter, without impaired thyroid function. Dyscirculatory encephalopathy of the second stage of mixed genesis (atherosclerotic, hypertensive, diabetic and vertebrogenic) in the form of scattered neurological symptoms and a pronounced persistent pseudoneurotic syndrome. Chronic gastritis, stage of remission. Fatty hepatosis of the second stage, without dysfunction.
Certificate of incapacity for work: not issued
Total exposure dose 5.6 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, _____ disability group, degree of limitation
Outcome: discharged due to improvement
Complaints: pressing pains behind the sternum that occur during physical exertion, sensations of interruptions in the work of the heart, episodes of palpitations, shortness of breath when climbing to the second floor, walking up to 200 meters, diffuse headache, dizziness with an increase in blood pressure up to 160/110 mm. rt. Art., working 130/80 mm. rt. Art., general weakness, fatigue, irritability, memory loss, sleep disturbance, periodic dry mouth and thirst, heartburn with errors in the diet.
History of present illness. Since childhood, he often suffered from tonsillitis. In 1985, he was diagnosed with chronic tonsillitis, for which he was treated on an outpatient and inpatient basis. In 1995, after a sore throat, an infectious-allergic myocarditis developed, which proceeded with severe disturbances in heart rhythm and conduction. Subsequently, myocardial cardiosclerosis was formed with conduction disturbance in the form of a complete blockade of the right bundle branch of His, blockade of the anterior branch of the left bundle of His bundle. In the future, he was repeatedly treated for this in a hospital. Since 1999, she has been worried about shortness of breath during physical exertion; during a hospital examination, heart failure of the first functional class was verified. Since 2000, he has been worried about interruptions in the work of the heart, and frequent ventricular extrasystoles have been detected. Since 2004, pressing pains behind the sternum during physical exertion began to disturb, coronary heart disease, angina pectoris of the first functional class was diagnosed in a hospital, a constant intake of nitrates, antiplatelet agents was recommended, the patient partially fulfilled these recommendations. In August 2008, there was a hemodynamically significant paroxysm of ventricular tachycardia, stopped by electropulse therapy. In December 2008, coronary angiography was performed, in which angiographic signs of atherosclerotic lesions of the coronary arteries were not detected. In April 2009, when performing an endocardial electrophysiological study of the heart, stable paroxysms of ventricular tachycardia were induced from the outflow tract of the right ventricle. In this regard, on April 15, 2009, a cardioverter-defibrillator was implanted. In the future, the patient continues to be disturbed by pressing pains in the chest and shortness of breath during physical exertion, interruptions in the work of the heart. As a result, he was repeatedly hospitalized. Headache against the background of episodes of increased blood pressure up to 150/100 mm Hg. Art. worried since 1986. Since 1995, he has been observed for neurocirculatory asthenia of the hypertensive type, occasionally taking antihypertensive drugs with a positive effect. Since 2004, an increase in blood pressure to 150/100 mm Hg. Art. takes a persistent character, at a hospital examination, hypertension of the first stage is diagnosed. In 2008, against the background of constant intake of antihypertensive drugs, there were rises in blood pressure up to 160/100 mm Hg. Art., stationary diagnosed with hypertension of the second stage, the initial manifestation of cerebrovascular insufficiency. In September 2011, he suffered a hypertensive crisis, stopped permanently. Since 2000, he has noted the appearance of episodic dry mouth, thirst, was observed due to impaired glucose tolerance. In 2003, during a hospital examination, a diagnosis of type 2 diabetes mellitus, a mild course, was established. Until 2008, compensation was achieved by diet. Since 2008, hypoglycemic drugs have been added to the diet. In 2003, during a hospital examination, a diagnosis of type 2 diabetes mellitus, a mild course, was established. Until 2008, compensation was achieved by diet. Since 2008, hypoglycemic drugs have been added to the diet. In 2003, during a hospital examination, a diagnosis of type 2 diabetes mellitus, a mild course, was established. Until 2008, compensation was achieved by diet. Since 2008, hypoglycemic drugs have been added to the diet.
Currently taking Glibomet. Against this background, diabetes is compensated. In April 2009, a diffusely nodular goiter was detected without functional impairment. About fifteen years worried about heartburn with errors in the diet. Since 2003, chronic gastritis has been detected. In July 2009, the VVK was surveyed (a copy of the document is attached). In the course of this deterioration in health, he was hospitalized at the GT clinic of the Military Medical Academy for further examination and treatment.
As a result of the treatment: regimen, diet N9 Sol. NaCl-200ml Sol. Espalipon 24.0 IV drip N5, T. Carvedilol 37.5 mg/day, T. Preductal 70 mg/day, T. Aspicor 100 mg/day, T. Atoris 20 mg/day, T. Ramipril 2.5 mg/day, T. Glibomet 1600 mg/day, T. Detralex, T. Vazobral, there is a positive trend: the pain syndrome did not recur, blood pressure is stabilized and corresponds to the target values (normotension is maintained). He notes an increase in working capacity, an increase in tolerance to physical activity. Therapy for the outpatient stage of treatment was selected, recommendations were given.
Results of instrumental studies:
ECG from 05/14/2013: sinus rhythm with a heart rate of 70 per minute. A sharp deviation of the EOS. Blockade of the right leg of the bundle of His. Blockade of the anterior-upper branch of the left leg of the bundle of His. Hypertrophy of the left atrium. Left ventricular hypertrophy.
Ultrasound of the abdominal organs and kidneys on May 15, 2013: the liver is enlarged, due to the left lobe - 15.2 cm, the left - 6.6 cm, the contours are even, the structure is homogeneous, the echogenicity is increased, the vascular pattern is preserved, the vessels are not dilated, the portal vein is in normal, intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape, with a bridge, dimensions 8.0x3.2 cm, the contours are even, the walls are 3 mm, there are no calculi. The pancreas is not located, it is blocked by gases. Kidneys: typical right location, normal mobility, smooth contours, dimensions 12.6x6.7 cm, homogeneous parenchyma 23.0 mm. The PCS is not dilated, the left one is typically located, the mobility is normal, the contours are even, the dimensions are 12.5x6.2 cm, the parenchyma is homogeneous 19 (mm). PCS is not expanded. No pathological formations were found in the projection of the adrenal glands. The spleen is enlarged 10.5x4.1, the structure is homogeneous. Conclusion: diffuse changes in the liver according to the type of fatty hepatosis. Diffuse changes in the pancreas.
Radiography of the cervical, thoracic, lumbar spine dated May 16, 2013: cervical and lumbar lordosis is smoothed, osteochondrosis C4-5, Th4-5, Th5-6, L4-5, L3-4 motor segments and marginal bone growths up to 0, 1 cm.
Myocardial SPECT dated May 23, 2013: no pathology.
Echocardiography dated 05/15/2013:
Result, mm
Norm, mm
Aorta
At the level of AC
18
22-36
Valve opening
15-26
Left atrium
Anteroposterior size
38
25-40
Left ventricle
EFR
30
≤ 36
ECR
45
≤ 55
Posterior wall thickness (diast. )
11
Thickness of the interventricular septum (d.)
11
Right ventricle
ECD
48
≤
30
Anterior wall
6
≤ 5
Right atrium
Transverse
dimension
54
29-46
Longitudinal
dimension
50
34-49
Pulmonary
artery
At
the
valve
23
12-23 41
EF, %
60
≥55
Ve/Va
1.19
1.0-2.2
Conclusion: hypertrophy, pronounced dilatation of the right ventricle with a decrease in its contractile function, moderate dilatation of the right atrium. in the right cavities, the shadow of the EKS electrode is located with its fixation on the border of the middle and apical part of the interventricular septum. There are multiple thrombotic deposits on the right ventricular part of the electrode. Concentric LV remodeling. Moderate asynchronism of myocardial contraction. No zones of local disturbance of kinetics were revealed. Slight dilatation of the LP. The aorta and fibrous rings are condensed. Regurgitation of the 2nd degree on the tricuspid valve, 1st degree on the pulmonic valve. The pericardium is not changed.
Daily monitoring of blood pressure on May 16, 2013: mean systolic blood pressure during the day is typical for moderate stable hypertension, mean diastolic blood pressure during the day is typical for severe stable hypertension. At night, systolic and diastolic blood pressure fall adequately (dipper). The variability of systolic blood pressure and diastolic blood pressure during the day is within the acceptable range. Episodes of hypotension were not registered. There is an increase in the rate of morning rise in blood pressure.
24-hour ECG monitoring on May 16, 2013: sinus rhythm was recorded during the observation period. Heart rate from 60 to 119 per minute. The decrease in heart rate at night is insufficient. Average heart rate 73/75/68 per minute. The following rhythm and conduction disturbances were registered: frequent ventricular extrasystoles (total 1754) episodically paired, supraventricular extrasystoles (total 1011). Ischemic changes in the ST segment were not detected.
Consultation of an ophthalmologist dated May 17, 2013: hypertensive angiopathy of the retina in both eyes.
ENT consultation dated May 20, 2013: deviated nasal septum, vasomotor rhinitis.
Consultation of a neurologist dated May 21, 2013: first stage dyscirculatory encephalopathy with diffuse neurological symptoms and pseudoneurotic syndrome. Chronic vertebrogenic cervicalgia, lumbalgia, unstable remission.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Tr. *109/l
MCH
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
15.05
155
5.37
8.3
203
28.8
4
3
-
27
5
5
62
Urinalysis (automatic processing):
Date
U.weight
Reak
Protein
Sax
Ket.
Lei
Er.neiz
Urobil
15.05
1030
5.5
-
-
traces
0-6
-
3.2
Biochemical analysis of blood:
Name
Unit of measure.
Norm
15.05
O. protein
g/l
64-83
71
Glucose
mmol/l
4.2-6.4
7.02
Creatinine
mmol/l
0.05-0.12
0.1
Potassium
mmol/l
3.4-4.5
4.69
Sodium
mmol/l
130-150
143
Cholesterol
mmol/l
3.7-6.0
2.87
Total bilirubin
mmol/l
6.3-26
12.3
Urea
mmol/l
2.5-6 .5
5.6
AST
U/l
11-50
25
ALT
U/l
11-50
31
GGTP
U/l
87.1
Glykirov. HvA%
4-6.5
7.08
Triglycerides
0-2.37
3.28 Coagulation
system on May 15, 2013: prothrombin 91%, fibrinogen 3.11 g/l, INR 1.05;
Employment has been restored. Discharged in a satisfactory condition under the supervision of specialists of the clinic. A certificate of temporary incapacity for work was not issued.
Recommended:
26. Observation, therapist, angiosurgeon, neurologist, cardiologist, gastroenterologist.
27. 24-hour ECG monitoring after 2 months, followed by a consultation with a cardiologist.
28. Control of b / x blood after 3 months (AST, ALT, o. bilirubin, o. cholesterol, lipidogram, coagulogram) followed by a consultation with a therapist.
29. Regular monitoring of glucose levels.
30. Normalization of the regime of work and rest. Exclude the use of animal fats, easily digestible carbohydrates, alcohol, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet. exercise therapy.
31. Observe the water regime (fluid balance), daily monitoring of blood pressure and heart rate.
32. Continue taking:
6. T. Ramipril 2.5 mg 1 tab. in the morning.
7. T. Preductal 35 mg 1 tab. morning and evening after meals.
8. T. Carvidilol 12.5 mg 1 tab. in the morning and in the evening.
9. T. Metformin 850 mg 1 tab. in the morning and in the evening.
10. T. Pradaxa 110 mg 1 tab. in the morning.
11. T. Detralex 1 tab. in the morning and in the evening.
Main disease: Arrhythmogenic dysplasia of the right ventricle. Implanted cardioverter-defibrillator (2009) Atherosclerosis of the aorta and coronary arteries. Large-focal myocarditis (1995) and atherosclerotic cardiosclerosis with persistent cardiac arrhythmias of the type of frequent ventricular extrasystole and paroxysmal polytopic ventricular tachycardia. Hypertensive disease of the second stage (arterial hypertension 3, the risk of CVE is very high).
Complications of the underlying disease: Chronic heart failure of the third functional class, stage I.
Background disease: Diabetes mellitus type 2. Diabetic symmetrical distal sensory polyneuropathy. Target HbA1c < 7.0%
Concomitant diseases: Diffuse-nodular goiter, without impaired thyroid function. Dyscirculatory encephalopathy of the second stage of mixed genesis (atherosclerotic, hypertensive, diabetic and vertebrogenic) in the form of scattered neurological symptoms and a pronounced persistent pseudoneurotic syndrome. Chronic gastritis, stage of remission. Fatty hepatosis of the second stage, without dysfunction.
Federal State Institution "442 DISTRICT MILITARY CLINICAL HOSPITAL LENVO" Ministry of Defense of the Russian Federation
Discharge summary No.
1967 was on examination and treatment at 15 m / o 442 OVKG during the period with a diagnosis of:
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
Hospitalized in a planned manner with complaints of interruptions in the work of the heart.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/L
Leuc., *109/L
ESR, mm/h
Lf
%
M
%
Granulocytes%
12.05.
136
4.0
6.6
8
35.1
5.3
59.6
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
12.05
clear
1027
yellow
5.0
no
no
no
0
0
0
0
0
1-3
0
Biochemical blood test:
Name
Unit rev.
Norm
12.05
Creatinine
mmol/l
53-124
103.1
INR
U
1.7
Prothrombindex
%
70-120
42.6
ALT
U/L
8.4-53.5
35
AST
U/L
7-39.7
24
LDH
U/L
100-220
105
Glucose
mmol/l
4.2-6.4
6.61
Results of instrumental studies:
ECG from. 05/12/2010: atrial fibrillation with a heart rate of 90 in 1 min. EOS deviated sharply to the left. Blockade of the anterior branch of the left leg of the bundle of His. Left ventricular hypertrophy.
FLG of the chest organs No. 1521 dated May 13, 2010: Conclusion: no focal and infiltrative formations were detected in the lung tissue. The roots are expanded due to the vascular component. On the right, the sinuses are free; on the left, the dome is raised and flattened; the sinuses are obliterated. To the right above the diaphragm there is a linear shadow of the pleural ligament. The shadow of the heart is moderately enlarged, the cardiac arches are smoothed along the left contour.
State of emergency Echo-KG from 15.05.10: atrial cavities, including the area of both atria, the ventricular cavities are free. In the atrial cavities, there is a slightly pronounced phenomenon of pseudoregurgitation. The average velocity of blood flow in the left atrial appendage is 0.33 m/s, there is atrial dilatation, induration of the right coronary crescent. In the interatrial septum in the area of its connection with the aortic ring, there is a slight discharge of blood (a residual defect after suturing an ASD with a diameter of 0.2 cm). There is no effusion in the pericardium.
Treatment: regimen, diet, thrombo ass, cordarone
12.05.2010 performed electrical cardioversion - restored sinus rhythm.
The goals of hospitalization have been achieved. On the background of the therapy, the patient's condition improved. Restored sinus rhythm.
Discharged to the clinic at the place of residence in a satisfactory condition.
Recommended:
201. Outpatient observation of a cardiologist, endocrinologist of a polyclinic.
202. Exclude from the diet animal fats, fried, spicy, salty and spicy foods, foods containing large amounts of carbohydrates.
203. Increase in the diet: dried apricots, prunes, vegetable fats.
204. Dispensary observation:
a. clinical blood test, urinalysis - twice a year;
b. control of blood glucose level, lipidogram - in a week, then according to indications
c. Echocardiography - 1 time per year;
d. ECG - 1 time per quarter
205. Continue reception:
a. Siofor 850mg - 1 time per day (in the morning) constantly
b. Thrombo ACC 0.1 - 1 tablet in the morning constantly
c. Panagin - 1 tablet 3 times a day for 10 days of each month
d. Mildronate 0.5 - 1 capsule in the morning and in the afternoon for 10 days
e. Kordaron 0.2 1 tablet in the morning for a month with a break on Saturday and Sunday
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated
.
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
IHD: arrhythmic variant. Atherosclerosis of the aorta, coronary arteries, atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation, tachysitolic variant from March 2010, stopped by EIT on May 12, 2010, stage 1 NK, CHF II FC. Obesity 2 degrees, alimentary-constitutional genesis, stable phase. Diabetes mellitus of the second type, moderate degree, is compensated.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY № ARCHIVE №_________
Surname, name, patronymic: born in 1927
Was on inpatient treatment in the clinic of hospital therapy
In total, 16 days of treatment were carried out.
The final diagnosis was made on January 19, 2014.
ICD code I 48; MES 291180
Diagnosis:
Ischemic heart disease. Angina pectoris III functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis complicated by impaired conduction by the type of blockade of atrioventricular conduction of the first degree, transient complete blockade of the right leg of the bundle of His, rhythm disturbance by the type of supraventricular extrasystole, paroxysmal form of atrial fibrillation. Paroxysm of atrial fibrillation from 18.01.2014. (tachysystolic variant, CHA2DS2VASc 9.8% [6 points], EHRA grade 2, HAS-BLED 2 points), stopped medically on 19.01.2014.
Stage III hypertension (arterial hypertension of the 1st degree, the risk of cardiovascular complications is "very high").
Chronic heart failure II-a stage, 2 functional class.
cerebrovascular disease. Dyscirculatory (stroke stroke from 2000 in the PSMA pool) encephalopathy stage III in the form of moderate (deep in the hand) left-sided hemiparesis, hemihypesthesia, pseudobulbar syndrome, pronounced emotional and volitional disorders.
Secondary nephropathy of mixed (atherosclerotic, hypertensive) genesis. Solitary cyst of the right kidney. Chronic kidney disease C2Ax stage.
Autoimmune thyroiditis, clinically euthyroidism.
Fatty hepatosis I degree.
Chronic cholecystitis, remission. Lipomatosis of the pancreas.
Chronic vertebrogenic lumbosacral sciatica with L5-S1 root syndrome on the left in the phase of unstable remission.
Benign prostatic hyperplasia.
Varicose disease, deep form, subcompensation. Chronic venous insufficiency of the 2nd degree.
Keratoma of the right cheek area.
Mycosis stop.
Artifakia, destruction of the vitreous body, central chorioretinal dystrophy, peripheral chorioretinal dystrophy of both eyes.
Complaints at admission: pain in the region of the heart of a compressive nature against the background of physical (walking around the apartment) and psychoemotional stress, which stops on its own or after the use of nitropreparations; shortness of breath during physical activity (daily household activities), frequent headaches and lability of blood pressure levels (100-150 and 60-90 mm Hg); episodes of interruptions in the work of the heart, palpitations without connection with physical activity; swelling of the lower extremities up to the upper third of the lower leg, mainly the left; limitation of range of motion and violation of skin sensitivity of the left upper and left lower extremities; memory loss; pain in the lumbar region with prolonged static loads; decreased vision; frequent urination at night.
Anamnesis of the disease: Collection of anamnesis is difficult due to severe cognitive impairment. For a long time (more than 10 years) hypertension, coronary disease, noted cardiac arrhythmias. On this occasion, he is observed by a cardiologist at a polyclinic at the place of residence; he has repeatedly been treated and examined in cardiological hospitals. In 2000, he suffered a stroke, which was complicated by left-sided deep hemiparesis, hemihypesthesia (they still persist). The last hospitalization in a therapeutic hospital in August 2013 (clinic of faculty therapy of the Military Medical Academy), was diagnosed with: “CHD. Angina pectoris III FC. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis with arrhythmia according to the type of paroxysmal form of atrial fibrillation, conduction according to the type of AV blockade of the first degree. Hypertension stage III. CHF II-a stage, 2 FC. TsVB. Stage III DEP of mixed (post-stroke (2000), atherosclerotic) genesis in the form of left-sided deep hemiparesis, hemihypersthesia, cognitive impairment ”(copy of the discharge certificate in the medical history). The patient was discharged with improvement, the following therapy was recommended: losartan 12.5 mg/day, veroshpiron 50 mg/day, diuver 5 mg/day, pradaxa 220 mg/day, sotalol 40 mg/day. The regularity of taking drugs is observed (according to the patient). Deterioration of health has been noted since December 2013, shortness of breath has increased, edema of the lower extremities has appeared, lability of blood pressure levels, pains in the heart area, interruptions in the work of the heart, began to notice a decrease in exercise tolerance.
According to the patient, in 2000 he was diagnosed with autoimmune thyroiditis, subclinical hypothyroidism. On this occasion, it is observed by an endocrinologist. August 2013 - subclinical hypothyroidism; dose of L-thyroxine 25 mcg/day. In November 2013, thyroid status was monitored: T3, T4, TSH, and/tPO were normal values (results on the hands), L-thyroxine was canceled by the endocrinologist.
Objectively at the time of admission: the general condition is satisfactory. Consciousness is clear. The skin and visible mucous membranes are clean, dry, turgor is reduced. Limitation of motor activity of the left upper and lower extremities (left-sided hemiparesis due to previous ischemic stroke). The physique is correct, corresponds to age and sex. Normal nutrition: the thickness of the skin fold at the costal arch is 2 cm, near the navel 4 cm. The elasticity of the skin is reduced, slight acrocyanosis of the lips. Diagonal fold of the earlobe, senile arch of the eyes. There are no edema. The pulse is rhythmic, uniform, with a frequency of 80 beats. in min., BP 150 and 100 mm Hg. Heart sounds are muffled, rhythmic, accent II tone over the aorta, there is no pulse deficit. RR 17 per min. On auscultation over the lungs, breathing is vesicular, rales are not heard. The abdomen is soft, painless on palpation. A strengthened scar without signs of inflammation in the right iliac region is determined. The edge of the liver does not protrude from under the edge of the costal arch. The size of the liver according to Kurlov is 10*9*8 cm. The spleen is not palpable. Ragosa's symptom is negative. Tapping on the lumbar region is painless on both sides. There are no dysuric phenomena.
Treatment was carried out: mode 3, diet 10. Parenterally: NaCl, KCl, glucose, cavinton, cordarone. Inside: blocktran, spironolactone, trigrium, pradaxa, sotohexal, sonizim, finasteride, phenazepam, phenibut, propafenone. In the form of ointments mycoseptin, troxevasin.
Against the background of ongoing therapy, hemodynamic parameters are stabilized within the optimal values. The patient notes a moderate improvement in general well-being, increased exercise tolerance.
Repeatedly was on examination and treatment in therapeutic clinics of the Military Medical Academy and city medical institutions, diagnostically clear. Extreme hospitalization in August 2013 to the clinic of faculty therapy (a copy of the discharge summary on hand). Leading in the clinical picture is vascular pathology, represented by the consequences of ischemic stroke in the form of stage III dyscirculatory encephalopathy, left-sided hemiparesis, hemihypesthesia, and cognitive impairment; angina pectoris II-III functional classes, arterial hypertension with moderate symptoms of chronic heart failure, rare paroxysms of atrial fibrillation. The patient receives a full-fledged complex therapy of the underlying disease. Currently hemodynamically stable.
Results of instrumental studies:
ECG on January 20, 2014: sinus bradycardia with a heart rate of 56/min, horizontal EOS. Atrioventricular blockade of the first degree, complete blockade of the right leg of the bundle of His
Holter monitoring of the ECG from 01/21/2014: During the observation period, sinus rhythm was recorded with a heart rate of 50 to 76 per minute. The decrease in heart rate at night is insufficient. Average heart rate 59/59/59 per minute. The following rhythm and conduction disturbances were registered: single polytopic polymorphic ventricular extrasystoles (66 in total), mostly late, periodically paired, group; from 16.20h. until 18-20h. and from 20-20 h. up to 23-20 hours, frequent (up to 234 per hour), the rest of the time single polytopic supraventricular extrasystoles (1016 in total), periodically paired, group; at 1-56 a short run of supraventricular tachycardia (5 complexes); AV block I degree; transient blockade of the right leg of the bundle of His (recorded mainly in the daytime).
Ultrasound of the abdominal organs, thyroid gland from 01/16/2014: the liver is not enlarged, the right lobe is 10.2 cm, the left lobe is 6.0 cm, the contours are even, the echogenicity is increased, the vascular pattern is preserved, the vessels (portal vein, hepatic veins) not expanded. Intrahepatic bile ducts are not dilated. The gallbladder of the correct form, dimensions (length 4.6 cm, diameter 2.3 cm), smooth contours, wall 4 mm, not changed, intracavitary formations - sediment. The pancreas is blocked by intestinal loops. The spleen is not enlarged, dimensions: length 9.7 cm, thickness 5.4 cm, homogeneous structure. The kidneys are located in a typical place, the contours are clear, the right kidney with a large anechoic round formation with clear contours 9 cm in diameter, the left kidney 11 * 6 cm, the parenchyma is homogeneous 24 mm; ChLS of both kidneys is not dilated. The thyroid gland is located in a typical location, symmetrical, not enlarged. The contours are fuzzy, uneven, the structure is heterogeneous due to areas of different echogenicity. Right lobe: width 19.5 cm, thickness 20.6 cm, length 45.0 cm. Left lobe: width 19.7 cm, thickness 20.7 cm, length 43.0 cm. VΣ=17.5 ml. Volumetric formations with clear even contours are visualized in the right lobe 0.8 * 1.2 cm and 0.9 * 1.0 cm, in the left lobe with a diameter of 0.6 cm, 0.5 cm, 0.6 cm, 0.7 see Blood flow is not increased. Regional lymph nodes are not changed. 0.5 cm, 0.6 cm, 0.7 cm. The blood flow is not increased. Regional lymph nodes are not changed. 0.5 cm, 0.6 cm, 0.7 cm. The blood flow is not increased. Regional lymph nodes are not changed.
Ultrasound of the small pelvis: signs of adenoma (V 42.0 ml), chronic prostatitis.
Echo-KG from 17.01.2014:
Index
Value
Norm
Index
Value
Index
Aorta and pulmonary artery
Left atrium
Root, mm
26.4
22-26
Anterior-posterior. size, mm
44.6
30-40
Ascending,
mm
34.6
21-34 size, mm
49.0 29-49
AK
opening, mm
16.1
15-26
Length. size, mm
59.1 29-53
Leg
. artery, mm
16.0
15-21
Left ventricle
Right ventricle LV EDR
, mm
62.4
42-59 LV EDR
, mm
20-28
LV EDR, mm
34.3
20-36 LV EDR
, mm
28.1
27-33
TMZhP (dias), mm
10.0
6-10
CDR (basic-apex), mm
-
71-79
LV TZS (dias), mm
11.0
6-10
RV area (dias.), cm2
-
11-28
LVML, g
342
141
RV area (syst.) , cm2
-
7.5-16
LVMI, g/l2
163
109 Anterior
wall thickness, mm
4.1
< 6
OTS, units
0.34
< 0.42
Right atrium
EF (Teicholz),%
45
>
55 solution , mm
34.1
30-40
IVRT, ms
70-75
Longitudinal solution, mm
48.3
Mitral valve
< 50 years / > 50 years
Tricuspid valve
< 50 years / > 50 years
Peak wave velocity E, m/s
0, 68
0.58-0.68/ 0.48-0.86
0.49
0.34-0.68/0.33-0.49
Peak wave velocity A, m/s
0.57
0.30-0 .50/0.45-0.73
0.20
0.19-0.35/0.25-0.41
U/A
1.2
1.0-1.5
2.5
1.0-1.5
Regurgitation, degree
0-1
0
0
0-1
E wave deceleration time, ms
174
159-199/174-276
200
166-210/175-221
Aortic valve
Pulmonary valve
Peak blood flow velocity, m/s
1.5
1.0-1.7
0.9
0.6 -0.9
Regurgitation, degree
0
0
0
0
Conclusion: The walls of the aorta are indurated. The leaflets of the aortic valve are sealed and calcified. Eccentric LV hypertrophy with dilatation of its cavity. Dilatation of the cavity of the left atrium. Systolic LV function is reduced. Hypokinesia of the basal anterior and basal septal segments. Type II LV diastolic dysfunction. Applied mitral regurgitation. Pericardium without features.
Laboratory results:
Clinical blood test (hardware processing): RBC
date
, *1012/l
Hb
units.
Lake. *109/l
Tr.
109/l
HCT
PCT
ESR, mm/h
E
%
B
%
lim
%
mon
%
p/i
%
s/i
%
15.01.14
4.1
125
8.1
228
367
175
16
1
-
10
11
3
75
Rt,
‰
MCV,
fl
MCH,
pg
MCHC,
g/l
RDW,
%
MPV,
fl
PDW
%
Lf
%
M,
%
Gra,
%
Lf,
109/L
M,
109/L
Gra,
109/L
-
90
30.5
340
14.6
7.6
13.9
14.4
5.3
80.3
1.1
0.4
6.6
Date
RBC, *1012/l
Hb
unit
Lake. *109/l
Tr.
109/l
HCT
PCT
ESR, mm/h
E
%
B
%
lim
%
mon
%
w/w
% w/
w
%
16.01.14
4.26
129
5.0
215
383
171
18
-
-
18
11
3
68
Rt,
‰
MCV,
fl
MCH,
pg
MCHC,
g/l
RDW,
%
MPV,
fl
PDW
%
Lf
%
M ,
%
Gra,
%
Lf,
109/L
M,
109/L
Gra,
109/L
-
90
30.3
337
14.3
8.0
15.4
21.0
7.4
71.6
1.0
0.3
3.7
Biochemical blood test dated January 16, 2014:
Name
Unit of measure.
Norm
16.01
21.01
27.01
Urea
mmol/l
2.5-6.4
9.1
10.4
Glucose
mmol/l
4.2-6.4
5.02
5.15
Creatinine
mmol/l
0.05-0.12
0.09
0, 08
O. protein
g/l
63-87
73
69
Potassium
mmol/l
3.50-5.10
4.69
5.19
Sodium
mmol/l
136-145
134
134
Chlorine
mmol/l
98-107
106
Cholesterol
mmol/l
3.7-6.0
3.62
AST
U/l
11.0-50.0
14
ALT
U/l
11.0-50.0
12
LDH
U /l
120-246
125
CPK –MV
U/l
0.0-25.0
22
19
o.
bilirubin mmol/ l 6.8-26
18.7
ex
. bilirubin
mmol/l
0.0-7.0
4.8
Alkaline phosphatase
U/l
45-120
144
Prothrombin
%
70-130
62
82
Fibrinogen
Mg/dl
200-400
338
362
T3 free
pmol/l
4.0-8.6
5.9
Urinalysis
Date
16.01.14.y
Color
Yellow
Transparency
Transparent
Density
1020
pH
5.5
Protein (g/l)
0 .08
Leukocytes 3-4-4
in p / c
Erythrocytes
up to 100 in p / c
Glucose
4.4 mmol / l
Nechiporenko test: L 1.25x106 / l, E 0.5x106 / l
The goals of hospitalization have been achieved. Discharged in a satisfactory condition under the supervision of a neurologist, urologist, cardiologist, endocrinologist, at the place of residence.
RECOMMENDED:
11. Observation by a neurologist, cardiologist, gastroenterologist, urologist at the place of residence.
12. General measures, including regular, moderate in intensity physical dynamic loads in the air, sufficient sleep and rest, if possible, sanatorium treatment in sanatoriums of the local climate.
13. Limit the intake of animal fats, easily digestible carbohydrates, increase the amount of vegetable fiber, vegetable fats, foods containing an increased amount of potassium (dried apricots, raisins, prunes) in the diet.
14. TSH control 1 time in 3 months.
15. Permanent intake (under the control of the pulse level, blood pressure):
• T. Losartan 25 mg ½ tablet in the morning and evening after meals.
• T. Veroshpiron 25 mg 2 tablets 2 times a day.
• T. Sotalol 80 ½ tablet 2 times a day.
• T. Rocaltrol 0.25 mcg 1 tablet in the morning
• Caps. Cardionat 0.25 1 capsule 2 times a day after meals (for 1 month, courses 3 times a year).
• T. Pradaxa 110 mg 1 tablet 2 times a day
• T. Omnic 1 tablet in the evening
• T. Finasteride 1 tablet in the morning
• T. Seroquel 25 mg at night for a long time
MILITARY MEDICAL ACADEMY Form 12_Un.
DISCHARGE
HISTORY CASE HISTORY No.
Surname, name, patronymic born in 1973
He was hospitalized
at the clinic of hospital therapy
Total days of treatment were 10
The final diagnosis was established ICD code I 40.0
Diagnosis:
Primary: Infectious-toxic (viral-bacterial) myopericarditis, severe.
Complication of the underlying disease: Paroxysmal form of atrial fibrillation, frequent paroxysms of atrial fibrillation, tachysystolic variant. Severe effusion pericarditis, secondary pulmonary hypertension grade 1, heart failure grade 2. Systemic inflammatory response syndrome. DN-2st.
Accompanying: Community-acquired viral-bacterial focal polysegmental confluent pneumonia in the lower lobe of the left lung, severe, left-sided effusion pleurisy. Cholelithiasis, chronic calculous cholecystitis, remission. Obesity I degree, alimentary-constitutional type, stable phase. fatty hepatosis.
A disability certificate was not issued.
Employability has not been restored.
Clinical outcome (underline): improvement
Outcome: discharged due to improvement
Admission:
Complaints: pressing pain in the heart area during exercise; shortness of breath of an inspiratory nature; dry cough without sputum; an increase in body temperature up to 39 degrees; weakness.
Anamnesis of the disease: He considers himself ill since the beginning of March 2011, when these complaints appeared against the background of hypothermia. He did not apply for medical help, periodically took biseptol, amoxicillin. In connection with persistent complaints, he applied for medical help to the clinic on March 17, 2011, the ECG revealed atrial fibrillation, and focal pneumonia on the x-ray. Hospitalized by ambulance to the hospital therapy clinic.
Objective status: general condition is severe, no edema, heart rate 76 per minute, rhythmic, auscultatory heart sounds are muffled, accent of the second tone over the aorta, heart borders are expanded to the left, blood pressure 110/70 mm Hg, hard breathing in the lungs, wheezing No; the abdomen is soft, painless on palpation, tapping on the lumbar region is painless on both sides.
As a result of the treatment: mode III, diet No. 10, antibiotic therapy (Ceftriaxone 1.0 2 r / day), polarizing mixture (glucose 5%, potassium chloride, magnesium sulfate., Vit. C 6 ml - No. 5), metabolic therapy (Mildronate), antisecretory therapy (Omeprazole), anti-inflammatory therapy (Ibuprofen 0.4 3 r / day), GCS therapy (Prednisolone IV 90 mg 3 r / d), antiarrhythmic therapy (Cordaron 0.2 3 r / d) , anticoagulant therapy (Heparin s / c at 2500 4 r / d), the state of health improved in the form of a decrease in shortness of breath, the severity in the heart area, the divergence of the sheets of the pericardium decreased.
Results of instrumental studies:
ECG 22.03.2011 Large-wave atrial fibrillation tachysystolic form. The vertical position of the EOS. Signs of left ventricular hypertrophy. Decreased voltage of ECG waves.
ECG dated April 1, 2011. Atrial fibrillation, tachysystolic form. Normal position of the EOS. The predominance of LV potentials. Violation of the processes of repolarization along the god wall.
ECG from 04.04.2011 Sinus bradycardia with a heart rate of 56 per minute. Left ventricular hypertrophy. Diffuse changes in repolarization processes.
Echocardiography on March 18, 2011: Ascending aorta with a diameter of 28 mm, at the level of the aortic valve 30 mm., Opening of the aortic valve 19 mm. Left atrium: transverse dimension 41 mm, anterior-posterior 43 mm, longitudinal 48 mm. Left ventricle: ECR 35 mm, ECR 50 mm, FU 29%, ejection fraction 55%; UO 64 ml., back wall: diast. 10 mm; interventricular septum: diast. 10 mm. Pulmonary artery: at the valve 23 mm. Right atrium: transverse dimension 37 mm, longitudinal dimension 47 mm. Right ventricle: KDR 28 mm, anterior wall (diast.) 5 mm. The average calculated pressure in the pulmonary artery is 16.7 mm Hg. Conclusion: Sealing of the walls of the aorta, mitral valve leaflets, mitral valve ring. Slight enlargement of the left atrium. The rest of the chambers are not expanded. Two additional false chords are located in the cavity of the left ventricle. Myocardium is not thickened. Violations of local contractility were not revealed. Global contractility is preserved. Mitral regurgitation 0-1 degree. Tricuspid regurgitation grade 1. There is an expansion of the inferior vena cava up to 25 mm (decline on inspiration less than 50%), expansion of the hepatic veins up to 8-10 mm. slight deposition of fibrin. On the control on the visceral sheet is determined by a small deposition of fibrin. On the control on the visceral sheet is determined by a small deposition of fibrin. On the control
EchoCG from 03/21/2011. there is a positive trend in the form of a decrease in the divergence of the sheets of the pericardium: above the apex 5 mm, at the side wall of the left ventricle - up to 16 mm, along the back wall - 16 mm. EchoCG from 03/24/2011. compared with echocardiography of March 21, 2011, there is an increase in the divergence of the pericardial sheets along the lateral wall from 16 to 24 mm, along the top of the ear from 7 to 15 mm. On the back wall, the discrepancy is the same 16-18 mm. In the cavity of the pericardium, a formation measuring 26 * 18 mm (deposition of fibrin) is located. CT of the chest is recommended.
EchoCG from 04/01/2011. against the background of tachysystole (HR 170 per minute), there is a decrease in EF to 23-25%, otherwise without dynamics.
EchoCG from 04.04.11 LV=51/35mm; RV=24mm; MZHP=10mm; LA=23mm; open AC=17mm; EF=56%; FU=29% divergence of pericardial sheets up to 9 mm along the posterior wall. Slight hardening of the walls of the aorta. Cavities are not expanded, free. The myocardium is not thickened, the kinetics is not broken. The valves have not been changed. The blood flow is laminar. Regurgitation applied to the MK and TK. There are two additional transverse chords in the LV cavity. Circular divergence of the sheets of the pericardium (their thickening) up to 9 mm. In the lumen there are single fibrin strands.
Ultrasound of the abdominal organs 03/28/2011: the liver is enlarged, the right lobe is 17.3 cm, the left lobe is 8.5 cm, the contours are even, the structure is homogeneous, echogenicity is average, the vascular pattern is preserved. The vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated; there are no mass formations. the gallbladder is of the correct shape, the dimensions are normal, the contours are even, the wall is 0.2 mm, the contents are bile, the calculus is located 11.4 * 8.1 mm, there are no polyps. The common bile duct is 0.3 cm. The pancreas is located clearly, the contours are clear, even, homogeneous echo density, the Wirsung duct is not dilated. The kidneys are usually located, of a typical shape, not enlarged, the contours are even, the parenchyma is homogeneous with a thickness of up to 20-25 mm; CHLS is not dilated, there is a large number of microliths in the left kidney. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged, homogeneous. Conclusion: Hepatomegaly. ZhKB.
CT angiography on 03/30/2011: the results were handed out.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pya
%
Xia
%
24.03
141
4.5
14.5
31.3
54
0
-
19
3
3
73
31.03
142
4.74
23 ,0
30.1
42
0
-
13
5
4
78
01.04
133
4.39
24.4
30.4
4
1
-
13
5
1
80
03.04
138
4.6
12.1
12
4
3
4
89
_
_
_
Norm
24.03
31.03
Index
23.03
Creatinine
Mkmol/l
53-124
Color
yellow
Cholesterol
Mmol/l
3.7-6.0
Transparency
Clear
Triglycerides
Mmol/l
0-2.37
Specific. weight
1030
Fibrinogen
G/l
200-400
716
Reaction
Acid
Sodium
mmol/l
136.0-145.0
141.3
144.0
Protein (g/l)
No
Potassium
mmol/l
3.5-5.1
4.53
4.17
Sugar
No
Glucose
mmol/ l
4.2-6.4
Urobilin
0.2
Prothrombin
%
70-120
91
Leukocytes in p/ l
no
LDH
U/l
200-400
291
Erythr. unchanged in p/ l
no
CPK
U/l
10.0-160.0
342.1
Erythr. vysch. in p/sp
No
AST
U/l
11.0-50.0
104.9
Salt
no
ALT
U/l
11.0-50.0
126.4
Mucus
No
CPK MB
U/l
10.9
8.2
Consultation with a cardiac surgeon from 01.04.2011 recommended: -
restore sinus rhythm;
- continue therapy with corticosteroids and NSAIDs;
-continue broad-spectrum antibacterial therapy;
-metabolic therapy, electrolytes;
-an. blood for RNG with tuberculin hypertension, Mantoux reaction, consultation of a phthisiatrician.
Recommended:
5. Consultation of a phthisiatrician at the place of residence.
6. Continue treatment in the conditions of the cardiology department.
7. Correction of ongoing therapy ONLY after consulting a cardiologist!
8. Continue taking:
a. Tab. Prednisolone 5 mg - 6 tab. (30 mg) in the morning, crush, drink jelly.
b. Tab. Nurofen 0.4 x 1 t. 1 r / day - 2 weeks;
c. Tab. Kordaron 0.2, 1 t. 2 r / day, after 1 week, 1 t. 1 r / day - during the week;
d. Caps. Omeprazole 0.02 1 caps. 2 times a day - 2 weeks;
e. Caps. Mildronate 0.25 2 caps. 2 r / day - one month.
f. Tab. Metronidazole 0.5 for 1 t. 3 r / day - 2 weeks.
g. Tab. Enalapril 0.005 - ½ tab (2.5 mg) in the evening.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1943
She was on inpatient treatment in the clinic of hospital therapy
Total days of treatment were 14
The final diagnosis was established
ICD Code I 50.0; MES 291110
Diagnosis:
IHD: stable exertional angina 3 FC. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and large-focal post-infarction (of unknown age) cardiosclerosis.
Hypertensive disease of the third stage (arterial hypertension of the 3rd degree, the risk of cardiovascular complications is “very high”)
Chronic heart failure of the 2B stage, IV → III functional class. Recurrent attacks of cardiac asthma. Anasarca (edema, small right-sided hydrothorax). Congestive pneumonia in the lower lobe of the right lung. Cardiac fibrosis of the liver.
Autoimmune thyroiditis, diffuse nodular form, overt hypothyroidism
Mild type 2 diabetes mellitus, HbAc 6.88%, target HbAc<7.5%.
Android obesity 2 degrees, stable phase.
Chronic obstructive pulmonary disease, bronchitis type, moderate course, in the acute stage, DN-1 stage.
Dyscirculatory encephalopathy of the second stage of mixed (hypertensive, post-stroke (CVA according to the ischemic type in the LMMA pool from 12/31/2008), atherosclerotic, dysmetabolic) genesis.
Secondary nephropathy of mixed (atherosclerotic, hypertensive, metabolic) genesis. Chronic kidney disease C4 Ax stage (GFRCKD-EPI 28 ml/min). Chronic renal failure stage 1B. Secondary normochromic anemia of mild severity.
Cholelithiasis stage III. Chronic calculous cholecystitis, remission.
Degenerative-dystrophic disease of the spine.
Post-injection phlebitis of the cubital veins of the left upper limb
Disability certificate: not issued
Total radiation dose 0.78 mSv
Clinical outcome: improvement.
Outcome: discharged.
On admission:
Complaints: increasing dyspnea at rest of a mixed, mostly inspiratory nature, paroxysmal cough without discharge, increasing pronounced general weakness, swelling of the legs to the hips.
History of present illness. For a long time suffers from coronary heart disease, hypertension, obesity, COPD. Since 2010, diabetes. The working figures for blood pressure are 160/100 mm Hg. does not take regular therapy. With an increase in blood pressure, he takes nifedipine. In 2008, she suffered an ischemic stroke in the LCMA pool in the form of right-sided hemiparesis, mild cortical dysarthria, and partial right-sided hemihypesthesia. In 2010, he was diagnosed with large-focal post-infarction cardiosclerosis, chronic renal failure stage 2, CKD stage 3. During the last year, she notes a significant deterioration in the form of increased edema, shortness of breath. From the beginning of September, the edema increased significantly, she independently took veroshpiron, furosemide with a short-term positive effect. Recently, she slept sitting up, with difficulty moving around the house on her own. Outpatient took digoxin 0.5 tab./day, furosemide. Over the past few days, there has been a significant increase in dyspnea at rest. Given the progressive deterioration of her condition, she was hospitalized at the hospital therapy clinic for further diagnosis and treatment.
Objective examination data. Height 157 cm, body weight 93 kg, BMI 37.7 kg/m2. The general condition is severe, due to signs of multiple organ (cardiopulmonary and renal failure, dyscirculatory encephalopathy, disorders of thyroid and carbohydrate metabolism) Hypersthenic physique. Obesity II degree. The skin is earthy-yellow, dry, icterus of the sclera, mucous membranes. Tension swelling of the legs to the level of the waist, trophic changes in the skin of the feet. Peripheral lymph nodes are not enlarged. The thyroid gland on palpation is enlarged, compacted, heterogeneous. Pulse 82 per minute, rhythmic. AD - 150/90 mm. rt. Art. heart sounds are deaf, rhythmic, weakening of the first tone at the apex, systolic murmur at all points of auscultation with a maximum in the projection of the mitral valve. On auscultation of the lungs, breathing is rough, against the background of multiple dry rales scattered over all fields in the lower sections, moist, finely bubbling rales are heard on both sides. Resting respiratory rate 22/min. The abdomen is enlarged in volume due to the subcutaneous fat layer, the correct shape. The edge of the liver +4 cm from under the costal arch. The size of the liver according to Kurlov is 16x14x9 cm.
As a result of the treatment: regimen, diet No. 9, amlodipine, carvedilol, levothyroxine, metabolic therapy, furosemide (with a switch to diuver), berodual, ceftriaxone, lazolvan, heparin, cardionate, the state of health improved. The maximum possible compensation of the functions of internal organs and systems was achieved.
Results of instrumental studies:
ECG dated 10/10/2013: sinus rhythm with a heart rate of 70/min, EOS is indeterminate due to the presence of large-focal cicatricial changes in the area of the lower wall (qII; avF; QIII). Incomplete stem blockade of the left leg of the bundle of His (QRS 0.105 s). Hypertrophy of the left chambers of the heart, diffuse repolarization disorders, diastolic overload of the left ventricle.
ECG No. 825 dated October 18, 2013: sinus rhythm with a heart rate of 60/min, EOS is indeterminate due to the presence of large-focal cicatricial changes in the region of the lower wall (qII; avF; QIII). Incomplete stem blockade of the left leg of the bundle of His. Hypertrophy of the left chambers of the heart, diffuse repolarization disorders, diastolic overload of the left ventricle. In the dynamics, there are positive changes in the form of reversion of the T waves V1-3, approaching the isoline of the ST segment V4-6
ECHO-KG from 10/14/2013: Aorta (root) 33 mm, LV 60/45 mm, MZhVlzh = ZSlzh 12.8 mm, IMMLV 219 g/m2, EF 50%, FVlzh 25%, LA 48 × 58 × 60 mm, PP 54 ×58mm, RV 30 mm, RV free wall 6 mm. Symmetrical eccentric myocardial hypertrophy, hypokinesia of the posterior wall in the basal and middle sections. The atrial and left ventricular cavities are moderately dilated. Aorta, fibrous rings of AK and MK are sealed with the inclusion of calcifications. Calcifications in the structure of the posterior cusp of the MV and the non-coronary crescent of the AV do not limit their opening. The blood flow on the valves is laminar, LV diastolic dysfunction II (pseudo-normal) type. Pulmonary hypertension 1 degree. In the right pleural cavity in the sinus region, free fluid is located up to the level of the 9th rib along the scapular line.
X-ray of the chest organs in direct and lateral projections from 10/15/2013. The pulmonary fields are emphysematous, the pulmonary pattern is strengthened and deformed due to pneumofibrosis and venous congestion. The roots of the lungs are compacted and expanded due to the vessels. Pleural cords in the supradiaphragmatic regions on both sides. The diaphragm is sealed, free fluid in the pleural cavities is not detected. The heart is in a horizontal position, expanded in diameter to the left.
FVD dated 10/18/2013. VC 47%, FEV1 50% moderate-to-severe disorders (St. III) VFL by restrictive type. Bronchodilation coefficient 5.8%.
Ultrasound of the abdominal organs from 10/17/2013.
Liver
Enlarged, the right lobe is 17.5 cm, the left lobe is 10.8 cm, the contours are even, the structure is homogeneous, the echogenicity is significantly increased, the vascular pattern is preserved .
The gallbladder is
5.2 * 3.0 cm, the contours are uneven, the walls are 3 mm, the contents are calculi , common bile duct 0.3 cm
Pancreas
Clearly located, 24.0 * 20.5 * 19.0 mm, echogenicity is significantly increased, Wirsung's duct is not dilated, 2 mm
Kidneys
Right kidney: 9.8 * 5.6 cm, parenchyma homogeneous, 22.0 mm, microliths. Left kidney: 11.0*4.7 mm, homogeneous parenchyma 19.0 mm
Adrenal glands
No pathological formations detected
Spleen
12.5*6.4 cm, homogeneous structure
Conclusion: diffuse changes in the liver, pancreas. JCB. Thinning of the parenchyma of the left kidney. Microliths of the right kidney.
Ultrasound of the thyroid gland from 10/17/2013.
Right lobe
26.2*31.8*48.0 cm. Volume 18.4 cm3.
Left lobe
23.0*27.0*43.0 cm. Volume 14.0 cm3.
Isthmus
7 mm.
The total volume
is 32.3 ml. The structure is heterogeneous, multiple hypo- and hyperechoic areas. In the area of the isthmus, an isoechoic formation with clear, even contours with a diameter of 11.0 mm is located. The blood flow is moderately increased. Regional lymph nodes are not enlarged.
Conclusion: hyperplasia of the thyroid gland. Ultrasound signs of autoimmune thyroiditis.
Results of laboratory tests
Complete blood count
Date
11.10.2013
21.10.2013
Hb, g/l.
106
100
Erythrocytes *1012/l
3.65
3.49
Leukocytes *109/l
8.5
6.7
Myelocytes
1
-
ESR, mm/h
35
50
Eosinophils %
2
-
Basophils %
1
-
Lymphocytes %
16
22
Monocytes %
6
7
Band %
5
7
Segmented %
74
64
Urinalysis
Date
15.10.11.g
Color
Yellow
Transparency
Transparent
Density
1010
pH
5.5
Protein (g/l)
Neg.
Leukocytes
2-3 in p / c
Erythrocytes
None
Glucose
4.4 mmol / l
daily loss of protein
Diuresis 2100 ml, protein was not detected
Nechiporenko test: L 3.25x106 / l, E 0.75x106 / l
Biochemical analysis of blood:
Name
Unit of measure.
Norm
11.10
14.10
22.10
Urea
mmol/l
2.5-6.4
18.4
27.0
24.6
Glucose
mmol/l
4.2-6.4
7.24
5.5
6.08
Creatinine
mmol/l
0.05-0, 12
160
250
230
O. protein
g/l
63-87
71
73.5
71
Albumin
g/l
30-55
41.9
globulins
g/l
17-35
32
Potassium
mmol/l
3.50-5.10
5.29
5.75
5.31
Sodium
mmol/l
136-145
142.2
142.3
Chlorine
mmol/l
98-107
111.7
Triglycerides
mmol/l
0-2.3
1.34
Cholesterol
mmol/l
3.7-6 ,0
3.4
b-lipoproteins (LDL)
ED
350 - 650
400
LDL
mmol/l
1.9-4.4
1.81
VLDL
mmol/l
0.6-1.2
0.61
HDL
mmol/l
0.78- 2.303
0.98
coefficient atherogenicity
units.
0.0-3.0
2.47
AST
U/l
11.0-50.0
10
ALT
U/l
11.0-50.0
24
LDH
U/l
120-246
214
CPK
U/l
10.0-160.0
CPK –MV
U/l
0.0-25.0
o.
bilirubin mmol/ l 6.8-26
6.1
ex
. bilirubin
mmol/l
0.0-7.0
3.4
Amylase
U/l
30-115
Alkaline phosphatase
U/l
45-120
56
GGTP
U/l
8- 63
72
Prothrombin
%
70-130
92
Fibrinogen
Mg/dl
200-400
539
TSH
mIU/ml
0.3-4.0
75.10
TG
ng/ml
0-50
AT to TPO
mIU/ml
up to 30
AT to TG
mIU/ml
up to 100
T4 total
nmol/l
52-155
36
T4 free
pmol/l
10-25
T3 total
nmol/l
1.2-3.0
T3 free
pmol/l
4.0-8.6
Glycated hemoglobin
%
4.0-6.5
6.33
C-reactive protein
mmol/l
0-5.0
101 ,8
HBsAg, anti-HCV, serological tests for syphilis, F-50 10/14/2013. negative.
Capillary blood for glucose from 10/14/2013. 8-00 4.9 mmol/l, 10-00 5.6 mmol/l, 12-00 5.1 mmol/l
The goals of therapy were achieved: manifestations of chronic heart failure, congestive pneumonia were stopped, the maximum possible compensation of the function of internal organs was achieved at this stage. organs and systems, the genesis of pronounced congestion was determined, and therapy was selected for the initial stage of outpatient treatment. In a satisfactory condition, he is discharged to the polyclinic at the place of residence under the supervision of specialist doctors.
Recommended:
57. Lifelong dispensary supervision of a nephrologist, endocrinologist, cardiologist at the place of residence.
58. Control study (at least once every 3 months): ECG, general blood and urine tests, blood tests for cholesterol, triglycerides, LDL, creatinine, potassium, urea, glucose.
59. Determination of blood levels of T3, T4, antibodies to thyroglobulin, cortisol, thyroid-stimulating hormone - 2 times a year, followed by correction based on the results of a dose of levothyroxine
60. Continuous monitoring of body weight !!! with an increase in body weight of more than 1 kg (in comparison with the discharge data), consultation with a cardiologist in order to exclude the worsening of the course of chronic heart failure and correct (if necessary) the therapy.
61. Diet: restriction of protein intake with food to 0.8-1 g / kg (up to 50-60 g per day), depending on the severity of renal failure. At the same time, 30 g should be a high-value protein, and only 10 g of protein per day should fall on the share of bread, cereals, potatoes and other vegetables. 30-40 g of complete protein. In general, the patient's menu is compiled within table No. 7. The following products are included in the patient's daily diet: meat (100-120 g), cottage cheese dishes, cereal dishes, semolina, rice, buckwheat, barley porridge. A potato and potato-egg diet is recommended. Particularly suitable due to their low protein content and at the same time high energy value are potato dishes (pancakes, meatballs, grandmothers, fried potatoes, mashed potatoes, etc.), salads with sour cream, vinaigrettes with a significant amount (50-100 g) of vegetable oil. Tea or coffee can be acidified with lemon, put 2-3 tablespoons of sugar in a glass, it is recommended to use honey, jam, jam. Thus, the main composition of food is carbohydrates and fats and dosed - proteins. Calculating the daily amount of protein in the diet is a must. It is allowed to replace 1 egg with: cottage cheese - 40 g; meat - 35 g; fish - 50 g; milk - 160 g; cheese - 20 g; beef liver - 40 g.
Approximate diet:
• Breakfast: Soft-boiled egg + Rice porridge 60 g + Honey 50 g
• Lunch: Fresh cabbage soup 300 g + Fried fish with mashed potatoes 150 g + Apples
• Dinner: Mashed potatoes 300 g + Vegetable salad 200 g + Milk 200 d
Correction of water balance disorders: take enough liquid to maintain diuresis in the range of 1.5-2.0 liters per day.
Correction of electrolyte imbalance: salt intake should be limited to 5 g per day
62. Continue taking:
• Amlodipine 5 mg - 1 tab. in the morning constantly;
• Carvedilol 12.5 mg - ½ tab. 2 times a day;
• Torasemide (Diuver) 10 mg - 1 tab. in the morning;
• L-thyroxine 50 mcg - 2.5 tab. (125 mcg) in the morning;
• Spiriva - n 1 capsule through an inhaler 1 time per day;
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1978
He was in the day hospital regime
at the hospital therapy clinic Departed from the VMA
Total days of treatment 11
The final diagnosis was established ICD code I 10 (MES 291250)
Diagnosis:
Hypertension stage I (arterial hypertension 2, the risk of CVE is medium). Chronic heart failure I functional class.
Sliding hernia of the esophageal opening of the diaphragm of the second degree. Distal catarrhal reflux esophagitis, hernial gastritis of the proximal stomach.
Peptic ulcer of the duodenum, HP-associated frequently relapsing form, in the acute phase in the form of erosive bulbitis. Cicatricial deformity of the duodenal bulb without disturbing the evacuation function.
Diffuse-nodular goiter of the first degree, euthyroidism.
Certificate of incapacity for work issued no.
Ability to work restored
Total radiation dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity
, disability, established _____ disability group, degree of disability _______________________________, other _____________________________________________ where) _____________________________________________________________________________
Examined by MSEC: yes / no
On admission:
Complaints: headache with an increase in blood pressure to 160/100 mm Hg, palpitations, fatigue, weakness; discomfort in the epigastric region, heartburn.
History of present illness. Over the past 6 years (the patient associates with frequent stressful situations) notes frequent episodes of headache, increased blood pressure to 160/100 mm Hg, constant feeling of rapid heartbeat. He considers the working values of blood pressure to be 130-140 / 80-95 mm Hg. He was not examined, he independently took Andipal on demand (“a pill in his pocket”). Over the past year, arterial hypertension has assumed a permanent stable character, general weakness and fatigue began to increase. October 22, 2013 independently applied to the clinic at the place of residence, from the same day a sheet of temporary disability (outpatient treatment) was opened. Appointed Enalapril 5 mg 2 times a day. Despite ongoing therapy, increasing the dose to 20 mg/day, complaints persisted.
From the age of 21, he notes the appearance of pain in the epigastric region with errors in the diet, spring and autumn. Repeatedly passed inpatient treatment for exacerbations of duodenal ulcer. The development of cicatricial deformity of the bulb against the background of a frequently recurring form of duodenal ulcer was the reason for dismissal from the ranks of the Armed Forces of the Russian Federation in 2004. Over the past 7 years, regularly 2 times a year, conducts courses of antiulcer therapy with a moderate positive effect in the form of reducing the intensity and duration of abdominal pain. FGDS control has not been performed since 2006. The last aggravation, according to the words, was in March 2013.
In December 2004, he suffered from destructive pneumonia with a decay site in the region of the lower lobe of the left. From the proposed lobar pulmonectomy (from the words) refused. Later, an emphysematous transformation of this area was formed, without dynamics in the period from 2005 to 2008. was not observed.
Objectively at admission: Height 177 cm. Body weight 86 kg. BMI=27.5 kg/m2. The general condition is satisfactory. Correct physique. Visible mucous membranes are clean, of normal color. Posture is not broken. The load along the axis of the spine is painless. Movement in all parts of the spine is not limited. The thyroid gland is not visible, palpation is not changed. Heart rate 72 per minute. Blood pressure 150/90 mm Hg. Art. The boundaries of relative cardiac dullness were not changed. Heart sounds are clear and pure. Above the lungs percussion clear pulmonary sound. Breathing is vesicular, no wheezing. The respiratory rate is 16 in 1 minute. The abdomen is soft, painful on palpation in the epigastric zone and the Shofarr point. The liver and spleen are not enlarged. The kidneys are not palpable. Tapping on the lumbar region is painless on both sides.
As a result of the treatment: regimen, diet No. 1, noliprel-forte, metabolic and diuretic therapy, de-nol, omeprazole, almagel, eradication therapy, the state of health improved.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
29.10
147
4.55
9.5
44.3
4
271
3
35
6
1
55
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
29.10
full
1025
light yellow
5.5
no
no
oxalate
no
no
no
0-1
no
0-2
0-1
daily urine: urea 506 mmol/l, creatinine 20 mmol/l, albumin 20.6 units (up to 14 units)
Biochemical analysis of blood:
Name
Unit of measure.
Norm
29.10
Urea
mmol/l
2.5-6.4
4.4
Glucose
mmol/l
4.2-6.4
4.94
Creatinine
mmol/l
0.05-0.12
0.09
O. protein
g/l
63-87
70
Albumin
g/l
30-55
48
globulins
g/l
17-35
28
Potassium
mmol/l
3.50-5.10
4.47
Sodium
mmol/l
136-145
140.7
Chlorine
mmol/l
98-107
106
Triglycerides
mmol/l
0-2.3
1.7
Cholesterol
mmol/l
3.7-6.0
5.81
b-lipoproteins (LDL)
ED
350-650
600
LDL
mmol/l
1.9-4.4
3, 31
VLDL
mmol/l
0.6-1.2
0.78
HDL
mmol/l
0.78-2.303
1.72
coefficient atherogenicity
units.
0.0-3.0
2.38
TSH
mIU/ml
0.3-4.0
1.73
T4 free
mg/dl
4.5-15
7.4
Results of instrumental studies:
FGDS from 10/29/2013: The esophagus is freely passable. Prolapse of the gastric mucosa into the esophagus is noted. The Z-line is above the crura of the diaphragm, clear, in the distal section, the mucosa is edematous, hyperemic, due to reflux. Folds of the stomach of the usual caliber. In the upper third of the stomach, the mucosa is hyperemic and edematous. In other departments pink, in the antrum with focal atrophy. The pylorus does not close completely, there is a reflux of duodenal contents. The bulb of the duodenum is deformed due to cicatricial changes. The mucosa is edematous, inflamed due to single flat-inflammatory and petechial erosions up to 2-3 mm. Conclusion: 2nd degree collapsing hiatal hernia, distal catarrhal reflux esophagitis, hernial proximal gastritis with focal atrophy of the distal segment. Duodeno-gastric reflux. Cicatricial deformity of the duodenal bulb, erosive bulbitis. Urease test strongly positive (+++)
ECHO-KG dated October 30, 2013. IVS=WS=10.5 mm, LV 55/38 mm, EF 56%, FU 28%, VR 80 ml, LA 39 mm, PP 40 mm, aorta 36 mm, aortic dilatation 21 mm, e/a 1.4 The myocardium is not thickened, the kinetics is not disturbed, the cavities are not enlarged, free. Aorta, valves, pericardium are not changed. Systolic and diastolic functions are not disturbed.
Ultrasound of the abdominal organs from 28.10.2013.
The liver
is enlarged, the right lobe is 16.6 cm, the left lobe is 7.8 cm, the contours are even, the structure is homogeneous, the echogenicity is increased, the vascular pattern is depleted .
The gallbladder
is 4.8x3.8 cm, the contours are uneven, the walls are 4 mm, the contents are
homogeneous
. clear, 24.4*18.0*20.0 mm, moderately increased echogenicity, Wirsung's duct is not dilated, 2 mm
Kidneys
Right kidney: 10.2x6.0 cm, homogeneous parenchyma, 18.0 mm. Left kidney: 11.5 * 6.8 mm, homogeneous parenchyma 18.0 mm
Adrenal glands
No pathological formations were detected
Spleen
9.2x4.2 cm, homogeneous structure
Conclusion: diffuse changes in the liver, pancreas.
Ultrasound of the thyroid gland from 28.10.2013.
The right lobe
is 18.0x33.2x51.4 cm. The volume is 16.2 cm3.
Left lobe
16.6x20.3x41.8 cm. Volume 9.1 cm3.
Isthmus
5.5 mm.
The total volume
is 25.3 ml In the right lobe, an isoechogenic formation with clear, even contours is located D1=7.8x11.4mm, D=3.8x4.0mm. In the left lobe isoechoic formation 14.5x7.2 mm. The blood flow is not enhanced. Regional lymph nodes are not enlarged.
Conclusion: hyperplasia of the thyroid gland. thyroid nodules.
No pathological formations were revealed on the chest radiograph dated November 1, 2013.
The goals of hospitalization have been achieved. Employment has been restored. Discharged for work, return to work 09.11.2013. A certificate of incapacity for work was issued from 28.10.2013. to 08.11.2013 for the period of treatment
It is discharged in a satisfactory condition under the supervision of a polyclinic therapist.
Recommended:
63. Dispensary observation of a polyclinic therapist,
64. Control of FGDS after 2 weeks with a test for HP (assessment of the effectiveness of eradication therapy).
65. Consultation with an endocrinologist in a planned manner,
66. Continue taking:
f. Caps. Omeprazole 0.02 1 capsule in the evening for 2 weeks.
g. Caps. Linex 1 capsule 3 times a day for 10 days.
h. Noliprel A biforte 10/1.25 1 tab. in the morning.
67. Limit the consumption of animal fats, fried and spicy foods, increase the amount of vegetable fiber, vegetable fats, products in the diet.
68. Course of antiulcer therapy during autumn-spring exacerbations:
a. Caps. Omeprazole 0.02 1 capsule 2 times a day for 4 weeks.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr., 63 tel. (812) 577-11-35
EXECUTIVE SUMMARY
CASE HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1948
Was on inpatient treatment (in the day hospital mode)
in the hospital therapy clinic
Total days of treatment were 7
The final diagnosis was established ICD code I.48 MES 291180
Diagnosis: Generalized atherosclerosis.
Coronary artery disease. Angina pectoris II functional class. Atherosclerosis of the aorta, coronary and cerebral arteries, atherosclerotic cardiosclerosis with arrhythmias of the type of paroxysmal atrial fibrillation. Paroxysm of atrial fibrillation, tachysystolic variant of 08.10.2013, stopped independently on 10.10.2013. Atherosclerotic aortic valve disease with a predominance of insufficiency (regurgitation of I degree). Mitral valve prolapse with grade I regurgitation.
Hypertensive disease stage II (arterial hypertension 1, the risk of CVE is high).
Chronic heart failure stage I, functional class II.
Chronic non-obstructive bronchitis. Diffuse moderate emphysema. DN-0.
Dyscirculatory encephalopathy stage II of hypertensive, atherosclerotic and vertebrogenic genesis in the form of right-sided pyramidal-cerebellar insufficiency and pseudoneurotic syndrome.
Polysegmental intervertebral osteochondrosis and deforming spondylosis, uncovertebral arthrosis of the cervical and lumbar spine with pain syndrome. Cervical-thoracic sciatica with C6-radicular syndrome on the right. Angiotrophoneurosis of the upper extremities stage I, without impaired circulation and function.
Chronic gastroduodenitis in the phase of unstable remission.
Deviation of the nasal septum. Bilateral sensorineural hearing loss (initial manifestations).
Presbyopia.
Certificate of incapacity for work: 102 207 201 045.
Ability to work restored
Total exposure dose 0.26 mSv
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, _____ disability group, degree of disability _______________________________, other _____________________________________________
Outcome: discharged according to a report, discharged on improvement, discharged on recovery, transferred to another medical institution (what) ____________________, transferred to rehabilitation treatment (where) _____________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service, unfit for service in the military specialty, discharged to the unit without a medical
examination
.
Complaints: episodes of weakness, palpitations, shortness of breath; for heaviness and headache in the occipital region, severe weakness, fatigue against the background of an increase in blood pressure to 160/100 mm. rt. Art. (normal value of blood pressure 130/80 mm. rdest.) for interruptions in the work of the heart; memory loss, sleep disturbance; to increase urination; weakness in the lower extremities; pain in the thoracic and lumbar spine: pain in the left knee joint.
Anamnesis of the disease: Since 1990, pain in the region of the heart has been disturbing, IHD has been diagnosed on an outpatient basis, angina pectoris I f. class In 1992, a paroxysm of atrial fibrillation developed, which was stopped by the introduction of novocainamide. Subsequently, paroxysms of atrial fibrillation regularly recurred, stopped on their own, took verapamil with panagin, in the absence of effect, an ambulance brigade was called. Headaches with increased blood pressure appear since 1995, took ACE inhibitors. In the future, he was repeatedly treated in a hospital with a diagnosis of coronary artery disease, angina pectoris II f. class, rhythm disturbance by type of paroxysmal atrial fibrillation. Hypertension II stage. NC I Art. For more than 20 years he has been suffering from chronic gastroduodenitis, EGDS - in the spring of 2004. For fifteen years he has been suffering from intervertebral osteochondrosis and deforming spondylosis of the cervical and lumbar spine, and has been treated on an outpatient basis and in sanatoriums. After a business trip to Antarctica, numbness and blanching of the fingers in the cold are disturbing. Angiosurgeon diagnosed angiotrophoneurosis of the upper extremities, was treated on an outpatient basis, took courses of vascular drugs. For 7 years, she has noted a significant deterioration in memory, sleep disturbance, increased dizziness, unsteady gait, a neurologist diagnosed dyscirculatory encephalopathy, and takes nootropic drugs. Diagnosed with hemorrhoids for 25 years, for 5 years - frequent bleeding from hemorrhoids, in October 2004 operated on - excision of hemorrhoids. After surgical treatment, body weight decreased by 10 kg. In the spring of 2004, the FCS was performed, no neoplasms. In 2002, he was examined by the VVK, recognized as partially fit for military service. In 2003 and 2004, a limitation of the ability to work was revealed, certified by MSEK: IHD. Angina pectoris III f. class Atherosclerosis of the aorta, coronary and cerebral arteries, atherosclerotic cardiosclerosis with rhythm disturbances by the type of paroxysmal tachysystolic atrial fibrillation. Atherosclerotic defect of the aortic valve with a predominance of insufficiency (regurgitation of the I degree). Mitral valve prolapse with grade I regurgitation. Hypertension stage II (AH II, risk IV). Dyscirculatory encephalopathy stage II of hypertensive, atherosclerotic and vertebrogenic genesis. CHF II f. class Right-sided pyramidal-cerebellar insufficiency. Slight dysfunction of the spine. Slight dysfunction of the right upper limb. pseudoneurotic syndrome. Chronic non-obstructive bronchitis. Diffuse moderate emphysema. DN-0. Polysegmental intervertebral osteochondrosis and deforming spondylosis, uncovertebral arthrosis of the cervical and lumbar spine with pain syndrome. Cervical-thoracic sciatica with C6-radicular syndrome on the right. Angiotrophoneurosis of the upper extremities stage I, without impaired circulation and function. Chronic gastroduodenitis in remission. Deviated septum of the nose. Bilateral sensorineural hearing loss (initial manifestations). Presbyopia. Later in 2006 and 2007 was treated permanently in the clinic of GT VMedA for paroxysms of atrial fibrillation, successfully stopped. After discharge in 2007, he was prescribed and constantly took Concor 5 mg / day, panangin courses. Against this background, paroxysms did not recur, blood pressure at the level of normotension. Deterioration of condition from 08.10.2013, when, after physical exertion (running after the bus), severe weakness and shortness of breath appeared against the background of “palpitations”. Independently took 3 tab. panangin and 10 mg of concor without a positive effect. On 09.10.2013, he applied to the Central Clinical Laboratory of the Medical Academy of Medicine, ECG registered atrial flutter 2:1, 3:1. He refused hospitalization. On October 10, 2013, he independently applied to the HT VMedA clinic, was hospitalized for urgent indications. On 09.10.2013, he applied to the Central Clinical Laboratory of the Medical Academy of Medicine, ECG registered atrial flutter 2:1, 3:1. He refused hospitalization. On October 10, 2013, he independently applied to the HT VMedA clinic, was hospitalized for urgent indications. On 09.10.2013, he applied to the Central Clinical Laboratory of the Medical Academy of Medicine, ECG registered atrial flutter 2:1, 3:1. He refused hospitalization. On October 10, 2013, he independently applied to the HT VMedA clinic, was hospitalized for urgent indications.
Objective status Condition is satisfactory. The elasticity of the skin is reduced. The physique is correct, corresponds to age and sex. Normosthenic constitution. Subcutaneous tissue of a homogeneous consistency. There are no edema and pastosity. The hairline is developed according to age and sex. Gray hair, dull nails. The shape of the neck is not changed, the contours are even. Thyroid gland: not visually determined. Lymph nodes are not enlarged, painless. The muscular system is developed satisfactorily, muscle tone is preserved, strength in the upper and lower extremities is sufficient. The pulsation of the dorsal arteries of the feet and popliteal arteries is normal. Reticular varicose veins of the lower extremities are determined.
.
Lab Results:
CBC:
Date
Hb, units
Er., *1012/l
Leuk., *109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
11.10.2013
133
5.03
5.3
26.4
11
4
0
28
6
2
60
Biochemical blood test: dated October 11, 2013 Urinalysis dated October 11, 2013
Name
Unit of measure.
Norm
Index
11.10
Creatinine
umol/l
53-124
100
Color
Light Yellow
Cholesterol
Mmol
/l
3.7-6.0
5.50
Transparency
Triglycerides
Mmol/l
0-2.3
2.19
Specific. weight
1020
Total protein
G/l
63.0-87.0
66
Reaction
5.0
Potassium
Mmol/l
3.5-5.1
4.42
Protein (g/l)
No
Sodium
Mmol/l
130-150
140.9
Sugar
No
Glucose
Mmol/l
4.2- 6.4
6.4
Urobilin
3.2
Prothrombin
%
70-130
Leukocytes in p/s
3-4
Fibrinogen
Mg/dl
200-400
258
Erythr. in p/sp
No
AST
U/l
11.0-50.0
17.5
Erythr. vysch. in p/w
No
ALT
U/l
11.0-50.0
16.7
Salts
No
LDH
U/l
200-400
Mucus
2
CPK
U/l
10.0-160.0
72
Urea
Mmol/l
3.0-8, 3
o. bilirubin Mmol
/l
6.8-26
8.5
b-lipoproteins
AU
350 - 650
660
VLDL
Mmol/l
1.00
LDL
Mmol/l
3.50
Albumin
g/l
30.00-55.00
51.45
Amylase
U/l
30-115
115
CPK
U/l
10-160
72
Alkaline phosphatase
U/l
45-120
96
HDL
Mmol/l
0.78-2.30
1.00
CPK –MV
U/l
0.0- 25.0
23.1
Investigation of excrement from 10.11.2013: Macroscopic examination Color brown; Consistency designed; Slime 0; Blood 0; Pus 0. Microscopic examination: Muscle fibers are digestible 1-2; Muscle fibers not digested 0-1; Vegetable fiber digested 0; Vegetable fiber not digested 1; Starch grains intracellular 0; Starch grains extracellular 1-2; Iodophilic flora 0; No helminthic eggs were detected
. Thyroid hormones dated 11/10/2013: T4(b.), TSH, T3(b.), antibodies to TPO and TP are normal
Results of instrumental studies:
ECG from 09.10.2013: atrial fibrillation. Normal position of the heart of the electrical axis of the heart. Violation of repolarization processes in the region of the upper lateral wall. indirect signs of left ventricular hypertrophy.
ECG dated 10/10/2013: Sinus bradycardia with a heart rate of 55 per minute. Normal position of the EOS.
Ultrasound examination of the abdominal organs dated 10/11/2013: the liver is not enlarged, the right lobe is 14.0 cm, the left lobe is 6.1 cm; echogenicity is moderately increased, the vascular pattern is preserved, the vessels are not dilated, the intrahepatic bile ducts are not dilated, there are no mass formations. The gallbladder was of regular shape, dimensions 5.8 x 2.0 cm, smooth contours, walls 4 mm, intracavitary formations were not detected. The pancreas is not clearly located, not enlarged, the head is 21.2 mm, the body is 17.5 mm, the echogenicity is increased, the structure is heterogeneous, with fibrous inclusions, the Wirsung duct is not expanded, 2 mm. The spleen is enlarged 10.3 x 4.7 cm, homogeneous. Kidneys: right - typical location, dimensions 9.1 x 4.1 cm, homogeneous parenchyma 17.1 mm, pyelocaliceal system is not expanded; left - typical location, smooth contours, dimensions 11.2 x 5.5 mm, parenchyma homogeneous 20.6 mm. The thyroid gland is not enlarged, the contours are clear, even, the structure is homogeneous. Isthmus 4 mm. Right lobe: width 20.2mm; thickness 20.4mm.; length 44.0mm; volume 9.5 mm. Left lobe: width 20.0 mm; thickness 14.0 mm; length 44.0 mm; volume 6.2 mm. In the right lobe, an aneochogenic formation is located, d <1 cm, with clear, even contours. The blood flow is not enhanced. Peripheral lymph nodes are not changed. Conclusion: Diffuse changes in the liver, pancreas, Nodules of the right lobe of the thyroid gland. with clear, even contours. The blood flow is not enhanced. Peripheral lymph nodes are not changed. Conclusion: Diffuse changes in the liver, pancreas, Nodules of the right lobe of the thyroid gland. with clear, even contours. The blood flow is not enhanced. Peripheral lymph nodes are not changed. Conclusion: Diffuse changes in the liver, pancreas, Nodules of the right lobe of the thyroid gland.
Ultrasound examination of the pelvic organs 15.10.2013. The bladder is filled with 320 ml. The contours are clear, even, the walls are not thickened. The content is uniform. The prostate gland is located in a typical place, the contours are not clear, not even, the structure is with light hyperechoic and hypoechoic areas. Dimensions: 20.8 x 55.0 x 31.6 mm V = 27.1 ml. The volume of residual urine is 30 ml.
Fluorography of the organs of the chest cavity from 10/15/2013: The organs of the chest cavity within the limits of age-related changes.
Echocardiography on 10/14/2013: Sinus rhythm. The leaflets of the aortic valve are sealed and calcified. Dilatation of the aortic root. Eccentric hypertrophy of the left ventricle with dilatation of its cavity. Dilatation of the cavity of the left atrium. The cavities of the heart are free. The systolic function of the left ventricle is preserved. Diastolic dysfunction of the left ventricle of the rigid type. LV contractility (global and local) is not broken. Applied aortic regurgitation. Pericardium without features
Goals of hospitalization achieved. Discharged in a satisfactory condition under dispensary supervision of a cardiologist of the clinic.
Employment has been restored. Discharged for work, return to work on 10/18/2013. A certificate of incapacity for work was issued 102 207 201 045 from 10.10.2013. to 17.10.2013 for the period of treatment.
Recommended:
72. Observation by a cardiologist.
73. Consultation of a urologist in a planned manner
74. Observe the drinking regimen of 1-1.5 l/day; restriction of the use of table salt (no more than 3 g per day).
75. Limit the consumption of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes), protein (cottage cheese, veal) in the diet.
76. Continue taking:
a. Tab. Sotalol 80 mg 1 tab. 2 times a day.
b. Tab. Prestarium A 5 mg - ½ tab. once a day continuously
c. Tab. Mildronate 500mg - 1 tablet 2 times a day for 2 weeks.
d. Tab. Cardiomagnyl 75 mg - 1 tab. in the morning all the time.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1983
He was in the hospital therapy clinic
He left the VMA
Total days of treatment were 11
The final diagnosis was established “ICD Code F 45.3 KES 511069
Diagnosis:
Neurocirculatory asthenia of hypertensive type without heart failure. Dyslipoproteinemia IIa
Peptic ulcer of the duodenum, rarely relapsing course, remission phase. Cicatricial deformity of the duodenal bulb without disturbing the evacuation function. Alimentary obesity of the first degree (BMI 30.4 kg/m2), android form, stable stage.
A disability certificate was not issued.
Ability to work restored
Total exposure dose 0.26 mSv Clinical outcome (underline): recovery,
improvement
, no changes, chronicity, disability, _____ disability group
was established
Certified by MSEC: yes / no
On admission:
Complaints of headache mainly in the parieto-occipital region, increased blood pressure to 155/100 mm Hg, overweight.
History of present illness. During the last year against the background of increased psycho-emotional stress. He independently measured the level of blood pressure, which began to be labile with episodes of its increase during psycho-emotional stress. He did not apply for medical help, he did not undergo an in-depth medical examination. Peptic ulcer of the duodenum for 5 years. Last update in October 2012. In spring and autumn, on the recommendation of a gastroenterologist, he conducts courses of antiulcer therapy with a positive effect. Increase in body weight within 5 years, during the last 3 years the body weight is stable.
Objectively at admission: hypersthenic physique, overnutrition (BMI-30.4). Peripheral lymph nodes and thyroid gland are not enlarged. Movement in the joints of the limbs and the spine in full. Pulse 62 per minute, rhythmic. The borders of the heart are normal, the tones are clear, there are no murmurs. BP 130/90 mm Hg. Art. Respiration is vesicular. The abdomen is soft and painless. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology.
As a result of the treatment: regimen, diet No. 10, perindopril, idrinol, the state of health improved.
Laboratory results:
Complete blood count, urinalysis 01.10.2013: normal.
Biochemical blood test 01.10.2013: cholesterol 6.02 mmol/l, LDL 950U (norm up to 650U), ALT, glucose, AST, CPK, LDH, urea, uric acid, creatinine, total protein, potassium, sodium, chlorine, fibrinogen, PTI norm.
HBsAg, anti-HCV, serological tests for syphilis, F-50 02.10.2013 negative.
ECG 10/01/2013: sinus bradycardia with a heart rate of 52 per minute. The horizontal position of the EOS. Partial violation of intraventricular conduction. Violation of the repolarization of the lower wall of
the ECHO-KG from 02.10.2013. - the norm
of ultrasound of the OBP on 04.10.2013: liver, pancreas, portal vein, common bile duct, gallbladder, spleen, kidneys without pathology.
FLG 04.10.2013 without pathology.
Daily monitoring of blood pressure from 04.10.2013. mean blood pressure during the day 135/78 mm Hg. (time index 41% SBP and 6% DBP), mean BP at night 117/63 mm Hg. (time index 5%)
The goals of hospitalization have been achieved, the ability to work has been fully restored.
Discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
69. Observation of the doctor of the unit according to DM-1,
70. Normalization of the regime of work and rest. Exclude the use of animal fats, easily digestible carbohydrates, alcohol, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet. exercise therapy.
71. Observe the water regime (fluid balance), daily monitoring of blood pressure and heart rate.
72. Continue taking:
III. T. Prestarium A 5 mg ½ tab. in the morning.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1931
Was on inpatient treatment in the clinic of hospital therapy
Total days of treatment 10
The final diagnosis was established on October 04, 2013
ICD code I 50.1 MES 291110
Diagnosis: Ischemic heart disease. Stable angina pectoris III functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (1998, 2002) cardiosclerosis. Complete blockade of the right leg of the bundle of His. Dyslipoproteinemia type IIb.
Hypertensive disease stage III (drug normotension, the risk of cardiovascular complications is "extremely high").
Chronic heart failure stage II-A, functional class III.
Type 2 diabetes mellitus, HbAc 7.85%, target HbAc<7.5%.
Secondary nephropathy of mixed (atherosclerotic, hypertensive, metabolic) genesis. Chronic kidney disease C3a A1 stage (GFRCKD-EPI 55.4 ml/min).
operated thyroid gland. Right-sided hemistrumectomy (1971). Diffuse-nodular goiter I degree, clinically euthyroidism.
Chronic gastroduodenitis without exacerbation. Fatty hepatosis without impaired liver function.
Chronic pancreatitis without exacerbation.
Varicose disease. Varicose veins of the superficial veins of the legs. CVI 2nd degree
Android obesity of the 1st degree (BMI 32.7 kg/m2), stable course
Chronic anemia of mixed (B12-iron deficiency) genesis, compensated by medication
Disability certificate: not issued
Total radiation dose 1.4 mSv
Clinical outcome: improvement.
Outcome: discharged.
Upon enrolment:
Complaints: episodes of pressing pain behind the sternum that occur against the background of physical (tolerance was difficult to clarify) and psycho-emotional stress, including at rest, stopped by taking nitrosorbide; episodes of palpitations, shortness of breath during physical exertion (climbing one flight of stairs) and episodes of it at rest, significantly aggravated by physical exertion, dizziness, flickering of “flies” before the eyes, general weakness against the background of an increase in blood pressure to 180/100 mm Hg. ; frequent urination at night, the presence of varicose veins of both legs, heaviness in the legs; general weakness, malaise, increased fatigue.
History of present illness. According to him, he considers himself ill for 30 years, when, against the background of psycho-emotional stress, periodic pains in the region of the heart appeared, shortness of breath, aggravated by previously well-tolerated physical activity, general weakness against the background of an increase in blood pressure to 180/100 mm Hg. (working blood pressure 130/70 mm Hg). I saw a therapist in a clinic. No medical documentation provided. In 1998, according to the words, she suffered a myocardial infarction. She was treated on an outpatient basis. In 2003, according to the words, there were pressing pains behind the sternum that were not relieved by taking nitrosorbide, shortness of breath at rest. By ambulance, she was hospitalized in St. George's Hospital with a diagnosis of myocardial infarction. According to the words, against the background of ongoing therapy in the intensive care unit, the patient developed a clinical death with successful resuscitation. In 2005, according to A chest CT scan revealed pulmonary embolism. She was treated permanently in the clinic of the Military Medical Academy. No medical documentation provided. The last hospitalization in 2012 in the clinic of GT VMedA due to: “Ischemic heart disease. Angina pectoris III functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (1998, 2002) cardiosclerosis. Complete blockade of the right leg of the bundle of His. Frequent polytopic polymorphic ventricular and frequent polytopic supraventricular extrasystoles. Hypertensive disease stage III (drug-achieved normotension, the risk of cardiovascular complications is "extremely high"). Chronic heart failure stage II-a, functional class II. Diabetes mellitus type 2, mild severity. Secondary mixed nephropathy (atherosclerotic, hypertensive, metabolic) genesis. Chronic kidney disease stage III (GFRCKD-EPI 55.4 ml/min). Diffuse-nodular goiter I degree. Right-sided hemistrumectomy (1971), clinically euthyroidism. Chronic gastroduodenitis without exacerbation. Fatty hepatosis without impaired liver function. Chronic pancreatitis without exacerbation. mild hypochromic anemia. She is currently taking carvedilol, cardiomagnyl, liptonorm, L-thyroxine. Over the past 3 months, the patient's condition has worsened, in the form of an increase in pressing pain behind the sternum, blood pressure lability with a downward trend. In connection with the deterioration of health, she turned to the Military Medical Academy. Hospitalized for examination and treatment in the clinic in a planned manner. She arrived at the clinic unaccompanied by herself. According to 2008 Diabetes mellitus was revealed during the examination by the therapist in the polyclinic.
As a result of the treatment: regimen, diet No. 9, antihypertensive, metabolic, antianginal, lipid-lowering therapy, the state of health improved.
The results of instrumental studies:
ECG 01.10.2013: sinus rhythm, heart rate 70 per minute. Normal position of the EOS. Complete blockade of the right leg of the bundle of His. Cicatricial (focal) changes in the region of the lower (posterior) wall.
ECG 07.10.2013: sinus rhythm, heart rate 50 per minute. EOS is deflected to the left. Frequent ventricular extrasystole. Complete blockade of the right leg of the bundle of His. Blockade of the anterior branch of the left leg of the bundle of His
Echocardiography on 02.10.2013: left ventricle: VTRV (diastole) 9.6 mm, LV EDD 53.5 mm, LVEC (diastole) 9.6 mm, LV ESR 38.4 mm, LVMM 225 g, mass index LV myocardium 128 g/m2, OTC 0.34 units, fr. overshoot 53%, FU 28%, IVRT 60 ms. Aorta: annulus 24.5 mm, sinuses of Valsalva 31.8 mm, pulmonary artery 26.5 mm. Left atrium: transverse dimension 35.6 mm, anterior-posterior dimension 35.3 mm, longitudinal 39.3 mm. Right atrium: diameter 36.5 mm, longitudinal 42.5 mm. Right ventricle: CDR (middle) 28.9 mm, anterior wall 6.0 mm. Valve apparatus: mitral valve - Vmax E 0.84 m/s, Vmax A 0.47 m/s, E/A 1.8, gradient 2.8 mm Hg. st., regurgitation 1 st, DTe 111 ms; aortic valve - Vmax 1.15 m/s, gradient 5.3 mm Hg. Art., regurgitation 0 Art.; tricuspid valve - Vmax E 0.48 m/s, Vmax A 0.34 m/s, E/A 1.4, gradient 0.9 mm Hg. st., regurgitation 0 st., DTe 167 ms; pulmonary valve - Vmax 0.8 m/s, gradient 2.6 mm Hg. Art., regurgitation - 0 Art. The average systolic blood pressure in the pulmonary artery (AT / ET) 28 mm Hg. Art. Conclusion: the walls of the aorta are sealed. The leaflets of the aortic valve are sealed and calcified. Eccentric hypertrophy of the left ventricle with dilatation of the cavity. Systolic LV function is reduced. Total myocardial hypokinesia. Restrictive LV diastolic dysfunction. Pericardium without features. Doppler examination revealed no pathology. Systolic LV function is reduced. Total myocardial hypokinesia. Restrictive LV diastolic dysfunction. Pericardium without features. Doppler examination revealed no pathology. Systolic LV function is reduced. Total myocardial hypokinesia. Restrictive LV diastolic dysfunction. Pericardium without features. Doppler examination revealed no pathology.
Ultrasound of the abdominal organs on 10/03/2013: the liver is not enlarged, the right lobe is 15.0 cm, the left lobe is 5.5 cm, echogenicity is increased, the vascular pattern is _______. The portal vein is not dilated. Intrahepatic bile ducts are not dilated. Gallbladder: cholecystectomy in 2005. The pancreas is located indistinctly, blocked by bowel loops. The kidneys are located in a typical location, the contours are even, the dimensions of the right kidney are 9.6x4.3 cm, the left kidney is 9.8x4.6 cm, the parenchyma is homogeneous 14.0-14.0 mm, the PCL is not expanded, there are no calculi. The spleen is not enlarged, 8.6x4.6 cm, the structure is homogeneous. Thyroid gland: the right lobe and isthmus are not located. An isoechoic formation is visualized in the left lobe, with clear, even contours in d=14.3 mm x 13.7 mm with hyperechoic inclusions in d=3.2 mm. Conclusion: Condition after cholecystectomy. Diffuse changes in the liver.
X-ray of the chest organs on October 3, 2013: in the lungs without focal and infiltrative changes. Fibrous changes in the lung pattern in the root zone. The roots of the lungs are structural. The sinuses are free. The heart is in a horizontal position. The aorta is compacted, elongated and deployed.
Laboratory results:
Clinical blood test (hardware processing): Hb
date
, units.
Er., *1012/L
Le*109/L
Tr.,
109/L
HCT
PCT
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
02.10
116
4.85
6.0
380
373
273
29
1
0
35
7
1
58
Rt,
‰
MCV,
fl
MCH,
pg
MCHC,
g/l
RDW,
%
MPV,
fl
PDW
%
Lf
%
M,
%
Gra,
%
Lf,
109/l
M,
109/l
Gra,
109/L
---
77
23.9
310
15.4
7.2
14.4
39.4
7.3
53.3
2.3
0.4
3.3
07.10
Hb, units
Er
.
,
*
1012
/
L
Le
*
109
/
L
Tr
.
,
109
/
L
HCT
PCT
ESR
,
mm
/
h
_
_
_
34
10
1
51
Rt,
‰
MCV,
fl
MCH,
pg
MCHC,
g/l
RDW,
%
MPV,
fl
PDW
%
LF
%
M,
%
Gra,
%
Lf,
109/l
M,
109/l
Gra,
109/l
77
24.1
313
13.6
7.7
13.6
33.9
5.5
60.6
2.7
0.4
5.1 Complete
urinalysis (hardware processing):
Date
Sp. weight
Reaction
Protein
Sugar
Cylinders
Ketones
Lake
Er.neiz
Urobil
02.10
1025
5.5
traces
No
No
No
1-1-2
0-1-1
3.2
Biochemical blood test: 02.10.
Name
Unit
Norm
result
Total cholesterol
mmol/l
3.7-6.0
6.63
Triglycerides
u/l
120-246
3.20
Urea
mmol/l
2.5-6.4
4.7
Creatinine
mmol
0.05-0.12
0.10
Total bilirubin
µmol/l
6.8-26.0
11.8
direct bilirubin
µmol/l
0-7.0
2.5
Total protein
G/l
63-87.0
73
albumin
g/l
30-55
45.23
globulin ratio
17-35
28
Glucose
mmol/l
4.2-6.4
5.6-6.3-4.3
Prothrombin
%
70-120
93
Fibrinogen
g/l
2.-4.0
3.14
AST
U
/l
11-50.0
22
ALT
U/l
11-50.0
96
HDL
mmol/l
0.78-2.33
1.76
LDL ratio
1.9-4.4
,
3.4
VLDL
ratio
0.6-1 .2
1.47
KA
ratio 0-3.0
2.77
GGT
U
/L
8-63
27
LDH
U/L
120-246
213
A\G
ration
1.1-2.5
1.6
ALP
U/L
45-129
96
iron
mmol/l
20-250
15.7
Feces for worm eggs 02.10.2013: Not found.
Microreaction with cardiolipin antigen: negative.
AT-HIV ½: not detected.
Capillary blood glucose on September 23, 2013: 8:00-5.6 mmol/l, 10:00-6.3 mmol/l, 12:00-4.3 mmol/l.
Urinalysis according to Nechiporenko: Lei 25 * 109 / l
Recommended:
73. Observation of a therapist, endocrinologist at the place of residence.
74. Diet: increase in the diet beef meat, fish, liver, kidneys, lungs, eggs, oatmeal, buckwheat, beans, porcini mushrooms, cocoa, chocolate, herbs, vegetables, peas, beans, apples, wheat, peaches, raisins, prunes, herring, hematogen.
75. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
76. Limit the consumption of animal fats, spices; increase in the diet the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium.
77. Urinalysis according to Nechiporenko and blood test for serum iron level after 1 month
78. Continue taking:
a. Tab. Carvedilol 12.5 mg 1/4 tablet 2 times a day continuously.
b. Tab. Diuver 10 mg - 1 tablet daily in the morning.
c. Tab. Thrombo ACC 0.05 1 tablet in the morning constantly.
d. Tab. Akorta 0.01 1 tablet 1 time per day constantly.
e. Tab. Kanefron 1 tablet 3 times a day for 1 month
f. Tab L-thyroxine 25 mcg - ½ tablet in the morning constantly
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCUSSION (TRANSFER) EPICRISIS CASE
HISTORY №, ARCHIVE №_________
Last name, first name, patronymic
Was on inpatient treatment at the hospital therapy clinic
In total, 4 days of treatment were carried out .
The final diagnosis was established. ICD code
Diagnosis:
Main diagnosis: post-injection phlebitis of the superficial veins of the lower extremities. angiogenic sepsis.
Complications of the underlying disease: Primary infective endocarditis with lesions of the tricuspid valve in the active phase. CH-2 Bilateral embolic pneumonia. Right-sided small hydrothorax. DN 2-3 tbsp. Multiple post-injection granulating wounds of the lower extremities. Secondary anemia of moderate degree.
Background disease: chronic opiate addiction (heroin, methadone) severe. Chronic viral hepatitis C. Secondary immunodeficiency.
Certificate of incapacity for work was not
issued
Total exposure dose 0.78 mSv____________________________________________
Clinical outcome (underline): recovery, improvement, no changes, chronicity, disability, established _____ disability group, degree of disability _______________________________, other __
Outcome: discharged due to improvement, discharged due to recovery, transferred to another medical institution ), transferred to rehabilitation treatment (where) __________________________________________________________________________
Conclusion of the VVK (VLK): fit for military service, fit for military service with minor restrictions, limited fit for military service, temporarily unfit for military service (sick leave for ____ days must be granted, exemption for ___ days must be granted, unfit for military service,
unfit
for
service in the military specialty, discharged to the unit without medical examination. cough, shortness of breath, general weakness, headache.
Anamnesis of the present illness: Considers himself ill for about 10 last days, when, against the background of relative well-being, she felt a pronounced general weakness, noted episodes of a decrease in blood pressure to 90/80 mm Hg. Art. On the second day of illness, she noted an increase in body temperature up to 380C. Independently, on the recommendation of a polyclinic doctor, she made intramuscular injections of an antibacterial drug, the name is difficult to specify. On February 15, 2011, against the background of an increase in cough and shortness of breath, she called an ambulance. She was taken to the Alexander Hospital, which she left on her own the same day. On February 17, 2011, she called the ambulance again, and was hospitalized at the GT VMedA clinic.
Objective status: general condition is severe, due to the underlying disease. Consciousness is clear. The position is active within the bed. The physique is correct, corresponds to age and sex. Skin turgor is slightly reduced. On the skin of the legs, there are multiple post-injection wounds, abrasions, under fibrin, with swelling of the soft tissues around, on the right there is a granulating wound. Along the course of the peripheral veins of the forearms, there are multiple cicatricial changes in the skin. Subcutaneous tissue of a homogeneous consistency. The shape of the neck is normal, its contours are even, there is no swelling of the jugular veins. The thyroid gland is not enlarged, its isthmus is palpable, which has a homogeneous, soft-elastic consistency, painless. Peripheral lymph nodes are not enlarged. The muscular system is developed satisfactorily. Movements in the peripheral joints are possible in full. On palpation of the radial arteries, the pulse is the same on both arms, low filling, rhythmic with a frequency of 98 beats per minute, the vascular wall is not palpable outside the pulse wave. Blood pressure 100/70 mm Hg. Art. The pulsation in the peripheral arteries is preserved, the same on both sides. The borders of the heart are not expanded. On auscultation, the heart sounds are muffled. Accent II tone over the pulmonary artery, systolic murmur in the projection of the tricuspid valve. The chest is of the correct form, symmetrical. The respiratory rate when breathing atmospheric air is 28-30 per minute (SpO2 = 88-90%), when inhaling 100% oxygen through nasal catheters - 22-24 per minute (SpO2 = 100%), respiratory movements are rhythmic, both halves of the chest are even participate in the act of breathing. With comparative percussion over the lower lobes of the lungs, dullness of the percussion sound is determined. During auscultation over the lungs, hard breathing is determined on both sides, multiple wet sonorous rales in the area of dullness. The tongue is wet. The abdomen is of the correct form, symmetrical, evenly participates in the act of breathing, is not enlarged in size, soft and painless on palpation. The edge of the liver protrudes from under the edge of the costal arch by 3 cm, moderately painful on palpation. The size of the liver according to Kurlov is 11*10*8 cm. The spleen is palpable in the region of the lower pole. Ragosa's symptom is positive. Kidneys: tapping on the lumbar region is painless on both sides. evenly participates in the act of breathing, is not enlarged, soft, painless on palpation. The edge of the liver protrudes from under the edge of the costal arch by 3 cm, moderately painful on palpation. The size of the liver according to Kurlov is 11*10*8 cm. The spleen is palpable in the region of the lower pole. Ragosa's symptom is positive. Kidneys: tapping on the lumbar region is painless on both sides. evenly participates in the act of breathing, is not enlarged, soft, painless on palpation. The edge of the liver protrudes from under the edge of the costal arch by 3 cm, moderately painful on palpation. The size of the liver according to Kurlov is 11*10*8 cm. The spleen is palpable in the region of the lower pole. Ragosa's symptom is positive. Kidneys: tapping on the lumbar region is painless on both sides.
As a result of the treatment: regimen, diet No. 15, antibacterial (Avelox 400 mg/day, Invanz 1.0/day, Amoxiclav 1.2x2r/d), anticoagulant (heparin 10,000 IU/day, APTT from 21.02.11 – 44 s), lazolvan, metabolic therapy, the patient's condition is stabilized.
Results of instrumental studies:
ECG 17.02; 02/21/2011: sinus rhythm, normal position of the EOS, heart rate 93 per minute. In the future, there is an increase in heart rate, the appearance of diffuse disorders of repolarization processes.
X-ray of the chest on February 18, 2011: on the chest radiographs in 3 projections in both lungs, there are multiple foci of lung tissue compaction with decay. Fluid in the right pleural cavity at the level of the fifth rib.
Results of laboratory researches:
Clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
Thrombus.
*109/l
MCH
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
18.02.2011
97
3.66
17.2
155
26.5
70
0
-
3
7
31
56
20.02.2011
78
2.65
17.1
92
-
60
-
-
9
1
10
80
Biochemical blood test: Urinalysis
Name
Unit of measure.
Norm
18.02.11
Indicator
18.02.11
Color
Red-yellow
Glucose
mmol/l
4.2-6.4
8.7
Transparency
Turbid
Potassium
mmol/l
3.4-4.5
3.91
Specific. weight
1025
Sodium
mmol/l
130-150
134.8
Reaction
5.0
Urea
mmol/l
2.5-6.4
8.2
Protein (mg/dL)
100
Creatinine
mmol/l
53-124
0.10
Sugar
No
Total protein
g/l
64.0-83.0
56.8
Urobilin
No
APTT
26-36
42.8”
Leukocytes in p/sp
1-2
Erythr. unchanged in p/sp
0-2
Nitrogenous bases
Yes
Ketone bodies (mg/dL)
15
Salts
Oxalates
Echocardiography from 18.02.2011:
Result, mm
Norm, mm
Aorta
At the level of AC
24
22-36
Ascending
23
21-34
Arc
-
24-36
Valve opening
20
15-26
Left atrium
Antero-posterior dimension
32
25-40
Transverse
38
25-45
Longitudinal
40
29-53
Left ventricle
RV
31
≤ 36
RV
46
≤ 55
Posterior wall thickness (diast.)
9
7-11
Interventricular septum thickness (n)
7
7-11
Right ventricle
EKR
27
≤ 30
Anterior wall
3
≤ 5
Right atrium
Transverse dimension
34
29-46
Longitudinal dimension
41
34-49
Pulmonary artery
Near valve
19
12-23
Indicator
Result
Norm
FU, %
33
28-41
EF, %
61
≥55 SV
, ml
-
70-85
Mean calculated pressure in the pulmonary artery - N
Conclusion: Vegetation on the tricuspid valve leaflets. Mitral valve prolapse 1 degree. Mitral regurgitation 0-1 degree. The chambers of the heart are not dilated. Myocardium is not thickened. Violations of local contractility were not revealed. Global contractility and diastolic function are preserved. Tricuspid regurgitation grade 1. The pericardium is unchanged.
Blood tests for safety factors (HIV, hepatitis, RW) are in progress, the results will be given to the husband.
X-rays of the chest organs No. 630 in 3 projections were given to the hands As a result of the treatment: regimen, diet No. 15, antibacterial (Avelox 400 mg/day, Invanz
1.0/day, Amoxiclav 1.2x2r/d), anticoagulant (heparin 10,000 IU/day, APTT from 21.02.11 - 44 s), lazolvan, metabolic therapy, the patient's condition is stabilized.
By agreement with the Deputy Chief Medical Officer of the Mariinsky Hospital, the patient is transferred to the Department of Cardiovascular Surgery for further surgical treatment.
Transportable, accompanied by a medical team.
Order for transfer No. 1805
Form 12_Un.VmedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky prospect, 63 tel. (812) 577-11-35
EXECUTIVE STATEMENT No.
born in 1989 was on inpatient examination and treatment at the hospital therapy clinic of the Military Medical Academy from January 29, 2014 to February 18, 2014 with a diagnosis of
Acute infectious myocarditis with a rhythm disturbance according to the type of frequently recurrent focal high atrial tachycardia, heart failure of the first functional class.
Chronic periodontitis 16, 24, 46 teeth. Chronic odontogenic osteomyelitis of the lower jaw from the 37th tooth, chronic periodontitis of the 16th tooth (extraction of 16th and 37th teeth on 31.01.2014). Retention 28, 48 teeth.
Deviation of the nasal septum. ARVI by type of rhinopharyngitis, residual effects.
The final diagnosis was established ICD code I 40.0 MES 291030
Clinical outcome: improvement. ICD code K 10.2 MES 331140 Certificate of
incapacity for work: issued from 01/29/2014. to 18.02.2014 Coming to work February 19, 2013 LN No. 124 744 788 005.
Complaints at admission: severe palpitations, dizziness, moderate general weakness, discomfort in the precordial region.
During the last month, against the background of a protracted episode of acute respiratory illness, she began to notice the daily occurrence of palpitations without a visible provocative situation with a clear onset lasting up to an hour, stages of "warming up", "plateau" and "cooling down"; progressive increase in general weakness, fatigue, the appearance of constant discomfort in the precordial region, low-grade fever. Independently consulted a neurologist (healthy), an endocrinologist (thyrotoxicosis excluded). On the night of January 28-29, she noted a progressive increase in severe weakness, dizziness, nausea, and the appearance of signs of pre-syncope. The ambulance team that arrived at the scene was provided with emergency measures, delivered to the admission department of the Military Medical Academy, where about 30 minutes ago,
Treatment was carried out: mode 2, diet 10. Intravenously: glucose 5% -200 ml, ascorbic acid 5% -10 ml, analgin 50% - 2 ml, asparcam 20 ml. No. 5. Solvent. Metronidazole 500 ml (01.02-04.02.2014) Intramuscularly: Dissolv. Dicynon 2 ml intramuscularly 4 times a day (01.02-02.02.2014). Solv. Novocain 0.5-5 ml, por. Ceftriaxoni 1.0 intramuscularly 2 times a day (01.02-04.02.2014). Inside: tab. metoprolol 25 mg 1 tab in the morning and 12.5 mg in the evening, caps arbidol 0.1 1 caps 4 times a day, biomax 1 tab 1 time a day, caps azimycin 0.5 mg 1 tab 1 time a day, caps. Linex 1 caps 3 times a day, caps. mildronat 0.5 1 caps 2 times a day, susp. viferon 500000 units 2 suppositories 2 times a day per rectum.
Results of instrumental studies:
ECG on January 29, 2014: P-0.08 s, QT-0.40 s, PQ 0.12 s, QRS 0.08 s. Heart rate 60 per minute. Sinus rhythm. Vertical position of the electrical axis of the heart.
ECG on January 30, 2014: P-0.12 s, QT-0.34 s, PQ 0.14 s, QRS 0.08 s. Heart rate 93 per minute. Sinus rhythm. Vertical position of the electrical axis of the heart. Violation of intraventricular conduction. WPW cannot be ruled out. Violation of repolarization processes in the region of the lower wall.
ECG on February 11, 2014: P-0.08 s, QT-0.32 s, P 0.08 s, PQ 0.12 s, QRS 0.09 s. Heart rate 96 per minute. Minor sinus tachycardia. Vertical position of the electrical axis of the heart. ECG signs of left ventricular hypertrophy. Violation of repolarization processes in the posterolateral sections. Negative dynamics in the form of T wave inversion in II, III, AVF, V6 and slight depression of the ST segment in II, III, AVF, V5-V6 leads.
Holter monitoring of the ECG on January 30, 2014: During the observation period, sinus rhythm was recorded with a heart rate of 51 to 145 beats per minute. During wakefulness, tachycardia was recorded with an average hourly heart rate of up to 145 per minute. The decrease in heart rate at night is adequate (circadian index 44%). Average heart rate (day/day/night) 76/85/59 per minute. Solitary polymorphic ventricular extrasystoles (total 198), once as an episode of trigeminia, single polytopic supraventricular extrasystoles (total 196), periodically in the form of couplets (total 61), once as an episode of bigeminia, jogging sinus tachycardia with a heart rate of up to 15 per minute ( total 43, maximum 17 complexes). At 7:30 am, with an increase in heart rate to 133 beats per minute, horizontal and obliquely ascending depression of the ST segment up to 1.5 mm lasting 5 minutes was recorded.
Echo-KG dated 07.02.2014
Index
Value
Norm
Index
Value
Index
Aorta and pulmonary artery
Left atrium
Root, mm
19.7
22-26
Anterior-posterior. size, mm
27.8
27-38
Ascending, mm
21.0
21-34
Cross. size, mm
31.6
29-49
AK opening, mm
16.4
15-26
Length. size, mm
33.8
29-53 Lung
artery, mm
13.3
15-21
Area, cm2
Left ventricle
Right ventricle
LV EDR, mm
41.6
39-53 KDR (bas
.), mm
20-28
KSR LV, mm
23.8
20-36
KDR (average), mm
27.2
27-33
TMZhP (dias)
,
mm
7.2 mm
71-79
LV CRT (dias.), mm
7.8
6-10
RV area (dias.), cm2
11-28
LVML, g
100
<141
RV area (syst.), cm2
7.5-16
LVMI, g/l2
64
<109 Anterior
wall thickness, mm
3.0
< 5
IOT, units
0.36
< 0.42
Right atrium
EF (Teicholz),%
74
> 55
Transverse solution, mm
31.3
29-45
FU %
43
27-45
Longitudinal solution, mm
31.7
Mitral valve
< 50 years / > 50 years
Tricuspid. Valve
<
50
years
/
>
50
years waves А, m/s
0.46
0.30-0.50/0.45-0.73
0.33
0.19-0.35/0.25-0.41
Е/А
2.2
1.0-1.5
1.9
1.0-1.5
Maximum gradient, mm Hg Art.
4.2
0.6
Regurgitation, degree
0-1
0
0
0-1
E wave deceleration time, ms
261
159-199/174-276
144
166-210/175-221
Aortic valve
Pulmonary valve
Peak blood flow velocity, m/s
1.20
1.0-1.7
0.75
0.6-0 .9
Maximum gradient, mmHg Art.
5.8
2.2
Regurgitation, grade
0
0
0
0
IVC 1.2 cm (less than 1.7 cm), inspiratory collapse >50% (greater than 50%). The average systolic pressure in the pulmonary artery (AT / ET) 12 mm Hg. Art. (norm 20-30). Conclusion: Normal geometry of the left ventricle. The cavities of the heart are not dilated, free. Systolic and diastolic functions of the left ventricle are preserved. Heart valves are intact. Applied mitral regurgitation. Pericardium without features.
Ultrasound examination of the abdominal organs on 02/03/2014: liver, gallbladder, pancreas, spleen without pathology.
Consultation of the maxillofacial surgeon on January 31, 2014: On the orthopantogram, the bone tissue at the root of the 37th tooth is determined by the type of a deep bone pocket. Granuloma at the roots of 16, 12 teeth. Retention 28, 48 teeth. Examined by a dentist. Diagnosis: Chronic periodontitis 16.24, 46 teeth. Chronic odontogenic osteomyelitis of the lower jaw from the 37th tooth. Retention 28, 48 teeth. Recommended: sanitation of foci of odontogenic infection - removal of 16, 37 teeth, endodontic treatment of 24, 46 teeth; extraction of impacted teeth 28, 48 in a planned manner. Based on objective data, X-ray examination and examination by the head of the Department of Hospital Therapy of the Military Medical Academy, in order to sanitize foci of chronic infection, teeth 16 and 37 were removed under local anesthesia Sol. Ultracaini 1.7 #4. Hole revision. Nasal tests are negative. Hemostasis.
Consultation of the maxillofacial surgeon on 02/03/2013: Wells of extracted teeth under a clot. There are no signs of inflammation. Monitoring is recommended, if necessary, a second consultation.
X-ray of the chest organs on January 28, 2014: no pathological changes were detected.
Radiography of the paranasal sinuses on January 28, 2014: thickening of the mucous membrane of the left maxillary sinus of the parietal nature.
Radiography of the paranasal sinuses on February 12, 2014: the paranasal sinuses were pneumotized.
Consultation of an ENT doctor on February 11, 2014: On examination of the ENT organs: the mucous membrane of the nasal cavity is hyperemic, edematous, there is no pathological discharge in the nasal cavity, the nasal septum is complexly curved. Nasal breathing is moderately difficult. The external auditory canals are wide, free, there is no pathological discharge. ShR 6/6 meters, BP gray, contoured. The mucous membrane of the pharynx is hyperemic, the palatine tonsils are not enlarged, swallowing is free. In other organs of ENT organs without visible pathology. Diagnosis: ARVI by type of rhinopharyngitis, residual effects. Deviated septum of the nose. Recommended: Rg SNP, lavage of the nasal cavity with saline solutions 3 times a day for 7 days.
Ultrasound examination of the pelvic organs on 05.02.2014: the body of the uterus is determined, in the usual position, the dimensions are normal, length 45 mm, width 46 mm, thickness 44 mm, diffusely heterogeneous myometrium, spherical shape. Endometrium thickness of the functional layer is 7 mm (taking into account the day of the cycle is not thickened), the structure is not changed secretory, the contours of the endometrium at the border with the inner muscle layer are clear, the reflection from the endometrium is not deformed, the uterine cavity is not expanded. The cervix is of normal size, length 30 mm, thickness 20 mm, normal shape, the cervical canal is not dilated. The left ovary is determined, of normal size, length 27 mm, thickness 23 mm, the structure is not changed. The right ovary is determined, the dimensions are normal, length 25 mm, thickness 24 mm, the structure is not changed. Conclusion: Echographic signs of adenomyosis.
Gynecologist's consultation on 05.02.2014: Conclusion: Practically healthy. Observation by a gynecologist at the place of residence is recommended.
Laboratory results:
Clinical blood test (hardware processing): RBC
date
, *1012/l
Hb
units.
Lake. *109/l
Tr.
109/l
HCT
PCT
ESR, mm/h
E
%
B
%
lim
%
mon
%
p/i
%
s/i
%
30.01.14
4.68
129
6.5
382
387
278
6
7
-
40
6
1
45
Rt,
‰
MCV,
fl
MCH,
Pg
MCHC,
g/l
RDW,
%
MPV,
Fl
PDW
%
Lf
%
M,
%
Gra,
%
Lf,
109/L
M,
109/L
Gra,
109/L
-
83
27.6
333
14.6
7.3
12.1
40.4
4.4
55.2
2.6
0.2
3.7
Date
RBC, *1012/L
Hb
units
Lake. *109/l
Tr.
109/L
HCT
PCT
ESR, mm/h
E
%
B
%
limf
%
mon
%
p/i
%
s/i
%
05.02.14
5.9
125
5.9
385
371
285
6
8
-
31
6
1
53
Rt,
‰
MCV,
fl
MCH,
Pg
MCHC,
g /l
RDW,
%
MPV,
Fl
PDW
%
Lf
%
M,
%
Gra,
%
Lf,
109/l
M,
109/L
Gra,
109/L
-
82
27.7
336
14.0
7.4
13.1
37.7
5.4
56.9
2.2
0.3
3.4
Urinalysis (hardware processing):
Date
Rel. dense
pH
Protein
Acetone
Glucose
Lake.
Erythrocytes
Epithelium
Bact
Urobil.
Slime
unchanged.
vyschel.
30.01.14 g
1030
5.5
traces Negative
Negative 2-1-1v p/z 0-0-1
U
in
p
/z
2-3
1
3.2
2
Biochemical analysis of blood dated January 30, 2014:
Indicators
Unit of measure
Indicators
Unit of measure
Cholesterol
4.40
3.7-5.0
mmol/l
LDH
202
120-246
U/l
Triglycerides
1.08
0-2,
mmol/l
VLDL
0.49
0.6 -1.2
U
Glucose
4.60
4.2-6.2
mmol/l
HDL
1.62
0.76-2.33
U/l
Urea
4.5
2.4-6.4
mmol/l
LDL
2.28
1.9-4.4
U/l
CPK
238
10-160
U/l
KFK-MB
19.6
0-25
U/l
GGTP
15
8-63
U/l
SRP
2.2
3-10
umol/l
Alkaline phosph.
89
36-129
U/l
Total protein
68
63-87
g/l
Creatinine
70
53-123
umol/l
ALT
20
10-50
U/l
K+
4.45
4-6
mmol/
AST
30
11-50
U/l
Fibrinogen
2.27
0 -4
g/l
Co. atherogenic
1.72
0-3.0
U/l
Blood test for myoglobin, CPK-MB, troponin 01/29/2014: positive.
Blood test for myoglobin, CPK-MB, troponin 15.02.2014:
negative (11-50), CPK 238 U/l (10-160), CPK-MB 19.6 U/l (0-25).
Biochemical blood test 01/31/2014: CRP 0.2, rheumatoid factor 10.
Biochemical blood test 02/05/2014: LDH 211 U/l (120-246), AST 30 U/l (11-50), CPK 350 U/l (10-160), CPK-MB 27.7 U/l (0-25), fibrinogen 2.38 g/l (0-4).
Blood for microflora and determination of sensitivity to antibiotics 01/30/2014: There is no growth of microflora.
Antibodies to the myocardium 1:10 (normal 1:10).
Myocardial antigen 6 mmol/l (norm <1.5).
Microreaction with cardiolipin antigen 31.01.2014: negative.
AT-HIV ½ 02/03/2014: not detected.
HBs, Anti-HCV 02/03/2013: not detected.
Fecal analysis on February 11, 2014: no worm eggs were found.
The goals of hospitalization have been achieved. Employment has been restored. Discharged for work, return to work on February 19, 2014. A certificate of incapacity for work was issued 124 744 788 005 from 01/29/2014. to 18.02.2014 for the period of treatment
RECOMMENDED:
16. Observation by a cardiologist at the place of residence
17. Control performance of daily ECG monitoring after 1 month
18. Normalization of lifestyle.
19. Limit the intake of animal fats, easily digestible carbohydrates, increase the amount of vegetable fiber and vegetable fats in the diet.
20. Continue taking medications:
a. metoprolol 25 mg - ½ tab. 2 times a day for 1 month
b. Mexicor 0.1 - 1 tab. 2 times a day 1 month
Form 12_Un.VmedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №, ARCHIVE №_________
Surname, name, patronymic: born in 1978
Stayed at the hospital therapy clinic
Total days of treatment 9
The final diagnosis was established by “ICD Code K 58.9; MES 311100
Diagnosis:
Irritable bowel syndrome with diarrhea. Chronic gastroduodenitis, exacerbation. Chronic internal hemorrhoids without exacerbation. Fibrocystic mastopathy of the left mammary gland.
Certificate of incapacity for work issued series no.
Ability to work restored
Total exposure dose 0.26 mSv Clinical outcome (underline): recovery,
improvement
, no changes, chronicity, disability, _____ disability group
was established
Certified by MSEC: yes / no
On admission:
Complaints: a feeling of discomfort in the right iliac region, heartburn, a feeling of "bitterness in the mouth", bloating, excessive gas formation, unstable stools (loose stools 2-7 times / day); swelling of the legs; throbbing pain in the right parietal region; node of the inner quadrant of the left breast.
History of present illness. At the age of 6 months, due to the developed complex (thin-thin) ileocolic intussusception, the operation of resection of the ileocecal angle with anastomosis of the small intestine to the side of the large intestine (submersible anastomosis) was performed. In the future, she often noted pain in the abdomen. In 1994, she was hospitalized for chronic gastroduodenitis. During the second pregnancy (5 years ago), she significantly gained body weight (since then her body weight has been stable) up to 94 kg, varicose veins of the lower extremities appeared and she began to notice the appearance of discomfort in the right iliac region, stool instability, bloating, excessive gas formation. In 2007, she independently identified the node of the inner quadrant of the left breast, was consulted by a mammologist at the regional hospital (fibrocystic mastopathy). In June 2013, she was consulted on an outpatient basis by a gastroenterologist (on FGDS there were signs of gastroduodenitis), a course of therapy was recommended, which included platifilin s / c, pariet, duspatalin, drip administration of drugs (analgin, papaverine) with a positive effect. In August 2013, while on vacation (Greece), she began to notice significant swelling of the feet and legs, heartburn, and “bitterness” in her mouth. Taking into account that the state of health does not allow to properly perform official duties, she was routinely hospitalized to the hospital therapy clinic for diagnosis and treatment. while on vacation (Greece), she began to notice significant swelling of the feet and legs, heartburn, and “bitterness” in her mouth. Taking into account that the state of health does not allow to properly perform official duties, she was routinely hospitalized to the hospital therapy clinic for diagnosis and treatment. while on vacation (Greece), she began to notice significant swelling of the feet and legs, heartburn, and “bitterness” in her mouth. Taking into account that the state of health does not allow to properly perform official duties, she was routinely hospitalized to the hospital therapy clinic for diagnosis and treatment.
Objectively at admission: hypersthenic physique, overnutrition (BMI-34.4). Peripheral lymph nodes and thyroid gland are not enlarged. Movement in the joints of the limbs and the spine in full. Pulse 62 per minute, rhythmic. The borders of the heart are normal, the tones are clear, there are no murmurs. BP 130/80 mmHg Art. Respiration is vesicular. The abdomen is soft, moderately painful in the epigastric region. The liver is not enlarged, the spleen and kidneys are not palpable. Tapping on the lumbar region is painless on both sides. Psychoneurological status without pathology.
As a result of the treatment: regimen, diet No. 1, duspatalin, almagel, hilak-forte, probiotics, loperamide, exercise therapy, d'arsonval, the state of health improved.
Results of laboratory researches:
Complete blood count, urinalysis 08.10.2013: normal.
Biochemical blood test 08.10.2013: glucose, ALT, AST, total bilirubin, amylase, urea, creatinine, total protein - normal.
HBsAg, anti-HCV, serological tests for syphilis, F-50 09.10.2013 negative.
The results of a blood test in the reaction of indirect hemagglutination (RIHA) with a complex salmonella antigen, with a group diagnosticum for a typhoid-paratyphoid group dated 08.10.2013 - negative
. Results of instrumental studies:
ECG 09.10.2013: sinus rhythm with a heart rate of 80 per minute. The horizontal position of the EOS.
Fluorography of the organs of the chest cavity No. 5025 dated 10/15/2013. - pathological changes are not determined
Colonoscopy from 10/12/2013. - chronic hemorrhoids without exacerbation, condition after resection of the ileum and caecum due to intussusception of intestinal obstruction. Dyskinesia of the colon by hypertonic type.
Ultrasound of OBP 09.10.2013 diffuse changes in the pancreas, deformation of the gallbladder (kink in the body), microliths of both kidneys
The goals of hospitalization have been achieved. Discharged in a satisfactory condition under the supervision of a gastroenterologist clinic.
Employment has been restored. Discharged for work, return to work on 10/17/2013. A certificate of incapacity for work was issued from 07.10.2013. to October 16, 2013 for the period of treatment.
Recommended:
79. Observation of a gastroenterologist at a polyclinic;
80. Performing routine stool culture for microflora, followed by a consultation with a gastroenterologist in order to resolve the issue of the advisability of prescribing probiotic preparations for the selective normalization of a hypoplastic germ;
81. Normalization of the regime of work and rest;
82. Lifestyle changes: reduction in the frequency of stress, additional intake of sedatives on demand or courses in prolonged stressful situations (afobazole);
83. Change in diet: frequent small meals during the day with an increase in the diet of foods that help fix the stool (poppy, dogwood, nuts, bananas, baked apples ...) and the exclusion of foods that help loosen the stool and gas formation (legumes, cabbage, kefir, melons , watermelons…);
84. Continue taking:
a. Almagel Neo - 1 scoop an hour after meals and at night - 1 month;
b. Hilak forte - 60 drops 3 times a day for 1 month, then 30 drops 3 times a day for 3 months;
c. Loperamide 4 mg (2 tablets) once in the morning, followed by an assessment of the effect and an additional 2 mg after each bowel movement until the effect is achieved or a daily dose of 16 mg (8 tablets).
Discharge summary No.
Clinic of hospital therapy of the Military Medical Academy named after S.M. Kirov, Suvorovsky pr., 63
39 years old, was examined and treated at the clinic of hospital therapy of the Military Medical Academy with a diagnosis of
Main - community-acquired focal pneumonia in the lower lobe of the left lung of mild severity. DN0 Examination
results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l MSI
,
pg
n, %
e, %
b, %
l, %
m, %
n %
s, %
ESR, mm/h
12.11
139
4.13
5.6
300
33.8
1
1
48
15
2
34
22
16.11
148
4.43
6.3
325
33.5
4
4
29
10
1
52
23
Urinalysis
Date
Transp.
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
12.11
clear
1.025
yellow
7.0
-
-
-
-
-
-
-
-
-
-
Feces per I/g 13.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11.09
Total protein
G/l
63.0-87.0
67.2
Cholesterol
Mmol/l
3.7-6.0
5.32
Triglycerides
Mmol/l
0-2.37
0.94
Glucose
Mmol/l
4.2-6.4
4.86
Prothrombin
%
80-105
98
Fibrinogen
g/ l
2-4
2.9
Sialic acids
Mmol/l
1.9-2.5
2.3
ECG dated 11/11/2009 No. 2528 .: sinus tachycardia, deviation of the electrical axis of the heart to the left. Partial violation of intraventricular conduction. The predominance of the potentials of the left ventricle.
According to the results of Rg-graphy of the organs of the chest cavity on November 12, 2009 in frontal and lateral projections without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The median shadow is not expanded.
According to the results of FVD 13.11.09 - slight violations of bronchial conduction. moderate decrease in
Against the background of therapy (regime, diet, bromhexine) notes an improvement in the condition (normalization of body temperature, a decrease in the frequency and intensity of cough, a decrease in weakness).
Recommended:
1. Observation of the doctor's part;
2. Mode of work and rest, dietary nutrition;
3. Complivit 1 tablet 2 times a day after meals for 2 weeks.
4. Exemption from physical exercises, outfits, work for 15 days.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCUSSION (TRANSFER) EPICRISIS CASE
HISTORY №, ARCHIVE №_________
Last name, first name, patronymic_
Was hospitalized
at the hospital therapy clinic
Total days of treatment 11
The final diagnosis was established ICD Code I 50.0
Diagnosis:
Primary: coronary artery disease: stable angina pectoris 3 functional class. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and postinfarction (2004) cardiosclerosis.
Complications of the underlying disease: Bleeding from the intercostal artery of the 9th intercostal space on the right. Aneurysm of the apex of the left ventricle. Right-sided hydrothorax. Chronic cor pulmonale, decompensation. Secondary pulmonary hypertension. CHF IIB stage, IV functional class. Cardiac asthma from 02.04.2011 DN-2.
Background disease: Hypertensive disease of the third stage, arterial hypertension of the 1st degree, the risk of CVE is extremely high.
Concomitant: Chronic viral hepatitis B, moderate degree of activity. Fibrosis of the liver of mixed (cardiac, dysmetabolic) genesis. Chronic liver failure A according to Child-Pugh, compensation. Dyscirculatory encephalopathy of the second stage of mixed (hypertonic, atherosclerotic, dysmetabolic) genesis. Degenerative-dystrophic disease of the spine. Diabetes mellitus of the second type, moderate severity, decompensation. Chronic pyelonephritis, latent course, remission. Nephorpathy of mixed (atherosclerotic, dysmetabolic, diabetic, hypertensive) genesis. Diffuse nephroangiosclerosis. CKD stage II (GFR=85.9 ml/min/1.73 m2 according to MDRD) CRF-0.
On April 4, a puncture of the pleural cavity was performed - 2200 ml of straw-yellow liquid was evacuated. April 05 - 2700 ml of straw-yellow liquid was evacuated
Total radiation dose 0 mSv
Clinical outcome (underline): recovery, deterioration, improvement, no changes, chronicization, disability, _____ disability group, degree of disability _______________________________, other ____________________________
Outcome: discharged due to improvement, discharged after recovery, transferred to the clinic of thoracic surgery of the Military Medical Academy, transferred to rehabilitation treatment (where) _______________________________
Examined by MSEC: yes (no) (____disability group, degree of disability:
Complaints: increasing shortness of breath of a mixed, predominantly inspiratory nature, discomfort in the right half of the chest at rest, paroxysmal cough without discharge, increasing weakness, decreased exercise tolerance.
History of present illness. For a long time he suffers from coronary heart disease, hypertension. In 2006, she suffered a massive myocardial infarction. On October 17, 2010, surgical treatment was performed for bleeding (shock 2-3) from a chronic stomach ulcer. During the same hospitalization, decompensated diabetes mellitus was revealed. After discharge, she did not comply with the doctor's recommendations, she began to notice an increase in the volume of the abdomen. On this occasion, she was repeatedly hospitalized in the hospitals of the city, where complex treatment was performed with active diuretic therapy. The last hospitalization in the pulmonology department of City Hospital No. 26. After discharge from the hospital on December 14, 2010, she began to notice a sharp increase in dyspnea at rest, the appearance of a cough without discharge, and an increase in general weakness. On December 23, 2010, she was admitted to the hospital therapy clinic. After discharge, he feels well for 2 weeks, but later on there is a progressive increase in the feeling of weakness, shortness of breath, which requires re-hospitalization. In February and early March, for the reasons described above, she underwent inpatient treatment, where punctures of the pleural cavity and evacuation of the contents were performed. After the last discharge, she felt well for 2 weeks, but shortness of breath began to increase again, her stomach increased in volume, in the last 7 days she slept half-sitting, and the last night - sitting.
Given the progressive deterioration of her condition, she called an ambulance team, which was hospitalized for urgent indications in the hospital therapy clinic for further diagnosis and treatment.
During hospitalization, taking into account the hemodynamically significant hydrothorax, the patient was evacuated 2200 ml of straw-yellow liquid on April 04. After a second puncture on April 05 (2700 ml of straw-yellow liquid was evacuated), profuse bleeding appeared from the puncture site. Suspected damage to the intercostal artery with the development of bleeding. The patient was reported to the Deputy Head of the Department of Hospital Surgery for clinical work. In order to stop the developed complication, in agreement with the clinical department, the patient is transferred to the hospital surgery clinic.
Objective status upon admission to the ICU: Height 165 cm Weight 77.3 kg BMI-29.3 kg/m2. The general condition is severe, due to signs of cardiopulmonary insufficiency. Consciousness is clear (SHG=15b). The situation is forced. The physique is correct, corresponds to age and sex. Normosthenic constitution. Earthy yellow skin, icteric sclera. The elasticity of the skin is reduced. Subcutaneous tissue of a homogeneous consistency, swelling of the legs. The hairline is developed in accordance with age and sex. Peripheral lymph nodes are not enlarged. The muscular system is developed satisfactorily. On palpation of the radial arteries, the pulse is rhythmic, with a frequency of 78 beats. per minute, satisfactory filling, uneven, not tense. Sat O2 at rest 90-92%. Arterial pressure - 135/70 mm. rt. Art. The boundaries of relative cardiac dullness are expanded in diameter. The width of the vascular bundle does not extend beyond the edges of the sternum. The number of heartbeats corresponds to the pulse. The heart sounds are muffled, the first tone at the apex is weakened, at the apex of the heart there is a coarse systolic murmur. The chest is symmetrical. The respiratory rate at rest is 24-26 per minute, the respiratory movements are rhythmic, the right half of the chest lags behind in the act of breathing. With percussion of the zones, dullness over the entire right half. On auscultation over the lungs, breathing is hard, breathing is not auscultated on the right. Tongue wet, pink. The abdomen is enlarged due to the accumulation of free fluid, the correct form, symmetrical, soft, peritoneal symptoms are negative. The edge of the liver +4 cm from under the edge of the costal arch, dense texture, bumpy, painless on palpation. The size of the liver according to Kurlov is 16x14x9 cm. The spleen is not palpable. Ragosa's symptom is positive. Urination free, painless. The kidneys in the supine position and standing are not palpable. Tapping on the lumbar region is painless.
Treatment in the ICU: regimen, diet No. 9, metabolic therapy, inotropic therapy (Korglicon 0.06% 1.0 IV 2 times a day), hypoglycemic therapy (Maninil 0.005, 2 tablets per day, Metformin 0.5, 2 tablets tab. 2 times a day), antibacterial therapy (Ceftriaxone 1.0 2 r / d i / m), diuretic therapy (Ffurosemide 80 mg i / v 1 r / d, Hypothiazid 0.025 1 tablet in the morning), Enalapril 2, 5 mg in the morning, humidified oxygen inhalation. On April 4, a puncture of the pleural cavity was performed - 2200 ml of straw-yellow liquid was evacuated. April 05 - 2700 ml of straw-yellow liquid was evacuated.
Results of instrumental studies:
On ECG No. 359 (ICU) of 04/05/2011, sinus rhythm is recorded with a heart rate of 74 per minute. EOS is deflected to the right. Complete blockade of the right leg of the bundle of His. Hypertrophy of the right ventricle. Widespread cicatricial changes in the anterior-septal-apical-lateral LV. Diffuse disorders of repolarization.
ECHO-KG from 03/09/2011:
PARAMETERS
Val.
NORMAL
PARAMETERS
Value
NORM
Aortic root diameter
30
20-37 mm
Left ventricular ERR
40
38-56 mm
Aortic valve leaflet opening
17
more than 15 mm
Left ventricular ERR
36
22-38 mm
Anterior-posterior size of the left atrium
55
25-40 mm
The thickness of the free wall of the right ventricle
7
less than 5 mm
The frontal dimension of the left atrium
42
25-45 mm
The ejection fraction of the left ventricle
20
more than 55% The
vertical dimension of the left atrium
is
29-53 mm
The dimension of the right atrium
47
30-46
The thickness of the interventricular septum
6-10
7-11 mm
Vertical size of the right atrium
57
34-49 mm
Thickness of the posterior wall of the left ventricle
10
7-11 mm
Right ventricular EDR anteroposterior
39
Less than 30 mm
Systolic pressure in LA
60
to 30 mm Hg
Diameter of the pulmonary trunk
26
12-23 mm
Conclusion: hypertrophy and dalatation of the right ventricle. Atrial dilatation. Paradoxical movement of the IVS. Total hypokinesia of the myocardium of the left ventricle, apex dyskinesia in the anterior, lateral and septal segments with parietal thrombi; akinesia of the interventricular septum, lateral wall and anterior stack in the middle section. Fibrosis and rupture of the interventricular septum. Dilatation of the pulmonary artery. Pulmonary hypertension grade 2. Regurgitation on all valves: TP - 3, MP - 2, PR - 1, AR - 0/1. Aorta, fibrous rings AK, MK, TK, PC are compacted. The pericardium is thickened, there is no effusion.
Index
04.04
Color
Yellow
Transparency
is cloudy.
Specific Weight
More than 1015
Reaction
6.0
Protein (g/l)
1.0 g/l
Sugar
No
Urobilin
0.2
Leukocytes in p/s
5-7
Erythr. unchanged in p/s
No
Erythr. Vyschi. In p / sp
No
Epithelium pl in p / sp.
All p/s
Results of laboratory tests:
Clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pya
%
Xia
%
04.03
144
5.49
7.7
26.2
5
1
35
7
2
72
05.03
146
5.09
7.8
28.6
10
2
1
27
8
1
61
07.03 10.41
133
4.63
11, 0
28.8
8
1
1
11
7
4
76
07.03 19.52
121
4.05
10.3
29.9
1
35
7
2
72
07.03 22.45
113
3.82
9.6
29.6
1
35
7
2
72
08.03 08.00
97
3.20
9.0
30.3
1
35
7
2
72
08.03 10.58
96
3.15
11.3
30.5
1
35
7
2
72
08.03 16.37
85
2.81
9.1
30.2
1
35
7
2
72
08.03 21.36
82
2.74
9.3
29.9
1
35
7
2
72
09.03 08.08
89
2 .94
10.0
30.3
1
35
7
2
72
09.03 17.30
87
2.86
9.8
30.4
1
35
7
2
72
10.03
87
2.94
9.7
29.6
1
35
7
2
72
11.03 08.02
88
3.00
9.9
29.2
1
35
7
2
72
11.03 08.56
90
3.06
9.7
29.6
44
5
2
18
3
4
68
Biochemical analysis of blood: Analysis of urine:
Name
Unit of measure.
Norm
06.03
07.03
11.03
Creatinine
Mkmol/l
53-124
100
70
70
Cholesterol
Mol/l
3.7-6.0
3.94
4.00
Triglycerides
Mol/l
0-2.37
Total protein
G/l
63.0-87.0
70
53
58
Calcium
Mol/l
2 ,1-2.5
2.37
2.12
2.09
Potassium
Mole/l
3.5-5.1
5.68
AST
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
U/l
11.0-50.0
56
36
56
Glucose
Mole/l
4.2-6.4
8.22
11.20
7.78
SC-MB
Mole/l
0-25
15.1
11.01
Analysis of the pleural fluid from 04/04/2011: yellow, slightly turbid liquid, 20 ml. Clear after centrifugation. Rivalta's test is negative. Protein 30 g/l. Cytosis 31.0*109/l, erythrocytes 23.5*109/l, leukocytes 4.5*109/l, mesothelium, epithelial cells, macrophages - 3.0*109/l. Microscopy: BC were not found; cocci in small quantities. Against the background of erythrocytosis, leukocytes up to 15-25 in the field of view, of which lymphocytes make up 80%. Mesothelial cells are degeneratively changed. Macrophages 0-3-5 in the field of view.
In view of the suspected damage to the intercostal artery with the development of bleeding, the patient was reported to the Deputy Head of the Department of Hospital Surgery for clinical work.
In order to stop the developed complication, in agreement with the clinical department, the patient is transferred to the hospital surgery clinic
. The patient is transportable by specialized ambulance, accompanied by a doctor.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1970 (39 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy Diagnosis: community-acquired focal pneumonia in the lower lobe of the left lung, mild severity DN-0. Astheno-vegetative syndrome. Right-sided nephroptosis I degree, lipoma of the left kidney, CRF-0.
She was admitted to the clinic for urgent indications with complaints of shortness of breath with moderate physical exertion, general weakness, cough with green discharge, and fever.
Laboratory results:
Clinical blood test
Date
Hemoglobin, g/l
Erythrocytes, *1012/l
Leukocytes, *109/l
Platelets, x109/l MSI
,
pg
n, %
e, %
b, %
l, %
m, %
n %
s, %
ESR, mm/h
12.11
139
4.13
5.6
300
33.8
1
1
48
15
2
34
23
16.11
148
4.43
6.3
325
33.5
4
4
29
10
1
52
22
Complete urinalysis
Date
Clear
Rel. Density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
Epit.
Profit center in p.z.
Cyl. in p.z.
L
in p.z.
E
in p.z.
12.11
clear
1.025
Yellow
7.0
-
-
-
-
-
-
-
-
-
-
Feces per I/g 13.11.09 – no pathology
Biochemical blood test
Name
Unit of measure.
Norm
12.11.09
Total protein
G/l
63.0-87.0
67.2
Cholesterol
Mmol/l
3.7-6.0
5.32
Triglycerides
Mmol/l
0-2.37
0.94
Glucose
Mmol/l
4.2-6.4
4.86
Prothrombin
%
80-105
98
Fibrinogen
g/l
2-4
2.9
Sialic acids
Mmol/ l
1.9-2.5
2.3 Plain
radiograph of the chest in the direct and right lateral projection No. 304 (D=0.52 mSv) dated 11.11.09: in the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, not expanded. The heart is not enlarged.
On the survey radiograph and fluoroscopy of the chest in the direct and right lateral projection No. 317 (D = 0.52 mSv) dated 11/19/09: a stranded pattern is noted in the basal segments of the left lung. Pleural cords in the C8 projection on the left. The roots of the lungs are structural, not expanded. The heart is not enlarged.
ECG No. 2528 dated 11/11/09: sinus rhythm with a heart rate of 80/min. EOS is deflected to the left. Partial violation of intraventricular conduction. The predominance of the potentials of the left ventricle.
ECHO-KG No. 790 dated 11/18/09 Ao=27mm, ascending Ao=23mm, opening AC=19mm, LA=30mm, RA=34mm, RV=22mm, LV=43/30mm, IVS=9mm, AP=8mm, EF=58%, FU=31% , SV=55ml, E/A=1.39 The myocardium is not thickened, the kinetics is not disturbed, the heart cavities are not dilated. The aorta is not changed. The blood flow on the valves is laminar. Systolic and diastolic functions are not disturbed. The free edge of the anterior leaflet of the mitral valve is thickened, loosened. Applied regurgitation on MK and TK. The pericardium is not changed.
Ultrasound of the OBP from 23.11.09. No. 1278: the liver is not enlarged, the right lobe is 10 cm, the left lobe is 3.7x7.6 cm, the contours are even, the structure is homogeneous, echogenicity is average, the vessels are not dilated. The gallbladder is bent in the middle third 4.5x1.6 cm, the contours are even, the walls are 2 mm, it contains bile, calculi and polyps are not detected, the common bile duct is 3 mm. The pancreas is located clearly, the contours are clear, even, the head is 13mm, the body is 10mm, the tail is 11mm, echogenicity is increased, the structure is homogeneous, the Wirsung duct is not dilated. The lower pole of the right kidney to the edge of the liver is 10x3.4 cm, the parenchyma is homogeneous 15 mm, the PCS is not changed; the left kidney is located typically 8.5 x 4.4 cm, the parenchyma is homogeneous 19 mm, the PCS is not changed. In the projection of the adrenal glands, no pathological formations were revealed, the spleen was not changed.
FVD No. 106 dated 11/18/2009 results in hand.
Treatment: regimen, diet, antibacterial, anti-inflammatory, expectorant, sedative and restorative therapy.
Against the background of the therapy, the patient's condition improved: the general intoxication syndrome was stopped, there is no compaction of the lung tissue. However, a cough persists with a slight discharge of a light color, signs of asthenia. Discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
206. Outpatient supervision of a doctor in accordance with DM-1.
207. Control general blood test as of 30.11.2009.
208. Release from the performance of official duties for a period of 3 (three) days.
209. Exemption from physical. preparation for 30 days.
210. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
211. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
212. Continue taking:
a. Linex - 1 capsule 3 times a day for 1 month
b. Ascoril - 1 tablespoon in the morning for 7 days
c. Antigrippin – 1 powder 2 times a day for 3 days
d. Eleutherococcus - 1 teaspoon in the morning (dilute in 1/3 cup of water).
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Reference No.
1925 (83 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy
Diagnosis:
ischemic heart disease. Progressive angina from 12/17/08, with stabilization at the level of angina pectoris III FC from 12/22/08. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and post-infarction (of unknown duration) cardiosclerosis complicated by paroxysmal form of atrial fibrillation (paroxysm of unknown duration) was stopped on 18.12.08. Hypertension stage III (AH 2st, Risk 4) NK-I, CHF-IV→II FC. Obesity of the first degree, alimentary genesis. Chronic cholecystitis without exacerbation. Chronic pyelonephritis without exacerbation, multiple (two) cysts of the left kidney, CRF-I st. Benign prostatic hyperplasia.
He was admitted to the clinic for urgent indications with complaints of discomfort in the region of the heart during moderate (ascending to the 2nd floor) physical activity, shortness of breath, frequent nighttime urination, memory loss.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
17.12
146
4.87
8.0
47
8
1
1
19
7
72
19.12
144
4.62
6.4
44.7
9
5
27
8
60
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MV epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
11.12
mutn
1014
yellow
sour
0.04
no
no
++
no
no
0-2
no
2-4
12-15 Rehberg's
test
Date
Blood
creatinine Urine creatinine
Diuresis in 1 min
Glomerular filtration
Tubular reabsorption
24.12
0.16
14.53
0.95
86.3
98.9
Biochemical blood test:
Name
Unit. rev.
Norm
17.12
24.12
Name
Unit. rev.
Norm
17.12
24.12
Creatinine
mmol/l
53-124
160
160
CS
mmol/l
3.7-7
6.11
Urea
mol/l
3-8.4
9.0
11.3
TG
mmol/l
0-2.37
Prothrombindex
%
70-120
95
β-LP
u
350-650
Fibrinogen
g/l
200-400
330
HDL
mmol/l
0.78-2.33
Total protein
g/l
63- 87
67.5
72.2
LDL
mmol/l
1.9-4
ALT
U/L
8.4-53.5
12.6
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
16.0
Ig A
g/l
1.25-2.5
AP
U/L
36-92
CPK
U/L
10-160
46.5
LDH
U/L
100-220
Cl
mmol/l
95-108
111.6
GGTP
U/L
11-63
Na
mmol/l
130-150
148.4
148.2
Glucose
mmol/l
4.2-6, 4
5.52
5.77
Ca
mmol/l
2.0-2.7
2.32
2.43
Total bilirubin
µmol/l
6.8-26
25.4
K
mmol/l.
4-6
5.14
5.06
ECHO-KG No. 32 dated 12/15/08: Aorta - 36 mm, AV dilatation - 17 mm, RA - 50 mm, RV EDR - 32 mm, LA - 53 mm, LV ECR - 39 mm, LV EDR - 50 mm, FU - 30%, EF - 60%, IVS=14mm, WS=14mm, LA - 21 mm Hg, Dla - 38 mm Hg e/a = 0.89. Symmetrical concentric hypertrophy of the left ventricular myocardium. Dilatation of the left atrium and right chambers of the heart. The aorta is sealed. Regurgitation on the TC 2 degrees, applied to the mitral valve. Pulmonary hypertension of the first degree. The pericardium is not changed.
Ultrasound of the abdominal organs dated 23.12.08: The liver is not enlarged, the thickness of the right lobe is 13 cm, the contours are even, the structure is homogeneous. The gallbladder is without calculi, the walls are compacted, thickened up to 4 mm. Portal vein - 12 mm., Hepatocholedochus - 5 mm. The pancreas is not enlarged, the contours are even, the structure is hyperechoic, homogeneous. Kidneys: right - 9 × 4 cm, parenchyma up to 12 mm, uneven contours, expansion of individual cups up to 16 mm, PCS deformed; left - 11.5 × 6 cm, parenchyma up to 10 mm, expansion and deformation of the PCS, in the middle third, two cysts 2.6 and 2.2 cm in diameter. The spleen is not enlarged.
ECG No. 156 dated 12/17/08. atrial fibrillation, tachysystole 85-120 per 1 min, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 161/162/177 dated December 18-22, 08: sinus rhythm with a frequency of 60-78 beats per minute, vertical EOS, hypertrophy of both ventricles, more than the right one, widespread violations of repolarization processes, more than the lateral wall.
ECG No. 185 dated 12/23/08. sinus rhythm with a frequency of 82 per 1 min., vertical EOS, hypertrophy of both ventricles, more than the right one, in dynamics some worsening of repolarization of the apical-lateral region of the left ventricle
Treatment: regimen, diet, polarizing mixture, vinpocetine, enalapril, cordaflex, siofor, restorative therapy.
On the background of the therapy, the patient's condition improved. Discharged to the clinic at the place of residence in a satisfactory condition.
A temporary disability sheet was not issued.
Recommended:
213. Outpatient supervision of a polyclinic therapist.
214. Exclude animal fats, fried, spicy, salty and spicy foods from the diet.
215. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
216. Continue taking:
a. Enalapril 0.01 - 1 tab. 2 times a day (morning and evening) continuously
b. Cordaflex (retard) 0.02 - ½ tab. 2 times a day (morning and evening) continuously
c. Verapamil 0.08 - ½ tab in the morning and in the evening constantly
d.
Siofor
500 - 1 tab in the morning and in the evening 15 minutes before
meals (812) 577-11-35
Discharge summary No.
born in 1970 (40 years),
was on examination and treatment in the hospital therapy clinic
from May 26 to June 16, 2010 with a diagnosis of:
Hypertension stage II (Risk of CVE is moderate). Uncomplicated hypertensive crisis from 05/26/2010, stopped by medication on 05/26/2010. IHD: stable exertional angina 1 FC. Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis, complicated by rare ventricular and supraventricular extrasystoles, transient AV block II degree, type 2. NK-1, HSN 1 FK. Peptic ulcer of the duodenum, remission. Cicatricial deformity of the duodenal bulb. Chronic gastroduodenitis, remission. Fatty hepatosis without impaired liver function. Diffuse-nodular goiter of the 1st degree, euthyroidism. Alimentary-constitutional obesity of the second degree, stable phase Initial manifestations of cerebrovascular insufficiency with scattered neurological symptoms.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Rt,
‰
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
27.05
144
4.72
7.8
14.9
6
210
3
17
7
1
72
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
27.05
clear
1020
yellow
5.0
no
no
no
no
no
no
1-2
no
1-2
no
_
_
_ rev.
Norm
28.05
Name
Unit. rev.
Norm
28.05
Creatinine
mmol/l
53-124
100
cholesterol
mmol/l
3.7-7
2.9
Urea
mol/l
3-8.4
K
mmol/l.
3.5-5.1
4.23
Prothrombindex
%
70-120
104
Ab to TPO
nmol/l
0 - 34
19.22
Fibrinogen
g/l
2.00-4.00
3.66
TSH
nmol/l
0, 27-4.2
5.19
Total protein
g/l
63-87
80
T3
nmol/l
66-181
114.8
ALT
U/L
8.4-53.5
35
T4
nmol/l
1.3-3.1
2.03
AST
U/L
7-39.7
22.2
RW
quality
neg.
neg.
Glucose
mmol/l
4.2-6.4
5.2
HBsAg
quality
neg
.
Tot. bilirubin
µmol/l
6.8-26
37.5
AntiHCV
quality
neg
.
Etc. bilirubin
mmol/l
0-7
5.5
Ab to HIV 1/2
quality
neg.
neg.
Results of instrumental studies:
UZDG from 06/04/2010: the blood flow has the features of the main one, without signs of AVM and local stenosis, without pathological overflows. LBF in all located arteries is within acceptable limits, without significant asymmetry. The range of cerebrovascular reactivity was preserved in full.
MRI of the brain dated 04.06.2010: Conclusion: MRI signs of the initial manifestations of dyscirculatory encephalopathy, uneven expansion of the subarachnoid space.
ECG from. 06/03/2010: sinus rhythm with heart rate = 88 in 1 min., horizontal EOS. Incomplete blockade of the right leg of the bundle of His. The predominance of the potentials of the left ventricle.
ECHO-KG dated 06/03/2010: MZHP-12mm, ZS-11mm, KDRLZh-51mm, KSRLZh-34mm, FV-62%, FU-34%, UO-77ml, LP-40×40×50mm, PP-38 ×47mm, RV-25mm, E/A=1.1 IMMlzh-142g/m2 Myocardium is symmetrically thickened. The kinetics is not broken. The cavities are free, not dilated, the valves are not changed, there is valvular regurgitation on the pulmonic valve. The aorta is sealed. The pericardium is intact.
VEM dated 06/01/2010: functional class - 2. The VEM test was carried out against the background of antihypertensive therapy. The test is negative (no signs of coronary circulation disorders were detected). Load tolerance is average. BP response is adequate.
24-hour ECG monitoring from May 31, 2010: during monitoring, sinus rhythm was recorded with a heart rate of 47 to 170 per minute. The decrease in heart rate at night is adequate. Average heart rate 84/85/62 per minute. Registered single ventricular extrasystoles (2); solitary supraventricular, periodically frequent (from 13:00 to 14:00 - 103 extrasystoles; from 15:00 to 17:00 - 101 extrasystoles; in total 263 per day), with episodes of the type of bi- and trigeminia. At 21:25, a single episode of transient 2nd degree type 2 AV blockade (Mobitz 2) was registered with a pause of 2 seconds. When performing the planned load, the heart rate reached 166 and 170 in 1 minute, subjectively noted the heartbeat. Ischemic changes in the ST segment were not detected.
24-hour blood pressure monitoring from May 31, 2010: the study was performed against the background of antihypertensive therapy (amlodipine, enalapril). Mean systolic BP in the daytime is typical for mild labile hypertension, at night the average systolic BP is within the normal range. Mean diastolic BP during the day is typical for mild stable hypertension, at night - for moderate stable hypertension. At night, systolic and diastolic blood pressure fall adequately (dipper). The variability of systolic and diastolic blood pressure during the day is within the acceptable range. There is an increase in the magnitude of the morning rise in diastolic blood pressure, the speed of the morning rise in systolic and diastolic blood pressure. Episodes of hypotension were not registered.
Ultrasound of the abdominal organs from 06/07/2010: the liver is not enlarged, the right lobe: 14cm; left 7×6cm, smooth contours, homogeneous structure, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein 12 mm, hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder of the correct form, dimensions 7×2 cm, smooth contours, walls 2 mm, calculi are not visualized. The pancreas is located clearly 22x10x18mm, homogeneous structure, contours are clear, even, the structure is homogeneous, echogenicity is increased; Wirsung's duct is not dilated. Kidneys of normal size (right 10×5 cm, left 11×6 cm), normal location, with smooth contours, homogeneous parenchyma 16 mm thick on the right, 16 mm on the left; cavity systems are not expanded, there are no calculi. The spleen is not enlarged, 10 × 4.5 cm in size.
X-ray of the chest organs from 27.05.2010. Conclusion: without focal and infiltrative changes. Roots are structural. The heart is dilated to the left. The aorta is sealed.
FGDS from 05/31/201: the esophagus is passable, the cardial rosette does not close completely. In the stomach, the folds are rough, edematous, tortuous, can be traced in the antrum, and are easily straightened during insufflation. The mucosa is moderately hyperemic, "motley" in the antrum. The gatekeeper closes completely. The bulb of the duodenum is somewhat deformed due to cicatricial changes. Mucous edematous, with whitish bulges. In the postbulbar region without features, bile is not passaged. Conclusion: insufficiency of the outlet of the cardia. Chronic gastritis (mixed form, follicular bulbitis). Moderate cicatricial deformity of the duodenal bulb.
Neurologist: initial manifestations of cerebrovascular insufficiency with scattered neurological symptoms.
Ophthalmologist: hypertensive angiopathy of both eyes.
Cardiac surgeon-arrhythmologist: transient AV blockade of the 2nd degree, type 2
Treatment: regimen, diet, polarizing mixture, diuretic therapy, enalapril, ACC thrombosis, metoprolol, Rudotel.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition under the supervision of a doctor of the unit.
Recommended:
1. Supervision of the therapist of the part according to DM-1.
2. Release from duty for 5 (five) days
3. Optimization of the regime of work, rest, nutrition.
4. Control HM-ECG after 3 months
5. Continue taking:
• Enalapril 0.01 ½ tab.2 r/d. constantly
• Amlodipine 0.005 1 tab. in the morning
• Thrombo ASS 0.1 1 tab. 1 day after breakfast •
Mildronate
0.25 ½ capsule 2
times a
day (after breakfast and lunch) - 2 weeks .
DIAGNOSIS:
Primary disease: Hypertension II st. (AG-3, R-4). ischemic heart disease. Angina pectoris II f. class, Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis.
Complications of the underlying disease: NK IIA Art. (CHF II f.cl. according to NYXA).
Accompanying illnesses: . Dyscirculatory encephalopathy II st. in the form of right-sided pyramidal-cerebellar insufficiency and persistent moderately pronounced pseudoneurotic syndrome. Intervertebral osteochondrosis of the cervical, thoracic and lumbar regions; deforming spondylosis of the cervical spine, lumbarization of the first sacral vertebra, non-closure of the arch of the second sacral vertebra with a slight dysfunction of the spine. Chronic vertebrogenic lumbosacral sciatica with a predominant lesion of the fifth lumbar first sacral root on the right without impaired function of the lower extremities. Varicose disease of the right lower limb without chronic venous insufficiency. Chronic cholecystitis in remission. Chronic pancreatitis in remission. Chronic gastritis in remission. fatty hepatosis. M KB. CRF 0. Obesity I degree, alimentary-constitutional origin, stable phase. Diffuse-nodular goiter of the first degree without dysfunction. Hand dyshidrosis.
Treatment was carried out: infusion therapy with glucose; metoprolol, enalapril, nifedipine, furosemide, hypothiazide, sibazon.
Against the background of the therapy at the time of discharge, the general condition improved, blood pressure is at working values, pain cardiac syndrome did not recur. There are no edema.
Objectively at the time of discharge: the general condition is satisfactory, the pulse is 78 beats per minute, rhythmic, the boundaries of the heart are not expanded; auscultatory heart sounds are muffled, weakening of the 1st tone over the apex, accent of the 2nd tone over the aorta. BP 140/100 mmHg Art.; Respiratory rate 18 per minute, vesicular breathing, no wheezing; The abdomen is soft and painless. The edge of the liver is not palpated. The spleen is not palpable. Tapping on the lumbar region is painless on both sides.
Physiological functions are normal. The pastosity of the shins is preserved.
Results of instrumental studies:
ECG 20.10.2009: Hypertrophy of the left ventricular myocardium, violations of local intraventricular conduction.
Echocardiography 21.10.2009: IVS 10.4 mm, LV CR 63 mm, PSL 9.6 mm, LV CL 40 mm, EF 65%, FU 36%, SV 132, LA 36 mm, aortic root diameter 40 mm, aortic opening valve 21 mm, MK more than 4 cm2, Pulmonary artery 19 mm, PP 39 mm. MVE/A less than 1.0. Conclusion: Imaging is difficult due to obesity. Dilatation of the left ventricle as a manifestation of hypertension. systolic its function is preserved, diastolic its dysfunction. Consolidation of the aorta. Tricuspid regurgitation. The pericardium is not changed. Pulmonary hypertension 1 tbsp.
24-hour ECG monitoring on October 29, 2009: sinus rhythm, at night the heart rate decreases inadequately (not enough). single ventricular extrasystoles (4), single supraventricular extrasystoles (13), in 20-23 an episode of paired supraventricular extrasystoles was truncated. ectopic activity within the normal range. Significant dynamics of the ST segment was not revealed.
Ultrasound of the abdominal organs 10/29/2009. g.: the liver is enlarged, the right lobe is 16.5 cm, the left lobe is 10 cm, the contours are even, the structure is homogeneous, hyperechogenicity is increased, the hepatic veins and intrahepatic bile ducts are not dilated; portal vein 10 mm, hepatic veins 5 mm. The gallbladder is of the correct form, the contours are even, the dimensions are 9.1x2.9 cm, the contents are bile, no intracavitary formations were detected; the pancreas is located indistinctly, not enlarged, the contours are indistinct, even, the structure is homogeneous, hyperechoic, the Wirsung duct is not dilated; kidneys: normal size, homogeneous parenchyma, homogeneous parenchyma, PCS not dilated, calculi in the left kidney 4x4 mm; the spleen is not enlarged.
Ultrasound of the thyroid gland 02.11.2009: In the right lobe, a 9x6 mm node with a clear, even, apechoic contour of a homogeneous echostructure, without increased blood flow.
ENT consultation on October 30, 2009: no pathology.
Consultation of a physiotherapist 26.10.2009: It is recommended to alternate coniferous baths with oxygen baths. Massage of the lumbosacral and left thigh.
Laboratory results:
Clinical blood test (automatic processing): Hb
date
, units.
Er., *1012/l
Leuk., *109/l
MCHC,
g/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
21.10
146
5.01
6.4
305
14
3
1
33
11
1
51
Giant forms of platelets are present.
Complete urinalysis (automatic processing):
Date
Exp. weight
pH
Protein
Sax
Lay
Ep. class
Blood
Bacteria
21.10
1025
5.5
-
-
-
-
-
-
Biochemical analysis of blood:
Name
Unit of measure.
Norm
21.10
Total protein
G/l
63-87
70.3
Total bil-bin
mmol/l
6.8-26
16.2
Glucose
mmol/l
4.2-6.4
5.55
Triglycerides
mmol/l
0-2.37
0.90
AST
U/ l
11-50
43.1
GGTP
mmol/l
1.9-2.5
39.2
ALT
U/ml
11.0-50.0
66.7 !
Creatinine
mmol/l
0.05-0.12
0.12
Cholesterol
mmol/l
3.7-6.0
4.06
Fibrinogen
Md/dl
2.0-4.0
4.1
Prothrombin
%
70-130
86
Potassium
Mmol/l
3.50-5.10
4.09
B-lipoproteins
ED
350-650
Coprogram 21.10.2009: within normal limits.
Hepatitis markers 10/28/2009: negative.
Discharged in a satisfactory condition under the supervision of specialists of the clinic at the place of residence.
Discharged for work, able-bodied, return to work 04.11.2009 Issued a certificate of incapacity for work series BX No. 5789183.
Recommended:
1. Dynamic observation of a cardiologist, gastroenterologist, neurologist, nephrologist.
2 Normalization of the regime of work and rest. Limit the use of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet. exercise therapy.
2. Continue taking:
• T. Enziks-duo 1 tab. 1 time per day (in the morning) - take a long time;
• T. Coronal 1 tab. 1 time per day (in the morning) - take a long time;
• T. Thrombo Ass 50 mg, 1 tab. 1 time per day (in the evening after meals) - take a long time;
• T. Preductal MB 1 tab. 2 times a day (morning, evening) - 1 month, 4 courses per year;
• T. Panangin 1 tab 3 times a day - the first 10 days of each month;
• Caps. Essentiale forte N 1 caps 3 times a day with meals - take at least 3 months.
3. Control of blood pressure, heart rate daily, ECG 1 time in 1-2 months.
MILITARY MEDICAL ACADEMY
Hospital Therapy Clinic
Discharge summary No.
born in 1964 (43 years old), was examined and treated at the hospital therapy clinic with a diagnosis of:
Hypertension stage II. (AH grade 2, risk 3). ischemic heart disease. Angina pectoris II f.k. Atherosclerosis of the aorta, coronary arteries. Atherosclerotic cardiosclerosis. NC I Art. Dyscirculatory encephalopathy of the second stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders. Chronic toxic steatohepatitis with moderate activity. Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (27.02.02) due to a closed fracture of the surgical neck of the shoulder (15.02.02) and its repeated fracture (18.07.02) with moderate dysfunction of the left upper limb. A consolidating fracture of the neck of the right femur with the presence of a construct (September 25, 2006).
He was admitted to the clinic in a planned manner with complaints of compressive pain in the chest, shortness of breath during exercise, aching headaches with increased blood pressure, dizziness, general weakness, impaired concentration, memory loss, pain in the right shoulder and right thigh.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
Ht,
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Cia
%
22.12
138
4.36
15.0
42.4
33
396
1
10
7
7
75
Biochemical analysis of blood:
Name
Unit. rev.
Norm
22.12
Name
Unit. rev.
Norm
22.12
Creatinine
mmol/l
53-124
70
CS
mmol/l
3.7-6.0
6.31
Urea
mol/l
3-8.4
3.1
TG
Mole/l
0-2.37
1.32
Prothromb. index
%
70-120
102
β-LP
Unit
350-650
540
Fibrinogen
g/l
200-400
320
HDL
mol/l
0.78-2.33
Total protein
g/l
63-87
72.9 Cholesterol
/HDL
Times
3-5
Albumin
%
50-70
49.5
VLDL
mol/l
0.6-1.2
1
%
3 -6
6.2
odds atheros.
Unit
0-3
2
%
9-15
14.5
amylase
U/L
28-100
82.4
%
8-18
16.2
trypsin
u/l
0-0.35
%
15-25
13.6
Ig M
g/l
0.65-1.65
a/ G
1.1-2.5
0.98
Ig G
g/l
7.5-15.5
ALT
U/L
8.4-53.5
72.6
Ig A
g/l
1.25-2.5
AST
U/L
7-39.7
37 .0
CEC
U
6-66
ALP
U/L
36-92
54.6
Fe
Mmol/l
10.5-25
5.76
LDH
U/L
100-220
Na
Mmol/l
130-150
141.4
GGTP
U/L
11-63
77 .8
Ca mmol/
l
2.0-2.7
2.12
Glucose
mmol/l
4.2-6.4
5.49
K
mmol/l.
4-5.5
4.63
Tot. bilirubin
µmol/l
6.8-26
8.1
Sialic
acids mmol/l
1.9-2.5
3.1
Urinary
acid fmol/l
150-420
287
T3
mmol/l
66-181
CPK
units/ l
10-160
148.1
T4
Mmol
/l
1.3-3.1
HBsAg, antiHCV qual negative ref
RW
qual
Results
of
instrumental studies:
X-ray examination and ECG registration was refused due to a "recent study".
Ultrasound examination from 30.03.2007. The liver is enlarged, the right lobe is 17.8 cm, the left lobe is 10.4 cm. The contours are even, the structure is homogeneous, echogenicity is increased, the vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape (curved, partially reduced). The pancreas is located indistinctly, it is not enlarged, the contours are fuzzy, even, the structure is homogeneous, echogenicity is average, the Wirsung duct is not dilated. Kidneys: location and size are normal. Right - the contours are even, the parenchyma is homogeneous 16 mm, the cavity system is not expanded, there are no stones: the left one - the contours are not even, the parenchyma is homogeneous 18 mm, the cavity system is not expanded, there are no stones. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 8.8x3.6 cm, the structure is homogeneous. Flatulence.
EchoCG from 12/25/2008. Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed, calcifications in the AC. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no pericardial effusion.
Treatment was carried out: regimen, diet, olicard, ACC thrombosis, metoprolol, phenazepam.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
1. Observation of a therapist, neuropathologist, traumatologist of the TsKDP VMA.
2. Optimization of the regime of work, rest, nutrition.
2. Continue taking
• Olikard 0.04 1 caps. 1 r / d after breakfast
• Thrombo ACC 0.1 1 tab. 1 r / d after breakfast
• Metoprolol 0.05 ½ tablet 2 r / d (after breakfast and dinner)
• Asparkam 1 tablet 3 r / d the first 10 days of each month.
MILITARY MEDICAL ACADEMY
Hospital Therapy Clinic
Discharge summary No.
born in 1964 (43 years old), was examined and treated at the hospital therapy clinic with a diagnosis of:
ischemic heart disease. Angina pectoris II f.k. Atherosclerosis of the aorta, coronary arteries. Atherosclerotic cardiosclerosis. Hypertension stage II. (AH grade 2, risk 4). NC I Art. Dyscirculatory encephalopathy of the second stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders. Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (27.02.02) due to a closed fracture of the surgical neck of the shoulder (15.02.02) and its repeated fracture (18.07.02) with moderate dysfunction of the left upper limb. A consolidating fracture of the neck of the right femur with a construction (09/25/2006) with a slight dysfunction of the right lower limb.
He was admitted to the clinic in a planned manner with complaints of compressive pain in the chest, shortness of breath during exercise, aching headaches with increased blood pressure, dizziness, general weakness, impaired concentration, memory loss, pain in the right shoulder and right thigh.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
CP
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
21.03
141
4.5
11.0
0.94
24
1
27
3
6
63 Rehberg's
test
Date
Blood
creatinine Urine creatinine
Diuresis in 1 min
Glomerular filtration
Tubular reabsorption
22.03
0.08
18.65
0.83
193.5
99.6
Biochemical blood test:
Name
Unit. rev.
Norm
22.03
Name
Unit. rev.
Norm
11.12
Creatinine
mmol/l
53-124
CS
mmol/l
3.7-7
2.87
Urea
mol/l
3-8.4
6.4
TG
mol/l
0-2.37
0.44
Prothrombindex
%
70-120
β-LP
U
350-650
450
Fibrinogen
g/l
200-400
HDL
mol/l
0.78-2.33
Total protein
g/l
63-87
65
LDL
Mole/l
1.9-4
Albumin
%
50-70 Cholesterol
/HDL
Times
3-5
1
%
3-6
VLDL
Mole/l
0.6-1.2
2
%
9-15
coef. atheros.
Unit
0-3
%
8-18
amylase
U/L
28-100
%
15-25
trypsin
u/l
0-0.35
a/g
1.1-2.5
Ig M
g/l
0.65-1.65
ALT
U/L
8.4-53.5
14.6
Ig G
g/l
7.5-15.5
AST
U/L
7-39.7
11.02
Ig A
g/l
1.25-2.5
ALP
U/L
36-92
CEC
U
6-66
LDH
U/L
100-220
Cl
Mole /l
95-108
GGTP
U/L
11-63
11.8
Na
Mole/l
130-150
Glucose
mmol/l
4.2-6.4
4.5
Ca
Mole/L
2.0-2.7
1.85
Total bilirubin
µmol/l
6.8-26
5.6
K
mmol/l.
4-6
ALK pos
U/L
36-92
102.3
T3
Mol/l
66-181
Urinary
acid fmol/l
150-420
T4
Mol/l
1.3-3.1
CPK
u/l
10-160
RW
qual
Results of instrumental studies:
ECG from. 03/21/2007, Sinus rhythm with a heart rate of 58 beats, horizontal EOS. Left ventricular hypertrophy. Syndrome of early repolarization. Local violations of intraventricular conduction, violations of repolarization in the region of the lower wall.
Ultrasound examination from 30.03.2007. The liver is not enlarged, the right lobe is 13.8 cm, the left lobe is 6.4 cm. The contours are even, the structure is homogeneous, the echogenicity is medium, the vessels are not dilated, the portal and hepatic veins are normal, the intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape (curved, partially reduced). The pancreas is located indistinctly, it is not enlarged, the contours are fuzzy, even, the structure is homogeneous echogenicity is average, the Wirsung duct is not dilated. Kidneys: location and size are normal. Right - the contours are even, the parenchyma is homogeneous 16 mm, the cavity system is not expanded, there are no stones: the left one - the contours are not even, the parenchyma is homogeneous 18 mm, the cavity system is not expanded, there are no stones. In the projection of the location of the adrenal glands, no pathological formations were found. The spleen is not enlarged 8.8x3.6 cm, the structure is homogeneous. Flatulence.
EchoCG from 03/29/2007. Aorta 37 mm, aortic ring 24 mm, asc. aorta 39 mm, opening of the aortic valve 21.4 mm, LA 37 mm, CRLV 34 mm, CRLV 54 mm, fr thrust 28%, fr select 56%, AP 12.4 mm IVS 13 mm, PP 43 mm, RV 24 mm; the myocardium is symmetrically thickened, the cavities are not dilated. LV diastolic dysfunction. The aorta is sealed, calcifications in the AC. The valves are intact, the blood flow is laminar, there is valvular regurgitation on the MV. The pericardium is unchanged, there is no pericardial effusion.
The results of VEM and ECG Holter monitoring are on hand
X-ray of the chest organs dated 30.03.2007. In the lungs without fresh focal and infiltrative changes. The roots of the lungs are structural, the sinuses are free. The heart is slightly dilated to the left. The aorta is elongated.
X-ray of the skull from 30.03.2007. On survey craniograms in two projections, the Turkish saddle is normal. There is thinning of the bones of the cranial vault.
Radiography of the right hip joint dated April 2, 2007: on the radiograph of the right hip joint in two projections. Condition after metal osteosynthesis in the area of comminuted fracture of the upper third of the femur. The callus is expressed satisfactorily. The bolt of a metal structure protrudes into the soft tissue by 2.5 cm.
Specialist consultations
Optometrist: VIS OD 1.0; OS 1.0 IOP OD,OS - 18mm Hg
The auxiliary apparatus and the outer parts of the eyeballs are not changed, the optical media are transparent. The fundus of the eye: optic nerve disc of satisfactory nutrition, the contours are clear. The veins are moderately dilated, the arteries are sealed. Focal pathology is not defined.
Neurologist: Dyscirculatory encephalopathy of the 2nd stage of mixed genesis in the form of right-sided pyramidal-cerebellar insufficiency and astheno-neurotic syndrome with emotional-volitional disorders.
ENT: Endoscopic ENT organs without visible pathology. SR 6 m.
Traumatologist: Post-traumatic persistent combined contracture of the left shoulder joint after osteosynthesis with a plate (02/27/02) due to a closed fracture of the surgical neck of the shoulder (02/15/02) and its repeated fracture (07/18/02) with moderate dysfunction of the left upper limb . A consolidating fracture of the neck of the right femur with a construction (25.09.2006) with a slight dysfunction of the right lower limb.
Treatment was carried out: regimen, diet, olicard, ACC thrombosis, metoprolol, phenazepam.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition
Recommended:
1. Observation of a therapist, neuropathologist, traumatologist of the TsKDP VMA.
2. Optimization of the regime of work, rest, nutrition.
2. Continue taking
• Olikard 0.04 1 caps. 1 r / d after breakfast
• Thrombo ACC 0.1 1 tab. 1 r / d after breakfast
• Metoprolol 0.05 ½ tablet 2 r / d (after breakfast and dinner)
• Asparkam 1 tablet 3 r / d the first 10 days of each month.
MILITARY MEDICAL ACADEMY
Hospital Therapy Clinic
Discharge summary from case history No. 86
was examined and treated at the Military Medical Academy Hospital Therapy Clinic from 24.12.2009 to 12.01.2010.
DIAGNOSIS:
IHD: stable exertional angina 3 FC. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, out of paroxysm.
Hypertension III degree. (AH 2, CVE risk is extremely high). NK 2a st., 3 FC.
Cerebrovascular disease. Acute cerebrovascular accident of the ischemic type in the basin of the right middle cerebral artery from December 2009. Dyscirculatory encephalopathy of the 3rd stage of mixed (atherosclerotic, hypertensive) genesis in the form of scattered neurological symptoms, vestibulopathic and unexpressed psychoorganic syndromes.
Osteochondrosis of the thoracic spine with pain syndrome.
Cholelithiasis. Chronic calculous cholecystitis without exacerbation.
Omission of the right kidney 1 degree.
Varicose disease of the lower extremities, CVI-2st.
Phenomena of initial cataract in both eyes. Severe angiosclerosis of the retina. Initial macular degeneration of both eyes.
Upon admission, she complained of periodic pressing pains in the region of the heart, of varying duration, that occur after climbing to the 2nd floor, stopping on their own after the cessation of physical activity; periodic heartbeats, interruptions in the work of the heart; episodic increase in blood pressure up to 180\90 mm Hg, episodic dull aching headache without clear localization with an increase in blood pressure; pain in the spine, aggravated by physical exertion, unsteady gait, hearing and vision loss during the last month, memory loss, fatigue.
Results of instrumental studies:
X-ray of the chest organs No. 195 dated 12/25/09: on a chest radiograph and on fluoroscopy in the lungs without focal and infiltrative changes. Moderate diffuse emphysema, at the level of the 2nd rib on the left, areas of limited pneumofibrosis 1.5 * 1.0 cm are determined. The roots are structural, not expanded, free fluid in the pleural cavity is not determined. The diaphragm is flattened on the left, the costophrenic sinus is obliterated on the left. The heart is slightly dilated to the left. The aorta is compacted and deployed.
X-ray of the thoracic spine No. 2681 dated 11/17/09. in 2 projections - physiological kyphosis is enhanced (senile round back). Osteochondrosis in the mid-thoracic region with a decrease in the height of the discs, osteochondral sclerosis and marginal exophytes in direct projection up to 0.1 cm.
On ECG No. 176 dated 06.11.09. and 26.12.09. sinus rhythm is recorded with a heart rate of 65 per 1 minute, the EOS is deflected to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His). Left ventricular hypertrophy.
ECHO-KG from 01/08/2010: The cavities are not enlarged, free, the myocardium is not thickened, the kinetics is not disturbed, the aorta is sealed, the walls are thickened, calcification of the aortic crescents. Sealing, calcification of the mitral valve leaflets. Regurgitation of the 1st degree on the TC and MC, valvular on the aortic and pulmonary valves. Pulmonary blood flow is not disturbed. The pericardium is not changed
. Ultrasound of the OBP dated 11.01.2010. Multiple gallbladder calculi with a diameter of up to 10 mm., The right kidney is located 3 cm below its usual location. Visceroptosis.
FVD dated December 27, 2009. conclusion in hand.
CT scan of the head dated December 30, 2009. - conclusion on hand
Results of laboratory tests:
Clinical blood test (automatic processing):
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
MCHC, g/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
26.12.
113
3.62
5.1
326
25
2
1
46
7
1
43
11.01.
116
3.84
5.4
319
30
1
40
6
3
47 Complete
urinalysis (automatic processing):
Date
U.weight
Reak
Protein
Sach
Cylinder
Leu
Er.neiz
Urobil
26.12
1020
6.0
-
-
No
-
-
-
Biochemical blood test:
Name
Unit of measure.
Norm
25.12.2009
11.01.10
AST
U/l
11-50
20
ALT
U/l
11-50
16
CPK
U/l
10-160
68.6
O. bilirubin
mmol/l
6.8-26
8.4
Creatinine
mmol/l
0.05-0.12
0.12
Potassium
mmol/l
3.5-5.1
4.21
4.14
Serum iron
mmol/l
10.5-25
9.47
Total protein
g/l
64-83
70.8
72.7
glucose
mmol/l
3.9-6.2
5.57
F-50, HBsAg, HCV, RW: negative.
Examination of feces on December 26, 2010: no pathology, I/g were not detected.
Consulted by a neurologist. The diagnosis is specified, recommendations are given.
Consulted by an ophthalmologist. The diagnosis is specified, recommendations are given. A prescription for reading glasses has been issued.
Endoscopic examination of the gastrointestinal tract was not performed due to the patient's condition.
Treatment was carried out: regimen, diet, noliprel-forte, cordarone, aspicor, cytoflavin, rudotel, gliatilin, phezam, mildronate.
Discharged home in a satisfactory condition under the supervision of medical specialists of the clinic. A temporary disability sheet was not issued.
Recommended:
1. Supervision by a neurologist, a cardiologist.
2. Continue taking:
• Tab. Noliprel 1 tab. in the morning all the time.
• Tab. Thrombo ASS 0.05 1 tab. in the morning all the time.
• Tab. Preductal MB 1 tab. 2 times a day all the time.
• Tab. Gliatilin 0.4 1 tab. 3 times a day from 11 to 20 January 2010
• Caps. Phezam 2 caps. morning and afternoon from 11 to 20 January 2010.
• Quinax - 2 drops in each eye 4 times a day for 1 month.
• Actovegin 20% - 250ml intravenously 1 time per day for 2 weeks, starting from 20.01.10.
• Tanakan 1 tab 2 times a day from January 20 to February 20, 2010.
3. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
4. Limit the intake of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
5. Repeated hospitalization according to indications.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr., 63 tel. (812) 577-11-35
DISCUSSION REPORT CASE
HISTORY No. 657 ACCORDING TO ARCHIVE No. _________
She was hospitalized (in the day hospital mode)
in the hospital therapy clinic
from September 22, 2014 to September 26, 2014. Departed from VMA "26" 09 2014
Total days of treatment 5
The final diagnosis was established on 25.09.2014. ICD code I 11.9
Hypertension stage II (normotension, the risk of cardiovascular complications is “high”). Aortic atherosclerosis without heart failure.
Polyposis of the large intestine.
A disability certificate was not issued.
The ability to work is not impaired.
Total radiation dose 0.26 mSv
Clinical outcome: discharge.
The results of laboratory studies in dynamics:
General clinical analysis of blood:
Date
Hb, units.
Er., *1012/l
MCH
fl
Leuc., *109/l
Ht
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pi
%
Xia
%
22.09
133
4.91
27.1
6.2
44.5
8
349
5
22.1
10.3
1
60
_
_
_
Norm
22.09
Indicator
22.09
Creatinine
Mkmol/l
53-124
115.2
Color Yellow
Cholesterol
Mmol
/l
3.7-6.0
6.13
Transparency
trans.
Triglycerides
mmol/l
0-2.37
0.87
Specific Weight
1020
PSA
Mmol/l
up to 4
1.34
Protein (g/l)
no
Glucose
mmol/l
4.2-6.4
5.39
Sugar
No
Fibrinogen
g/l
2-4
3.67
Leukocytes in p/s
1-2-3
Potassium
mmol/l
4.0-6.0
4.46
pH
6.0
Urea
mmol/l
3.0-8.4
6.5
Results of instrumental studies:
ECG on September 22, 2014: Sinus rhythm, 74 per min. Normal position of the EOS. Partial violation of intraventricular conduction.
Ultrasound of the abdominal organs on September 22, 2014: Liver: right lobe - 13.2 cm, left - 5.7 cm, echogenicity is not changed, the vessels are not dilated. Portal vein less than 13 mm. The pancreas is located clearly, hyperechoic, the contours are clear, even. The gallbladder of the correct form, not enlarged. The PCL is not dilated; in the right kidney, the sinus is divided by a hypoechoic band. The spleen is not changed. Conclusion: Diffuse changes in the pancreas. Doubling of the right kidney.
ECHO-KG from 23.09.2014: MZHP-9.9mm, ZS-10.5mm, KDR LV-56.1mm, KSR LV-38.8mm, PV-58%, FU-31%, LP-32× 37×46mm, PP-37×46mm, RV-28mm, E/A=1.1 LV myocardial mass 267 g, IMM 136 g/m2. The walls of the aorta are sealed. The myocardium is slightly eccentrically hypertrophied. The cavities of the heart are free, not dilated. Global LV systolic function was preserved. Zones of local violation of contractility were not identified. Type I diastolic dysfunction. The valves are intact. Doppler examination revealed no pathology. Pericardium without features.
24-hour Holter ECG monitoring on September 23, 2014: during the observation period, sinus rhythm was recorded with a heart rate of 63 to 130 per minute, the decrease in heart rate at night was insufficient. Average heart rate 78/82/70 in 1 minute. Single supraventricular extrasystoles were registered (23 in total). When performing the planned load, the heart rate reached 130 and 123 in 1 minute, while the patient noted dizziness. No ischemic changes in the ST segment were detected.
Daily monitoring of blood pressure from 09/23/2014: Mean blood pressure 137/97 mm Hg. Art. during the day and 126/91 mm Hg. Art. at night. Daytime mean systolic BP is characteristic of mild labile hypertension, while nighttime BP is characteristic of mild stable hypertension. At night, systolic and diastolic blood pressure decrease insufficiently (nondipper). Episodes of hypotension were not registered.
X-ray of the chest organs No. 859 dated September 22, 2014: in the lungs without focal and infiltrative changes. The roots of the lungs are fibrously compacted, not expanded. Heart - aortic configuration due to the enlarged left ventricle. The aorta is enlarged and thickened.
Spirometry dated 09/25/2014: VFL within normal limits.
Spirometry (test with bronchodilator) from 09/25/2014: test with salbutamol: bronchodilation coefficient was 1.6%, which corresponds to the physiological variability of the bronchial lumen.
Fibrocolonoscopy dated 09/24/14: perianal skin is not changed. On digital examination, the tone of the rectal sphincter is normal. In the anus area, collapsed hemorrhoids and moderately tense internal hemorrhoids with inflamed mucosa above them are determined. The distal end of the fibrocolonoscope was inserted into the rectum, where 2 hyperplastic polyps on a wide base 0.3-0.4 cm in diameter were detected in the ampulla. At 15 cm in the upper ampullar part, a half-dip on a narrow base with a diameter of 0.5 cm. In the distal part of the sigmoid colon (23-25 cm), a polyp on a long stalk 2.0x2.5 cm (biopsy). In the descending colon - multiple (4) polyps on a narrow and wide base from 2 to 0.5 cm. In the region of the splenic angle, a polyp on a short stalk 1 cm (biopsy). Endoscopic electroexcision of polyps is recommended.
Conclusion: colon polyposis. Exacerbation of internal hemorrhoids.
Biopsy material (FCC dated September 24, 2014): in progress.
Recommended:
5. Supervision by a general practitioner, gastroenterologist at a polyclinic at the place of residence.
6. consultation of a surgeon to resolve the issue of surgical intervention for intestinal polyposis.
7. taking the drug: rosuvastatin 10 mg, 1 tab. in the evening for a long time.
8. with an increase in blood pressure above 140/90 mm Hg. Art. taking capoten sublingually 25 mg.
September 26, 2014.
DISTRICT MILITARY CLINICAL HOSPITAL IM. Z.P. SOLOVIEV
Discharge summary No.
born in 1948 (58 years old), was examined and treated in the 23rd cardiological department of the 442th OVKG with a diagnosis of:
Ischemic heart disease, angina pectoris of the third functional class, atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis. Hypertensive disease of the second stage (arterial hypertension-2 Risk-4). Circulatory insufficiency stage IIa. Chronic heart failure of the third functional class. Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of diffuse neurological symptoms. Osteochondrosis of the thoracic, lumbar spine with a slight dysfunction. Chronic vertebrogenic sciatica with L5-S1 with radicular syndrome in remission. Chronic atrophic gastritis in remission. Angioectasia of the stomach. Prostate adenoma. Partial secondary adentia.
He was admitted to the clinic in a planned manner with complaints of dull pressing pain in the left half of the chest and behind the sternum with irradiation to the left hand when climbing to the 2nd floor or walking on a flat area for 100-150m, dull diffuse headache, dizziness, rise in blood pressure to 170/110 mm Hg, shortness of breath, palpitations, nausea.
Laboratory results:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
24.11
132
4.51
6.0
4
248
-
-
30.2
5.3
3
61.5
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
14.11
clear
1030
yellow
sour
no
no
urate
no
no
no
no
no
1-2
1-2
Biochemical blood test:
Name
Unit. rev.
Norm
24.11
CS
mmol/l
3.7-7
5.97
Total protein
g/l
63-87
69
ALT
U/L
8.4-53.5
14
AST
U/L
7-39.7
21
Cl
mmol/l
95-108
106
Na
mmol/ l
130-150
142
K
mmol/l.
4-6
4.8
GGTP
U/L
7-63
24
Glucose
mmol/l
4.2-6.4
5.3 Vol
. bilirubin
µmol/l
6.8-26
22.9
Fibrinogen
g/l
2.0-4.0
2.47
1.12.2006: APTT (1.12.06) =46 sec, INR (1.12.06)=0.88
Results of instrumental studies:
ECG dated 24.11.2006 .: Sinus rhythm with a frequency of 60 bpm, vertical EOS (α=800), increased potentials of the left ventricle.
ECHO-KG from 11/24/2006: MZHP-11.0mm, ZS-11.0mm, KDRLV-48mm, KSRLZh-33mm, EF-45%, E/A=0.6 Myocardium is symmetrically thickened. The cavities are free, not dilated, the valves are not changed, the leaflets of the mitral and aortic valves, the aorta is sealed. The pericardium is intact. The kinetics is not broken. Diastolic dysfunction of the left ventricle.
Ultrasound of the abdominal organs dated 11/15/2006: the liver is not enlarged, the contours are even, the vascular pattern is not clear, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein 13 mm, hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder is of the correct form, the contours are even, calculi and polyps are not visualized. The pancreas is located indistinctly, diffusely heterogeneous structure, the contours are clear, even, echogenicity is increased; Wirsung's duct is not dilated. Kidneys of normal size, normal location, with smooth contours, homogeneous parenchyma. The spleen is not enlarged. In the projection of the location of the adrenal glands, no pathological formations were found. The bladder is full, with a volume of 250 ml, the contours are even, the walls are not thickened (3-4 mm) The prostate gland V = cm3, the contours are fuzzy, the structure is heterogeneous due to compaction areas. Fibrosis in the right lobe. Smoothed interlobar furrow. The middle lobe protrudes slightly into the lumen of the bladder. The volume of residual urine is 30 ml.
Fibrogastroduodenoscopy No. 1156 dated December 8, 2006: in the study of the esophagus, stomach, duodenum, cardiac sphincter insufficiency, chronic gastritis with diffuse atrophy of the mucous membrane of the antrum of the stomach is determined. In the prepyloric and antral regions, two angioectasias are determined along the lesser curvature. The duodenal bulb and postbulbar section are not visually changed.
X-ray of the chest organs dated November 25, 2006: Conclusion: On the survey radiograph of the chest cavity organs in the lungs without fresh infiltrative changes. The roots are structural, the diaphragm is flattened, no free fluid was found in the pleural cavity. The heart is expanded in diameter to the left, the aorta is sealed.
On spondylograms of the thoracic spine in 2 projections from 26.11.06: increased physiological kyphosis due to a decrease in the height of the vertebral bodies in the anterior section Th5-6-7-8 small cartilaginous hernias on the upper and lower areas of the vertebral bodies. Deforming spondylosis Th4-11. X-ray picture of the consequences of osteochondropathy.
Treatment was carried out: regimen, diet, polarizing mixture, asparkam, atenolol, thrombolytic ACC, enalapril, sydnopharm, metabolic therapy.
On the background of the therapy, the patient's condition improved. Does not require sick leave.
Discharged in a satisfactory condition.
Recommended:
217. Outpatient monitoring by a cardiologist.
218. Exclude animal fats, fried, spicy foods from the diet.
219. Increase in the diet: raisins, dried apricots, prunes, vegetable fats.
220. Dispensary observation:
a. clinical blood test (with platelet count), urinalysis - 4-6 times a year;
b. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - at least 2 times a year;
c. Echocardiography - 2 times a year;
221. Continue taking:
a. Concor 5mg - 1 tab. in the morning - constantly
b. Sidnopharm - 1 tab. 3 times a day - constantly
c. Thrombo ACC 0.01 - 1 tab. In the morning
d. Ko-renitek - ¼ tab 2 times a day MILITARY MEDICAL
ACADEMY
Form 12_Un
.
Last name, first name, patronymic_
Was on inpatient treatment
at the hospital therapy clinic
Total days of treatment 12
The final diagnosis was established ICD code_I 50.0_
Diagnosis:
Main: coronary artery disease. Stable angina pectoris III f.k. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and postinfarction (2004) cardiosclerosis. Secondary dilated cardiomyopathy.
Complications of the underlying disease: Aneurysm of the apex of the left ventricle. CHSN 2B, IVf.k. Right-sided hydrothorax. Cardiac asthma from 12/22/2010. DN 2 tbsp.
Accompanying: Hypertension III Art. (AH 1, risk IV). Chronic viral hepatitis B, stage of cirrhosis. Dyscirculatory encephalopathy 2 tbsp. mixed (atherosclerotic, hypertensive, dysmetabolic) genesis. Degenerative-dystrophic disease of the spine. Diabetes mellitus of the second type, compensation. Chronic pyelonephritis, latent course.
CKD 3 st (GFR=58 ml/ min
/ 1.73m2) CKD
-
1a
st
. :
Complaints: increasing dyspnea of a mixed, predominantly inspiratory nature, noted at rest, aggravated in a horizontal position; discomfort in the right half of the chest at rest, paroxysmal cough without discharge, increasing weakness, decreased exercise tolerance.
Disease history. For a long time he suffers from coronary heart disease, hypertension. I have been drinking alcohol for a long time. In 2004, she suffered a massive myocardial infarction. 17.10.10 performed surgical treatment for bleeding (shock 2-3) from a chronic stomach ulcer. During the same hospitalization, decompensated diabetes mellitus was diagnosed. After discharge, she did not comply with the doctor's recommendations, she began to notice an increase in the volume of the abdomen. On this occasion, she was repeatedly hospitalized in the hospitals of the city, where complex treatment was performed with active diuretic therapy. After discharge from the pulmonology department of City Hospital No. 26, his condition deteriorated sharply. From December 23, 2010 to January 14, 2011, she was treated at the GT VMedA clinic. In view of the resistance of pathological exudation in the right pleural cavity to diuretic therapy and mechanical removal of fluid during pleural punctures, in the diagnosis, the patient was recommended to perform a CT scan in order to exclude a neoplasm of the right lung, mediastinum, and abdominal organs. When trying to perform tomography, the study turned out to be uninformative, according to the patient, due to the presence of fluid in the pleural cavity. During the last week, she began to notice an increase in dyspnea, its occurrence at rest. In this connection, she was taken by an ambulance to the hospital therapy clinic for urgent indications. When trying to perform tomography, the study turned out to be uninformative, according to the patient, due to the presence of fluid in the pleural cavity. During the last week, she began to notice an increase in dyspnea, its occurrence at rest. In this connection, she was taken by an ambulance to the hospital therapy clinic for urgent indications. When trying to perform tomography, the study turned out to be uninformative, according to the patient, due to the presence of fluid in the pleural cavity. During the last week, she began to notice an increase in dyspnea, its occurrence at rest. In this connection, she was taken by an ambulance to the hospital therapy clinic for urgent indications.
Objective status: general condition of moderate severity, swelling of the feet, legs, heart rate 90 per minute, no deficit, rhythmic pulse, auscultatory tones of the heart are muffled, the 1st tone is weakened above the apex of the heart, there is a rough systolic murmur at the apex, the boundaries of the heart are expanded, BP 110/60 mm Hg in the lungs, hard breathing, single congestive rales in the lower lobe on the left, on the right, breathing is not heard in the zone of dullness from the level of the 5th rib; the abdomen is not enlarged, soft, painless on palpation, the edge of the liver protrudes 4 cm from under the costal arch, effleurage in the lumbar region is painless on both sides.
As a result of the treatment: regimen, diet No. 9, metabolic therapy (polarizing mixture: Sol.NaCl 0.9% -200.0, Sol.Asparcami 20 ml), inotropic therapy (Korglikon 0.06% 1.0 i.v. drip, Digoxin 0.00025, 0.5 tablets in the morning), hypoglycemic therapy (Maninil 0.0035, 2 tablets per day), antibacterial therapy (Augmentin, 1 tablet 2 times a day), diuretic therapy (Diuver 0.01 1 tab per day, Hypothiazid 0.025, 2 tab. in the morning), beta-adrenolytics (Betaloc-Zok 0.05, 0.25 tab. 2 times a day), antithrombotic therapy (Acecardol 0.1, 1 tab. 1 time per day), hepatoprotective therapy (Essentiale 5.0 No. 5 IV), punctures of the right pleural cavity (January 27, 31, February 07 with evacuation of 2700 ml, 1500 ml, 2000 ml of straw-yellow liquid, subsequent administration of 80 mg of gentamicin intrapleurally), the state of health improved, shortness of breath decreased,cough regressed, edema in the legs disappeared, a small amount of fluid remained in the supraphrenic parts of the right lung.
Taking into account the resistance of pathological exudation in the right pleural cavity to diuretic therapy and mechanical removal of fluid during pleural punctures, as well as taking into account the one-sidedness of the effusion (right pleural cavity), further diagnosis should still exclude a neoplasm (pleural mesothelioma?
) it is impractical, since this manipulation requires one-lung ventilation of the lungs - the patient will not tolerate this intervention due to functional disorders.
Data for tuberculosis were not received.
Results of instrumental studies:
ECG 02/27/2011, heart rate - 91 per minute Sinus rhythm, EOS to the right. Cicatricial changes in the anterior-septal, apical-lateral section of the left ventricle. Signs of hypertrophy of both ventricles, left atrium. Diffuse disorders of repolarization. Complete blockade of the right leg of the bundle of His.
ECG from 02/01/2011: Sinus tachycardia. Heart rate 95 per minute. EOS is deflected to the left. Cicatricial changes in the anterior-septal, apical-lateral section of the left ventricle. Complete blockade of the right leg of the bundle of His. Violation of repolarization processes along the posterior and lateral walls. Frequent monotopic monomorphic ventricular extrasystoles.
ECG from 02/07/2011: heart rate 90 per minute. There is a weakly positive dynamics in the form of normalization of repolarization processes, the absence of rhythm disturbances.
X-ray of the chest on 02/07/2011 (control after pleural puncture dated 02/07/2011): after a pleural puncture with the removal of 2 liters of fluid, the lung fills the pleural cavity completely. Fresh focal and infiltrative changes were not found. The roots of the lungs are moderately compacted. In the right pleural cavity, a small amount of fluid is retained in the supradiaphragmatic regions. The heart is considerably enlarged in diameter to the left. The aorta is sealed.
CT scan of the chest, abdomen, small pelvis dated 01/31/2011: condition after drainage of the right pleural cavity. Right-sided hydrothorax. Multiple subsegmental atelectasis of the right lung. Lymphadenopathy of the upper paratracheal group. Enlargement of the heart. Moderate hepatomegaly. Ascites.
Laboratory results:
Clinical blood test: Hb
date
, units.
Er
.
,
*
1012
/
l
Leuc
.
,
*
109
/
l
MCH
ESR
,
mm
/
h
_
_
_
_
_
_
_
_
18.01.
129
5.02
9.6
25.6
9
6
-
27
6
2
59
Biochemical analysis of blood: Analysis of urine:
Name
Unit of measure.
Norm
28.01
Indicator
28.01
01.02.
Creatinine
µmol/l
53-124
110
Color
Yellow
Yellow
Cholesterol
Mole/l
3.7-6.0
Clarity
Light hazy.
Transparency
Triglycerides
Mole/l
0-2.37
Specific. Weight
More than 1030
1.020
Total protein
G/l
63.0-87.0
63
Reaction
5.0
6.5
Calcium
Mole/l
2.1-2.5
2.25
Protein (g/l)
1.0 g/l
1.0
Potassium
Mole/l
3.5-5.1
4.88
Sugar
No
No
Glucose
Mole/l
4.2-6.4
5 .02
Urobilin
3.2
3.2
Prothrombin
%
70-120
113
Leukocytes in s/s
5-7
4-6
Fibrinogen
Mg/dl
200-400
300
Erythr. unchanged in s/s
1-2
0-1
CPK
U /l
10.0-160.0
Erythr. Vyschi. V p/s
No
no
AST
U/l
11.0-50.0
Salts
No
No
ALT
U/l
11.0-50.0
Mucus
1
1
Total bilirubin
Mole/
l
6.8-26.0
Hyal. 1-2
No
Urea mmol
/
l
8.2
11.9
7-10
5-7
LDH
U/L
251
Bacteria
Moderate Quantity
Moderate Quantity
Analysis of pleural fluid from 01/27/2011: 2500 ml yellow, cloudy. Revolta test negative. Protein 30 g/l. Leukocytes 6.2*109/l, erythrocytes 17.7*109/l, macrophages, mesothelium, epithelial cells 3.25*109/l. Leukocytes are represented by 70% lymphocytes. Macrophages make up 15%; in macrophages and neutrophils there are cocci, single diplococci. Mesothelial cells are single. VC were not identified.
Analysis of the pleural fluid from 01/31/2011: 1400 ml of a lemon-yellow liquid, slightly cloudy, was delivered. Protein 30.1 g/l. Revolt's test is negative. Leukocytes 15.25*109/l, erythrocytes 63.75*109/l, macrophages, mesothelium, histiocytes 55.75*109/l. There are a large number of cell complexes in the chamber grid and outside it. Glucose 6.14 mmol / l. LDH 240 U/l.
Sputum analysis from 02/03/2011: Pink, viscous, mucous with an admixture of blood. Epithelium squamous 0-3 in p/s, ciliated 0-5 in p/s, alveolar 0-3 in p/s, atypical cells were not found, leukocytes 10-20-50 in p/s, erythrocytes cover all p/s . VK not found. Staphylococci in moderation. Diplococci in small numbers. Yeast-like mushrooms.
Examination of pleural exudate for the activity of Adenosine DesAminase (a marker of tuberculosis): 14 U / l (the threshold value for the diagnosis of tuberculosis is 35 U / l).
Discharged in a satisfactory condition under the supervision of polyclinic doctors
Recommended:
31. Observation of a general practitioner, cardiologist, endocrinologist, hepatologist at the place of residence
32. Compliance with the diet, normalization of the regime of work and rest. Avoid psycho-emotional stress. Limit salt and liquid intake. Control of blood pressure and heart rate. exercise therapy.
33. Performing an analysis of the pleural fluid for atypical cells (Foundry 37, tel. 272-67-67). Glasses with smears of pleural fluid were handed out.
34. Consultation of cardiologists in the Federal Center. Almazov, tel. 702-37-06
35. Consultation of a thoracic surgeon at the place of residence for periodic pleural punctures.
36. Continue taking:
• Tab. Digoxin 0.00025 ½ tablet in the morning (except Saturday and Sunday)
• Tab. Metoprolol (Betaloc-ZOK) 0.05 ¼ tablet 2 times a day constantly.
• Tab. Enalapril 0.01 ¼ tablet 2 times a day continuously.
• Tab. Preductal MB (Trimetazidine) 1 tablet 2 times a day for a month.
• Tab. Maninil 0.0035 1 tablet 2 times a day continuously.
• Tab. Diuver 0.01 1 tablet on an empty stomach - in the presence of edema.
• Tab. Aspirin (Acecardol, Thrombo-ASS, Aspicor) 0.1, 1 tab. in the evening all the time.
• Tab. Panangin 1 tablet 3 times a day for 10 days of each month.
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
Discharge summary No. 963
was examined and treated at the hospital therapy clinic
from August 30 to September 13, 2010 with a diagnosis of
hypertension stage III. (AH 2, CVE risk is extremely high).
IHD: stable exertional angina 3 FC. Atherosclerotic cardiosclerosis. Atherosclerosis of the aorta and coronary arteries. Persistent form of atrial fibrillation. CHF 2a st., 3FC. Cerebrovascular disease. Dyscirculatory encephalopathy of the 3rd stage of mixed (atherosclerotic, post-stroke (December 2010), hypertensive) genesis in the form of diffuse neurological symptoms, vestibulopathic and unexpressed psychoorganic syndromes. Osteochondrosis of the thoracic spine with pain syndrome. Cholelithiasis. Chronic calculous cholecystitis without exacerbation. Diffuse nephroangiosclerosis of mixed (atherosclerotic, hypertensive, dysmetabolic) genesis. CKD stage 3, chronic renal failure stage 1a. Omission of the right kidney 1 degree. Varicose disease of the lower extremities, superficial form. HVN-2st. Primary cataract in both eyes. Severe angiosclerosis of the retina. Initial macular degeneration of both eyes.
Upon admission, she complained of periodic pressing pains in the region of the heart, of varying duration, shortness of breath that occurs after climbing to the 1st floor, stopping on its own after the cessation of physical activity; periodic heartbeats, interruptions in the work of the heart; episodic increase in blood pressure up to 180/90 mm Hg, episodic dull aching headache without clear localization with an increase in blood pressure; pain in the spine, aggravated by physical exertion, unsteady gait, hearing loss and vision loss during the last month, memory loss, fatigue.
Results of instrumental studies:
Ultrasound of the OBP from 09/01/2010. Multiple gallbladder stones up to 12 mm in diameter, the right kidney is located 3 cm below its usual location. Visceroptosis. Ultrasound signs of nephrosclerosis.
Ultrasound of the thyroid gland No. 1067 dated 10.09.2010. Conclusion: a cyst of the right lobe of the thyroid gland, the volume of the gland is at the upper limit of normal.
X-ray of the chest organs No. 1766 dated 09/01/10: on the chest radiograph and on fluoroscopy in the lungs without focal and infiltrative changes. Moderately expressed diffuse emphysema, diffuse pneumofibrosis. The roots are structural, not expanded, free fluid in the pleural cavity is not determined. The diaphragm is flattened on the left, the costophrenic sinus is obliterated on the left. The heart is slightly dilated to the left, "hanging". The aorta is compacted, elongated and deployed.
On ECG No. 1815 dated 08/30/10. sinus rhythm is recorded with a heart rate of 65 per 1 minute, the EOS is deflected to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His).
On ECG No. 1846 dated 06.09.10. sinus rhythm is recorded with a heart rate of 78 per 1 minute, the EOS is deviated to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His). No negative momentum.
ECHO-KG from 09/06/2010: The cavities are not enlarged, free, the myocardium is not thickened, the kinetics is not disturbed, the aorta is sealed, the walls are thickened, calcification of the aortic crescents. Sealing, calcification of the mitral valve leaflets. Regurgitation of the 1st degree on the TC and MC. Pulmonary blood flow is not disturbed. The pericardium is not changed. Without dynamics with ECHO-KG from 01/08/2010.
Holter ECG monitoring (against the background of therapy) dated 09/01/2010: during the observation period, the following rhythms were recorded: pacemaker migration through the atria, 4 prolonged episodes of atrial fibrillation, tachysystolic form (11:10-11:28; 13:58) -15:45; 18:20-19:28; 23:41-00:50) and many short episodes of atrial fibrillation lasting up to 2 minutes, 5 short episodes of atrial flutter, turning into atrial fibrillation. Heart rate from 52 to 166 in 1 minute. The decrease in heart rate at night is adequate. Average heart rate 81/89/69 in 1 minute. Single ventricular extrasystoles were registered (22 in total); ultra-frequent supraventricular extrasystoles (total 4632), periodically aberrant, paired, group, bi- and trigeminy type. Against the backdrop of atrial fibrillation,
Monitor observation of Holter ECG (against the background of therapy) dated 09.09.2010: during the observation period, migration of the pacemaker through the atria was recorded, many short episodes of atrial flutter-fibrillation, normosystolic form, were recorded. Heart rate from 52 to 116 in 1 minute. The decrease in heart rate at night is adequate. Average heart rate 81/89/69 in 1 minute. Registered single ventricular extrasystoles (total 12); frequent supraventricular extrasystoles (total 1562), periodically paired, group, bi- and trigeminy type. Against the background of atrial fibrillation, tachysystole, ST segment depression up to 2 mm is recorded.
Daily monitoring of blood pressure (against the background of therapy) from 09/01/2010: Mean systolic blood pressure during the day and mean diastolic blood pressure during the day are within the normal range, mean systolic blood pressure at night is characteristic of mild labile hypertension. At night, systolic blood pressure paradoxically rises (nightpicker), diastolic blood pressure does not decrease enough (nondipper). The variability of systolic and diastolic blood pressure during the day is increased, at night the variability of systolic and diastolic blood pressure is within the acceptable range. 3 episodes of hypotension in systolic blood pressure up to 94 mmHg were registered. (time index 6%), and 2 episodes of hypotension in diastolic blood pressure up to 48 mm Hg. (time index 23%). There is an increase in the average pulse blood pressure, the magnitude and speed of the morning rise in diastolic blood pressure.
The results of laboratory examination:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
Ht, %
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
31.08
123
3.94
5.2
37.6
32
269
1
34
11
1
53
09.09
121
3.83
5.2
37.0
30
309
5
50
6
1
38
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
31.08
clear
1010
yellow
6.5
no
no
no
-
-
no
0-3
-
4-8
1-2
09.09
clear
1010
yellow
5.5
no
no
no
2
-
no
2-5
-
8-15
0-2
Biochemical blood test:
Name
Unit. rev.
Norm
31.08
09.09
Creatinine
µmol/l
53-124
101.1
urea
mmol/l
2.5-6.4
9.3
glucose
mmol/l
3.9-6.2
5.7
potassium
mmol/l
3.5-5 .1
4.9
4.6
sodium
mmol/l
136-145
141.8
139.3
total cholesterol
mmol/l
3.7-6.0
9.56
8.93
triglycerides
mmol/l
0-2.37
0.7
o. bilirubin
mmol/l
6.8-26
7.1
Total protein
g/l
63-87
74.6
albumin
g/l
30-55
43.5
ALT
U/L
8.4-53.5
16.1
AST
U/L
7-39.7
15.5
Amylase
U/L
28-100
68.7
prothrombin index
%
70-120
102
Fibrinogen
mg/dl
200-400
408
Creatinine clearance according to the Cockcroft-Gault formula = 31 ml/min. GFR by MDRD = 47.5ml/min/1.73m2
Endoscopic examination of the gastrointestinal tract was not performed due to the patient's condition.
Treatment was carried out: regimen, diet, noliprel, cordarone, aspicor, cytoflavin, actovegin, tanakan, phenibut, amitriptyline, movalis, piracetam, betaserc.
Discharged home in a satisfactory condition under the supervision of medical specialists of the clinic. A temporary disability sheet was not issued.
Recommended:
1. Supervision by a neurologist, a cardiologist.
2. Continue taking:
• Tab. Noliprel ½ tab. in the morning all the time.
• Tab. Kordaron 0.2 1 tab. morning and evening for 1 month, then ½ tab. in the morning constantly
• Tab. Thrombo ASS 0.05 1 tab. in the morning all the time.
• Tab. Amitriptyline 25mg ½ tab. 2 times a day for 1 month
• Tab. Lucetam 0.8 1 tab. morning 1 month
• Tab. Preductal MB 1 tab. 2 times a day all the time.
• Quinax - 2 drops in each eye 4 times a day for 1 month.
• Tanakan 1 tab 2 times a day until September 30, 2010.
3. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
4. Limit the intake of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
5. Re-hospitalization after 3 months or earlier according to indications.
This block includes a number of mental disorders grouped together on the basis of the presence of clear etiological factors, namely, the cause of these disorders was brain disease, brain injury or stroke, leading to cerebral dysfunction. Dysfunction can be primary (as in diseases, brain injuries and strokes that directly or selectively affect the brain) and secondary (as in systemic diseases or disorders when the brain is involved in the pathological process along with other organs and systems).
Dementia [dementia] (F00-F03) is a syndrome caused by damage to the brain (usually chronic or progressive) in which many higher cortical functions are impaired, including memory, thinking, orientation, understanding, counting, learning ability, speech and judgment. Consciousness is not obscured. Cognitive decline is usually accompanied, and sometimes preceded, by deterioration in control of emotions, social behavior, or motivation. This syndrome is noted in Alzheimer's disease, in cerebrovascular diseases, and in other conditions that primarily or secondarily affect the brain.
If necessary, an additional code is used to identify the underlying disease.
MILITARY-MEDICAL ACADEMY. HOSPITAL THERAPY CLINIC
Reference No.
(53 years old), was examined and treated at the hospital therapy clinic of the Military Medical Academy with a diagnosis of
Chronic gastroduodenitis in remission. Dolichocolon. Myopia of both eyes 1.25 D with visual acuity with a correction of 1.0 in both eyes.
The clinic was admitted in a planned manner with complaints of recurrent cutting pains in the epigastric region and along the colon, bloating, loosening of the stool; subfebrile body temperature during the last month, headaches, periodic nosebleeds that occur against the background of a rise in blood pressure to 150/90 mm. rt. Art.
Results of laboratory researches:
General analysis of blood, urine, feces dated 12/12/2006 was normal. Blood biochemical parameters (AST, urea, creatinine, glucose, creatinine phosphokinase, total protein, total bilirubin, K+, Na+, Cl-, lipase) dated 11/28/2006 were normal. Antibodies to HIV 1.2 from 11/30/2006 were not found. 04/09/2006 HbsAg, anti-HCV antibodies were not detected. 04/08/2006 CRP - 0. RW microreaction-precipitation with cardiolipin antigen from 11/28/2006 - negative. RSK with chlamydial antigen from 29.11.2006 was negative. RNHA with tuberculosis antigen, with dysentery antigens of Shigella (Zone, Flexner, Newcastle), with complex salmonella antigen, with pseudotuberculous antigen, yersiniosis antigen from 11/30/2006 - negative. ECG dated April 27, 2006, sinus rhythm, heart rate 50 beats per minute. Incomplete blockade of the right leg of the bundle of His. Initial manifestations of left ventricular hypertrophy. Rotation of the heart with the right ventricle forward. Ultrasound of the abdominal organs dated November 30, 2006: the liver is not enlarged, the right lobe is 13.5 cm, the left lobe is 7.5 cm, the contours are even, the structure is homogeneous, the vessels are not dilated, the portal and hepatic veins, intrahepatic bile ducts are without features. The gallbladder is not enlarged, the contours are even, the walls are thin, the contents are homogeneous, calculi and polyps are not visualized. Pancreas, spleen without features. The kidneys are not enlarged, mobile. The parenchyma is homogeneous, without signs of pathology. The cavity system is not expanded. No pathological formations were found in the projection of the adrenal glands. The spleen is not enlarged, the structure is homogeneous. X-ray examination of the chest organs from 02.10.2006: no pathological changes. FCC dated December 11, 2006: the device is inserted 20 cm from the anus. Further study was terminated due to the patient's inappropriate behavior and at his urgent request. In the examined area of the intestine, the mucosa is thinned, the vascular pattern is enhanced. In the lumen fluid with an admixture of feces. Ampoule of the rectum without features. RRS dated 12/15/2006: the tube of the proctoscope was inserted up to 15 cm. Due to the patient's inadequate behavior, the study was not completed. No organic pathology was found in the rectum. The mucosa is pink, shiny, a vascular pattern can be traced. The tone of the intestinal wall is normal. FGDS from 8.12.2006: The esophagus is passable, the socket of the cardia does not close completely. In the stomach, a significant amount of mucus, liquid (foamy with an admixture of bile). The folds are rough, edematous, tortuous. The mucosa is hyperemic. The gatekeeper gapes
Treatment was carried out: regimen, diet, omeprazole 0.02 (1 tab 2 times a day), Almagel (1 spoon 4 times a day), Creon 10,000 IU (1 dr 3 times a day 30 minutes before meals), allochol (2 tablets 3 times a day).
On the background of the therapy, the patient's condition improved. Certified by VVK. Recognized on the basis of the articles of column III of the Schedule of Diseases and TDT (annex to the Regulations on the military medical examination, approved by the Decree of the Government of the Russian Federation of 2003 No. 123) "A" - fit for military service.
Recommended:
1. Observation of a therapist (gastroenterologist).
2. Omeprazole 0.02 (1 tab 2 times a day, morning and evening) - 1 week, then 1 tab at night - 2 weeks.
3. Almagel A or Maalox (1 spoon 4 times a day an hour after meals and at night) - 3 weeks
Does not need a sick leave. Discharged in a satisfactory condition.
MILITARY-MEDICAL ACADEMY. CLINIC OF HOSPITAL THERAPY
Certificate №
1937 (69 years old), was examined and treated in the hospital therapy clinic of the Military Medical Academy with a diagnosis
of duodenal ulcer in the acute phase. Multiple (ulcer of the duodenal bulb, ulcer of the back of the bulb) ulcers of the duodenum. Cholelithiasis. Asymptomatic stone carrying. Atherosclerotic cardiosclerosis. Solitary cyst of the right kidney.
He was admitted to the clinic with complaints of acute burning pain in the epigastric region, not associated with eating.
Laboratory results:
General clinical blood test:
Date
Hb, units.
Er., *1012/L
Leuk., *109/L
CP
Ht
%
ESR, mm/h
Thrombus
*109/L
E
%
B
% Lf
%
Pl.cl
%
M
%
Pia
%
Xia
%
20.12.
140
4.54
6.9
0.92
13
4
1
29
1
9
1
55
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
20.12
clear
1017
yellow
sour
no
no
no
1
no
no
0-2
no
0-2
no
Urinalysis according to Nechiporenko dated 12/14/06: Leu-0.75×109/l, Er.-0.25×109/l
Analysis feces: no features
Biochemical blood test:
Name
Unit. rev.
Norm
11.12
Name
Unit. rev.
Norm
11.12
Creatinine
mmol / l
53-124
CS
mmol / l
3.7-7
4.18
Urea
mol / l
3-8.4
TG
mmol / l
0-2.37
1.54
Prothrombin
%
70-120
90
LDL
units
350-650
500
Fibrinogen
g/l
2.0-4.0
3.5
Alpha 1
%
4.1
Total protein
g/l
63-87
67.8
Alpha 2
%
12.7
Albumin
%
50-70
56.1
Beta
%
12.8
a/g
1.1-2.5
1.28
gamma
%
14.4
ALT
U/L
8.4-53.5
Cl
mmol/l
95- 108
102.8
AST
U/L
7-39.7
16.1
Na
mmol/l
130-150
158.5
AP
U/L
36-92
56.4
K
mmol/l.
4-6
3.76
LDH
U/L
100-220
TSH
mmol/l
0.27-4.2
GGTP
U/L
7-63
ALP
Ukat/L
0.70-2.30
Glucose
mmol/l
4.2-6.4
4.5
form 50
quality
neg
. bilirubin
µmol/l
6.8-26
10.3
HBsAg
quality
neg
Sial
. k-ty
g/l
1.9-2.5
AntiHCV qual negative
Neg
Results
of
instrumental studies:
ECG dated 12/11/2006: Sinus rhythm with a frequency of 66 beats/min, EOS is not rejected (α=400), signs of hypertrophy of the left ventricle.
ECHO-KG No. 25 dated 12/10/2006: MZHP-10.0mm, ZS-11.3mm, KDRLV-52.4mm, KSRLZh-37.5mm, FV-54.5%, FU-28.4%, UO -72ml, LP-33.3mm, RV-24mm, E/A=0.7 Myocardium is not thickened. The cavities are free, not dilated, the valves are not changed. The pericardium is intact. The kinetics is not broken. The aortic valve annulus is sealed. Diastolic dysfunction of the left ventricle.
Ultrasound of the abdominal organs from 12/13/2006: the liver is not enlarged, the right lobe: 13cm; left 7.5 cm, smooth contours, homogeneous structure, echogenicity is not changed; intrahepatic vessels are not dilated; portal vein and hepatic veins of normal size. Intrahepatic bile ducts are not dilated. The gallbladder has a regular shape, dimensions 7.1×3.4 cm, smooth contours, walls 2 mm, calculi N4-5 up to 9-11 mm. The pancreas is not located. Kidneys of normal size, normal location, with uneven contours, heterogeneous parenchyma 17 mm thick, cavitary systems are not expanded. There are no concretes. Spava cysts with a diameter of 30 and 32 mm. The spleen is not enlarged, 9.9×6.8×4.4 cm in size. In the projection of the location of the adrenal glands, no pathological formations were found. Conclusion: Cholelithiasis (cholecystolithiasis). Cysts of the right kidney.
Fibrogastroduodenoscopy dated December 6, 2006: In the duodenal bulb on the posterior surface there is an ulcerative defect 0.7 * 0.7 cm under fibrin, the mucosa around is hyperemic, edematous with many acute erosions 0.1 cm under fibrin. In the postbulbar region there is a shallow ulcerative defect 2.0 * 2.0 cm under fibrin with areas of hemosiderin.
X-ray of the chest organs No. 71 dated 12/11/2006: Conclusion: On the survey radiograph of the chest cavity organs in the lungs without fresh infiltrative changes.
Treatment: regimen, diet, asparkam, omeprazole, amoxicillin, almagel, metronidazole, vikalin, motilium.
On the background of the therapy, the patient's condition improved. Does not require sick leave.
Discharged according to the report in a satisfactory condition.
Recommended:
222. Outpatient observation of a gastroenterologist.
223. Dispensary observation:
a. Frequency of observation by a doctor: - 4 times a year.
b. clinical blood test (with platelet count), urinalysis - 4 times a year;
c. biochemical blood test (fibrinogen, protein fractions, AST, ALT, total bilirubin, creatinine, urea) - 2 times a year;
224. Continue taking:
a. Omeprazole 0.02 (1 tab 2 times a day, morning and evening) - 1 week, then 1 tab at night - 2 weeks
b. 3. Almagel A or Maalox (1 spoon 4 times a day one hour after meals and at night) - 3 weeks
AND ABOUT. Deputy Head of the Department for Clinical Work M. Sarazov
Head of the 1st Department I. Pavlovich
Attending physician N. Gulyaev
December 23, 2006.
ENT /A.F. Sirotinin /
Complaints of periodic discomfort, a feeling of sore throat in the cold season, which have been bothering for 2 years.
Objectively: the maxillary lymph nodes are enlarged, painless on palpation. Pharyngoscopy: the mucous membrane in the area of the lateral ridges and palatine arches is hyperemic and edematous. Palatine tonsils of the 1st degree, loose, clear in the gaps. Swallowing is not difficult. Other ENT organs without features. Hearing acuity in the study of whispered speech - 6 m in both ears.
Diagnosis: Chronic compensated tonsillitis. Lateral pharyngitis.
Recommended:
p. Spray "Tantum Verde" 2 inhalations 3 times a day for 10 days,
q. Rinse with warm decoctions of sage, chamomile - 10 days
r. Suprastin - 10 days
s. Peach oil in the nose 1 drop in both nasal passages 3 times a day
t. Repeated examination in dynamics
OPHTHALMOLOGIST /A.Yan/
Complaints of discomfort when reading and writing
Vis.OD=0.6 with correction cyl. –1.0D = 1.0 (ax 1800→)
Vis.OS=0.6 with cyl correction. –1.0D = 1.0 (ax 1800→)
Intraocular pressure: OD=OS=21 mmHg
The eyelids are not changed, the usual form, the palpebral fissure is not narrowed. The position of the eyeballs is correct, the movements are full. Conjunctiva slightly hyperemic, superficial injection of blood vessels. The corneas are transparent, spherical, without pathological changes. The anterior chambers are of medium depth, moisture is transparent, does not opalize. Pupils are centered, regular round shape, photoreactions are alive, D=S. Deep optical media are transparent. The reflex from the fundus is pink. The discs are pale pink, in the plane of the retina, with clear boundaries, regular round shape. Vessels A:B=1:3, arteries are narrowed, veins are somewhat dilated, tortuous, a symptom of arteriovenous decussation of the first degree. No pathology was detected in the macular zone and on the periphery of the fundus.
Diagnosis: Simple myopic direct type astigmatism in 1.0 D, hypertensive angiopathy of the retina in both eyes.
SPH
CYL
AX
R
+0.50
-1.75
168
L
0.00
-1.25
19
PD=61, VD=12
Complaints of headaches, dizziness, unsteadiness when walking, numbness in the fingers of the upper extremities.
Neurological status: conscious, oriented. The pupils are D=S, the physiological reflexes of the pupils are reduced, the reaction of accommodation with convergence is reduced. There is no nystagmus. The face is symmetrical. Tongue in the midline. Swallowing, phonation are not disturbed. Reflexes of oral automatism are negative. Tendon reflexes D=S, functional areas are expanded. There are no pathological signs. Decreased sensitivity in the upper extremities of the radicular type (C5-C6, C6-C7). Performs coordination tests with a slight intention. He staggers in the Romberg pose. There are no meningeal signs.
Diagnosis: Dyscirculatory encephalopathy of the first stage of mixed (atherosclerotic, hypertensive) genesis in the form of cerebellar insufficiency. Widespread osteochondrosis of the spine.
REG from 18.09.03: the blood flow is slightly reduced in the basin of the carotid and vertebral arteries, symmetrical. The cerebrovascular tone is normal. The hyperventilation test is weakly positive. The elasticity of the vessels is moderately reduced. Venous outflow is difficult in the vertebrobasilar basin.
Makes no complaints.
The face is symmetrical. The mouth opens freely, in full. The mucosa is clean, moist. No foci of odontogenic infection were found. Dental formula:
km o pl o km km km o km o o o pl
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
km o o km pl km o o o km o
Diagnosis: partial secondary adentia.
Needs dentures.
ECHO-KG No. 631 dated 11/13/2006: MZHP-9.9mm, ZS-7.0mm, KDRLV-47mm, KSRLZh-24.1mm, FV-79%, FU-48.5%, UO-80.93ml , LP-33.3mm, RV-25.5mm, E/A=1.0 Myocardium is not thickened. The cavities are free, not dilated, the valves are not changed, on the mitral valve regurgitation I stage. The pericardium is intact. The kinetics is not broken. Diastolic dysfunction of the left ventricle.
MILITARY MEDICAL ACADEMY
Hospital Therapy Clinic The
discharge summary from the medical history No. 1033
was examined and treated at the Military Medical Academy Hospital Therapy Clinic from 06.11.2009 to 20.11.2009.
DIAGNOSIS:
IHD, stable exertional angina 3 FC. Atherosclerotic cardiosclerosis. Atherosclerosis of the aorta and coronary arteries. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation from 08.11.09. stopped medically on 08.11.09.
Hypertension III degree. (AH 2, CVE risk is extremely high). NK 2a st., 3 FC.
Dyscirculatory encephalopathy of the 3rd stage of mixed (atherosclerotic, hypertonic) genesis with a predominant lesion in the vertebrobasilar basin. Syndrome of intellectual-mnestic disorders.
Osteochondrosis of the thoracic spine with pain syndrome.
Cholelithiasis. Chronic calculous cholecystitis without exacerbation.
Omission of the right kidney 1 degree.
Varicose disease of the lower extremities, CVI-2st.
Upon admission, she complained of periodic pressing pains in the region of the heart, of varying duration, that occur after climbing to the 2nd floor, stopping spontaneously after the cessation of physical activity; periodic heartbeats, interruptions in the work of the heart; episodic increase in blood pressure up to 180\90 mm Hg, pain in the spine, aggravated by physical activity, weight loss by 5 kg during the year, memory loss, fatigue.
Results of instrumental studies:
X-ray of the chest organs No. 2590 dated 09.11.09: on the chest radiograph and on fluoroscopy, the lung fields are emphysematous, at the level of the 2nd rib on the left, areas of limited pneumofibrosis 1.5 * 1.0 cm are determined. The roots are structural, not expanded, the diaphragm is flattened, free fluid in the pleural cavity is not determined. The heart is slightly dilated to the left. The aorta is compacted and deployed.
X-ray of the thoracic spine No. 2681 dated 11/17/09. in 2 projections - physiological kyphosis is enhanced (senile round back). Osteochondrosis in the mid-thoracic region with a decrease in the height of the discs, osteochondral sclerosis and marginal exophytes in direct projection up to 0.1 cm.
On ECG No. 2487 dated 06.11.09. and 08.11.09. sinus rhythm is recorded with a heart rate of 90 per 1 minute, EOS is deflected to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His). Left ventricular hypertrophy.
ECHO-KG: The cavities are not enlarged, free, the myocardium is not thickened, the kinetics are not disturbed, the Aorta is sealed, the walls are thickened, calcification of the aortic crescents. Sealing, calcification of the mitral valve leaflets. Regurgitation of the 1st degree on the TC and MC. Pulmonary blood flow is not disturbed. The pericardium is not changed
by ultrasound of the OBP. Multiple gallbladder stones up to 10 mm in diameter, the right kidney is located 3 cm below its usual location.
Laboratory results:
Clinical blood test (automatic processing):
Date
Hb, units
Er., *1012/l
Leuk., *109/l
MCHC, g/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
09.11.
119
4.06
6.4
29.4
40
1
40
5
64
13.11.
116
3.74
5.9
31.0
34
2
1
31
4
3
59
Urinalysis (automatic processing):
Date
W.w
Reak
Protein
Sach
Cylind
Lei
Er.neiz
Urobil
29.10
1020
5.9
-
-
No
-
-
3.2
Biochemical blood test:
Name
Unit of measure.
Norm
09.11.2009
AST
U/l
11-50
23.5
ALT
U/l
11-50
16.4
CPK
U/l
10-160
64.3
Cholesterol
Mmol/l
3.7-6.0
5.78
Triglycerides
Mmol /l
0 - 2.37
Creatinine
mmol/l
0.05-0.12
0.11
Potassium
mmol/l
3.5-5.1
4.54
Serum iron
mmol/l
10.5-25
9.2
Total protein
g/l
64-83
68.3
Other blood tests: prothrombin 88%, fibrinogen 3.5 g/l,
F-50, HBsAg, HCV, RW: negative
Examination of feces on 11/13/2009: no pathology, I/g were not detected
Endoscopic examination of the gastrointestinal tract was not performed due to the patient's condition.
Treatment was carried out: regimen, diet, noliprel-forte, cordaron, aspicor, zovirax, cytoflavin, rudotel, gliatilin, phezam, mildronate.
Discharged home in a satisfactory condition under the supervision of medical specialists of the clinic. A temporary disability sheet was not issued.
Recommended:
1. Observation by a neurologist, cardiologist
2. Continue taking:
• Tab. Noliprel 1 tab. in the morning. (or noliprel-forte ½ tab. in the morning).
• Tab. Thrombo ASS 0.05 1 tab. in the morning.
• Tab. Preductal MB 1 tab. 2 times a day all the time.
• Caps. Cytoflavin 1 caps. 2 times a day for 1 month.
• Tab. Gliatilin 0.4 1 tab. 3 times a day for 2 months.
• Caps. Phezam 2 caps. morning and afternoon for 2 months.
3. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
4. Limit the intake of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr., 63 tel. (812) 577-11-35
DISCLAIMER CASE
HISTORY №
Surname, name, patronymic born in 1960
She was on inpatient treatment in the clinic of hospital therapy
Total days of treatment 15
The final diagnosis was established ICD code I 20.0
Diagnosis:
Primary: Ischemic heart disease. Progressive angina from 06/14/2011 (unstable angina IA according to E. Braunwald) with stabilization at the level of functional class II from 06/17/2011. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis. Stage III hypertension, stage II arterial hypertension with stabilization at the level of normal blood pressure, risk of CCO 4. Vitamin B12-folic deficiency anemia of severe degree.
Complications of the underlying disease: CHF stage IIA, II f.c.
Concomitant diseases: Bronchial asthma, mixed form (atopic, primary altered bronchial reactivity), moderate severity, unstable remission. DN 1. Urinary tract infection, exacerbation. Left kidney cyst. CKD stage I (GFR 94.1 ml/min/1.73 m2). CRF 0. Obesity 1 degree, android type, stable stage. cerebrovascular disease. Acute cerebrovascular accident from 2008. Myoma of the right scapular region. Varicose disease. Varicose veins. CVI stage I.
Certificate of incapacity for work was not issued
Clinical outcome: improvement
Outcome: discharged due to improvement
On admission:
Complaints: dull pressing pain behind the sternum, radiating to the left arm, left shoulder blade, stopped by taking nitroglycerin; shortness of breath with minimal exertion, accompanied by increased heart rate; fast fatigue with minimal physical exertion; feeling of heaviness in the limbs; asthma attacks that occur spontaneously about 1 time per day, stopped by taking salbutamol; swelling of the legs.
Anamnesis of the disease: considers himself ill for about 2 years, when there was a slight shortness of breath during physical exertion, stress. She did not go to the doctors about this, she was not treated, she considered shortness of breath as a manifestation of bronchial asthma, she used salbutamol with a positive effect. In March 2011, she suffered from acute respiratory infections, after which she suffered from acute thrombophlebitis of the right leg, both diseases were accompanied by fever, severe intoxication syndrome, and received antibiotic therapy. In May 2011, shortness of breath increased, weakness in the limbs progressed with minimal physical exertion (walking less than 100 meters, climbing stairs 1 flight). From the age of 17 he suffers from bronchial asthma. Attacks of suffocation occur on contact with animal hair, occupational hazards (substances of dental practice). At 24, at 30, asthmatic status. She did not receive glucocorticoid or combination therapy. She currently takes salbutamol on demand (about once a day). He notes that with age, asthma attacks are less common. In 2008, she suffered an ischemic stroke (according to words), after which residual phenomena remained in the form of impaired writing. The neuropathologist is not observed. Prior to the violation of cerebral circulation, the working pressure was considered 130/80 mm Hg. periodically there were rises in blood pressure up to 160/100 mm Hg. Therapy was prescribed: Renitek, ThromboASS. Over the past two months, she has noted a decrease in blood pressure to 110/70-60 mm Hg, she stopped taking Renitek on her own, but the pressure remains at the level of 110/70 mm Hg. (the words). On June 14, 2011, she felt a worsening condition in the form of pressing pain behind the sternum, which radiated to the left arm, left shoulder blade, treated with nitroglycerin. In connection with the strengthening of the listed complaints, the progression of pain cardiac syndrome for 2 days, according to urgent indications, she was hospitalized in the clinic of GT of the Military Medical Academy.
Objective status: general condition of moderate severity, swelling of the legs, ankles, on palpation of the radial arteries, the pulse is the same on both arms, rhythmic, 88 beats per minute. Blood pressure: 140/80 mmHg Art. Borders of relative cardiac dullness: right - along the right edge of the sternum; upper - on the third rib; left - on the left mid-clavicular line; on auscultation, the heart sounds are muffled; hard breathing in the lungs, single scattered wheezing in the lower parts of the lungs; the abdomen is soft, painless on palpation; tapping on the lumbar region is painful on both sides.
As a result of the treatment: regimen, diet, metabolic therapy (polarizing mixture: Sol.Glucosae 5% -200 ml, Sol.Asparcami 20 ml, Sol.Insulini 4U), anticoagulant therapy (Heparin 20 thousand U / day), antiplatelet therapy ( Acecardol 0.1 per day), antihypertensive therapy (Perindopril 0.01 per day), preventive antiarrhythmic therapy (Verapamil 0.24 per day), antiplatelet therapy (Acecardol 0.1 per day), mucolytic therapy (Lazolvan 2 ml / day through a nebulizer), glucocorticoids (Dexamethasone according to the scheme with a gradual decrease and withdrawal), vitamin therapy (B12 1000 mcg / day / m, folic acid 6 mg / day) the state of health has improved, cardiac pain syndrome does not bother, exercise tolerance has increased, weakness in the extremities is much less pronounced, occurs on a greater load than before hospitalization,BP is stabilized at the normal level, there is a tendency to normalize the hemogram.
After relief of cardiac pain syndrome and stabilization of angina pectoris at the level of II f.k. severe anemic syndrome came to the fore. B12 deficiency anemia, iron deficiency anemia, autoimmune nature of the lesion, as well as a mixed variant were considered. The patient was consulted by a hematologist, an examination was carried out in the direction of finding out the cause of anemia. It was established that at the moment there is no need for blood transfusion, blood loss did not occur acutely. An aspiration biopsy of the bone marrow, a blood test for vitamin B12, folic acid were performed. It seems that hemolysis, the signs of which are found in the biochemical analysis of blood, is due to the breakdown of macro- and megalocytes in the spleen and microcirculatory bed, which fits into the framework of B12-folic deficiency anemia. Apparently
Complete blockade of the left leg of the bundle of His has been taking place since 2008. Against this background, when performing a planned load, an increase in ST segment depression up to 4.0 mm is recorded, which can be regarded as a circulatory disorder. Considering the data of a clinical blood test (the size of erythrocytes is significantly increased), it can be argued that the effects of circulatory disorders are leveled after the restoration of the normal picture of the hemogram.
She was consulted by a surgeon about a subcutaneous mass in the angle of the right scapula: preliminary diagnosis: myoma of the right scapular region, targeted radiography of the right scapular region in two projections was recommended. No bone changes were found on sighting radiographs of the right scapula in two projections.
Results of instrumental studies:
ECG from 06/16/2011: sinus rhythm. The horizontal position of the EOS. Complete blockade of the left leg of the bundle of His. Cicatricial changes in the anterior septal region are not excluded. Hypertrophy of the left heart.
X-ray of the chest organs from 06/17/2011: the pulmonary fields are moderately emphysematous. The pulmonary pattern in the middle and lower sections on both sides is reinforced and deformed due to pneumofibrosis. The roots of the lungs are structural, not expanded. The sinuses are free. The median shadow is not expanded.
FVD from 05/24/2011: violation of FVL for obstructive type I degree. The test with Berotek is positive.
Ultrasound of OMT from 06/22/2011: the uterus is in anteflexio, not enlarged, the ovaries are not located. There is gas in the rectum (preparing for RRS), examination is difficult.
Myelogram dated 06/20/2011: bone marrow cell punctate. The erythroid germ is hyperplastic, megaloblastic. Of 57.4% of erythrokaryocytes, 19.2% are megaloblasts. Leukoerythroblastic ratio 1.3. Attention is drawn to a sharp increase in basophilic erythrokaryocytes, and in peripheral blood preparations, reticulocytosis up to 40%. megalocytes have Jolly bodies, Cabot rings, basophilic puncture. The granulocytic germ is narrowed, there are gigantic forms from myelocytes to p / neutrophils, polysegmentation of neutrophil nuclei. Megalocytic sprout within hematological reference values: platelets lace, 38% megakaryocytes, megakaryoblasts and promegakaryocytes account for 23%. In peripheral blood preparations: hemoglobin 58 g / l, erythrocytes 1.35 * 10 / l, MCH 43.2 pg, MCV 131 dl, anisopoikilocytosis, macrocytes, megalocytes, degenerative forms of erythrocytes, Jolly bodies, Cabot rings. Leukocytes 6.9 * 10 / l with a shift to myelocytes in the leukogram. Platelets 238*10 / l.
Ultrasound of the OBP dated 06/17/2011: flatulence. Left kidney cyst.
ECHO-KG from 06/17/2011:
PARAMETERS
Val.
NORMAL
PARAMETERS
Value
NORM
Aortic root diameter
328
20-37 mm
Left ventricular ERD
49
38-56 mm
Opening of the aortic valve cusps
21
more than 15 mm
Left ventricular ERR
35
22-38 mm
Anterior-posterior size of the left atrium
40
25-40 mm
Thickness of the free wall of the right ventricle
4
less than 5 mm
Frontal size of the left atrium
33
25-45 mm
Left ventricular ejection fraction
55
more than 55%
Vertical size of the left atrium
39
29-53 mm
Size of the right atrium
34
30-46
Thickness of the interventricular septum
13
7-11 mm
Vertical size of the right atrium
35
34-49 mm
Thickness of the posterior wall of the left ventricle
11
7-11 mm
CDR of the right ventricle anteroposterior
28
Less than 30 mm
Systolic pressure in the pulmonary artery
11.4
to 20 mm Hg
Pulmonary trunk diameter
17
12-23 mm
Conclusion: thickening of the walls of the aorta, the leaflets of the mitral valve. The chambers of the heart are not dilated, the cavities are free. Concentric hypertrophy of the left ventricular myocardium. Paradoxical movement of the interventricular septum. Global contractility is preserved. Diastolic dysfunction by the type of delayed relaxation. Mitral insufficiency I degree. The pericardium is not changed.
Holter monitoring from 07/01/2011: during the observation period, sinus rhythm was recorded with a heart rate of 60 to 110 per minute. The decrease in heart rate at night is insufficient. Average heart rate 79/83/72 per minute. The following rhythm and conduction disorders were registered: single monomorphic ventricular extrasystoles (3 in total); single polytopic supraventricular extrasystoles (38 in total). When performing the planned load in the form of climbing stairs, the heart rate reached 106 and 110 per minute (submaximal heart rate was not achieved), fatigue in the legs was noted. Against the background of the initial depression of the ST segment up to 2 mm, due to the complete blockade of the left leg of the His bundle, during the execution of the planned load, an increase in ST segment depression up to 4.0 mm is recorded, which can be regarded as a circulatory disorder.
Results of laboratory researches:
Clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
MSN
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
Rt, %o
16.06
64
1.51
5.9
67
1
44
5
1
49
Hypochrome, poikiloc.
17.06
65
1.52
5.0
43.1
48
1
61
2
35
30
_
20.06
58
1.35
6.9
43.2
40
133
4
1
59
44
_
_
24.06
61
1.42
9.0
42.7
60
12
2
1
85
61 Anisocys. 2
,
poikil. 2, Jolly bodies, hyperchromia
28.06
79
1.83
10.7
30
30
0
24
6
1
65
88 .2, macroc.2, polychromasia1, hyperchromia, myeloc.3, promyeloc.1.
01.07
86
2.28
15.0
37.7
28
0
36
13
1
51
97
Reactions to occult blood, eggs of helminths negative from 22.06, 24.06, 27.06.
Biochemical analysis of blood: Analysis of urine:
Name
Unit of measure.
Norm
17.06
20.06
23.06
Index
23.06
Creatinine
Mmol/l
53-124
80
Color Yellow
Cholesterol
Mmol
/l
3.7-6.0
5.96
Transparency Turbid
Triglycerides
Mmol
/l
0-2.37
Specific weight
1015
Total protein
G/l
63.0-87.0
73.1
Reaction
5.5
Calcium
Mmol/l
2.1-2.5
Protein (g/l)
No
Potassium
Mmol/l
3.5-5.1
4.55
Sugar
No
Glucose
Mmol/l
4.2-6.4
5.82
Urobilin
3.2
Prothrombin
%
70-120
75
90
Leukocytes in p/s
5-8
Fibrinogen
Mg/dl
200-400
393
589
Erythr. unchanged in p/s
No
CK
U /l
10.0-160.0
27.5
Epit.pl. V p/sp
1-2
AST
U/l
11.0-50.0
66.2
Salts
No
ALT
U/l
11.0-50.0
41.2
Mucus
1
Total bilirubin
µmol/l
6.8-26.0
39.4
34.7
Bacteria in a large number
Direct bilirubin
Mkmol/l
0-7.0
7.6
7.0
Indirect bilirubin
2.0-13.5
31.8
C-reactive protein
Mg/l
3.0-10, 0
3.32
CEC
Unit.
6-66
34
Sialic acids
Mole/l
1.9-2.5
2.0
Urea
ol/l
2.5-6.4
4.1
Amylase
U/l
28-100
Т3
Ng/ml
0.60-1.81
1.6
AtTpo
U/ml
<60
41.8
TSH
mIU/ ml
0.35-5.5
2.1
Т4
Mg/dL
4.5-12
8.9
AT-HIV ½ not detected (06/27/2011)
HBsAg not detected (06/27/2011), Anti-HCV not detected (06/27 .2011)
Folic acid in the blood from 06/22/2011: 5.1 ng / ml (norm 7.0-48)
Vitamin B12 in the blood from 06/22/2011: 88 ng / ml (norm 188-652)
AT to erythrocytes from 22.06 .2011: not identified.
Discharged to the clinic at the place of residence, the ability to work partially restored. Appearance at the clinic 07/01/2011.
Recommended:
1. Observation of a therapist, cardiologist, pulmonologist, endocrinologist, hematologist, surgeon at the place of residence.
2. Compliance with the diet, normalization of the regime of work and rest. Avoid psycho-emotional stress. Limit the use of animal fats, easily digestible carbohydrates, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
3. Therapeutic exercise.
4. Control clinical blood test on 04.07.2011 followed by a consultation with a general practitioner.
5. Control biochemical blood test (total bilirubin, fractions, AST, ALT, cholesterol) in a month, followed by a consultation with a therapist.
6. Performing fibrocolonoscopy in a planned manner, followed by a consultation with a therapist.
7. Continue taking medication:
• Tab. Cardiomagnyl 0.075 orally 1 tablet 1 time per day in the morning for a long time.
• Tab. Simvastatin 0.03 orally 1 tablet 1 time per day in the evening for a long time (under the control of cholesterol levels in the blood).
• Tab. Enalapril 0.01 orally ½ tablet 2 times a day for a long time.
• Cyanocobalamin (vit. B12) 1000 mcg 2 times a week intramuscularly for a week. Further, 1000 mcg 1 time per week intramuscularly for 4 weeks. Further on 1000 mcg once a month constantly. Control of hemoglobin, vitamin B12 in the blood.
• Tab. Folic acid 1 mg orally 3 tablets 3 times a day for 4 months. Control of hemoglobin, folic acid in the blood.
• Tab. Sorbifer Durules 320 mg 1 tablet 1 time per day until normalization of blood counts, after which another 2 weeks. Control of the level of iron in the blood serum.
• Tab. Panangin inside 1 tablet 3 times a day for 10 days of each month.
EXECUTIVE SUMMARY No.
born in 1971 was on inpatient examination and treatment with a diagnosis (I 40.0):
Acute infectious-immune myocarditis with arrhythmias of the type of frequent ventricular extrasystoles, unstable paroxysms of atrial fibrillation. Heart failure of the first functional class.
Widespread osteochondrosis of the spine with radicular syndrome. Lumbalgia.
Days of treatment 18.
Complaints at admission: pronounced palpitations, interruptions in the work of the heart, dizziness, moderate general weakness, discomfort in the heart area.
Within a month, against the backdrop of a protracted episode of acute respiratory illness, he began to notice the daily appearance of palpitations, interruptions in the work of the heart, a long-lasting feeling of general weakness, fatigue, the appearance of constant discomfort in the heart, low-grade fever.
Results of instrumental studies:
ECG on January 30, 2014: P-0.12 s, QT-0.34 s, PQ 0.14 s, QRS 0.08 s. Heart rate 94 per minute. Sinus rhythm. Horizontal position of the electrical axis of the heart. Diffuse disturbance of repolarization processes. Frequent ventricular extrasystoles.
ECG on February 11, 2014: P-0.08 s, QT-0.32 s, P 0.08 s, PQ 0.12 s, QRS 0.09 s. Heart rate 96 per minute. Minor sinus tachycardia. Horizontal position of the electrical axis of the heart. Diffuse violation of repolarization processes. Indirect ECG signs of left ventricular hypertrophy. Negative dynamics in the form of T wave inversion in II, III, AVF, V6 and slight depression of the ST segment in II, III, AVF, V5-V6 leads. Single ventricular extrasystole.
ECG 02/15/2014: Sinus rhythm with a heart rate of 74 per minute. Horizontal position of the electrical axis of the heart. Diffuse violation of repolarization processes. Single ventricular extrasystoles.
Holter ECG monitoring on January 30, 2014: during the observation period, sinus rhythm was recorded with a heart rate of 61 to 155 beats per minute. During wakefulness, tachycardia was recorded with an average hourly heart rate of up to 155 per minute. The decrease in heart rate at night is adequate (circadian index 44%). Average heart rate (day/day/night) 76/85/59 per minute. Frequent solitary polymorphic ventricular extrasystoles (4217 in total), once as an episode of trigeminia, single polytopic supraventricular extrasystoles (total 196), periodically in the form of couplets (total 61), once as an episode of bigeminy, unstable runs of atrial fibrillation with a heart rate of up to 155 beats were registered. minute (total 43, maximum 34 complexes). At 7:30, with an increase in heart rate to 150 beats per minute, a horizontal depression of the ST segment up to 1.5 mm was recorded for 5 minutes.
ECHO-KG dated 07.02.2014 IVS=WS=10.5 mm, LV 56/38 mm, EF 56%, FU 28%, VR 80 ml, LA 40 mm, PP 40 mm, aorta 36 mm, aortic dilatation 21 mm, e/a 1.4 The myocardium is not thickened, the kinetics is not disturbed, the cavities are not enlarged, free. Aorta, valves, pericardium are not changed. Diastolic dysfunction of the rigid type. Regurgitation of the 1st degree on the tricuspid and mitral valves.
Ultrasound examination of the abdominal organs on 02/03/2014: liver, gallbladder, pancreas, spleen without pathology.
X-ray of the chest organs on January 28, 2014: no pathological changes were detected.
Radiography of the paranasal sinuses on January 28, 2014: thickening of the mucous membrane of the left maxillary sinus of the parietal nature.
Radiography of the paranasal sinuses on February 12, 2014: the paranasal sinuses were pneumotized.
ENT on February 11, 2014: the mucous membrane of the nasal cavity is hyperemic, edematous, there is no pathological discharge in the nasal cavity, the nasal septum is curved. Nasal breathing is moderately difficult. The external auditory canals are wide, free, there is no pathological discharge. ShR 6/6 meters, BP gray, contoured. The mucous membrane of the pharynx is hyperemic, the palatine tonsils are not enlarged, swallowing is free. In other organs of ENT organs without visible pathology. Diagnosis: ARVI by type of rhinopharyngitis, residual effects. Deviation of the nasal septum. Recommended: Rg SNP, washing the nasal cavity with saline solutions 3 times a day for 7 days.
Laboratory results:
General clinical blood test:
Date
Hb, units
Er., *1012/l
Leu., *109/l
Ht, %
ESR, mm/h
T,*109/l
E, %
B, %
Lf, %
M, %
Pya, %
Xia, %
31.01
147
4, 55
9.5
44.3
14
271
3
35
6
1
55
15.02
134
4.35
8.6
44.1
10
286
1
1
34
7
1
56
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
31.01
full
1025
light yellow
5.5
no
no
oxalate
no
no
no
0-1
no
0-2
0-1
Biochemical blood test:
Name
Unit of measure.
Norm
31.01
Urea
mmol/l
2.5-6.4
4.4
Glucose
mmol/l
4.2-6.4
4.94
Creatinine
mmol/l
0.05-0.12
0.09
O. protein
g/l
63-87
70
Albumin
g/l
30-55
48
globulins
g/l
17-35
28
Potassium
mmol/l
3.50-5, 10
4.47
Sodium
mmol/l
136-145
140.7
Chlorine
mmol/l
98-107
106
Triglycerides
mmol/l
0-2.3
1.7
Cholesterol
mmol/l
3.7-6.0
5.81
b- lipoproteins (LDL)
ED
350 - 650
600
LDL
mmol/l
1.9-4.4
3.31
VLDL
mmol/l
0.6-1.2
0.78
HDL
mmol/l
0.78-2.303
1.72
coefficient atherogenicity
units.
0.0-3.0
2.38
TSH
mIU/ml
0.3-4.0
1.73
T4 free
mg/dl
4.5-15
7.4
CPK
U/l
10-160
238
CPK-MB
U/ l
0-25
38.6
ALT
U/l
10-50
20
AST
U/l
11-50
51
CRP
mmol/l
3-10
22
Myocardial antibodies
titer
less than 1:10
1:40
Cardiotest (myoglobin, CPK-MB, troponin) 01/30/2014: positive.
Cardiotest (myoglobin, CPK-MB, troponin) 02/15/2014: negative
Biochemical blood test 02/05/2014: LDH 211 U/l (120-246), AST 30 U/l (11-50), CPK 350 U/ l (10-160), CPK-MB 27.7 U/l (0-25), fibrinogen 2.38 g/l (0-4). CRP 0.2,
Blood for microflora and determination of sensitivity to antibiotics (three times 31.01-04.02): no growth of microflora.
Microreaction with cardiolipin antigen 31.01.2014: negative.
AT-HIV 1.2 02/03/2014: not detected.
HBs, Anti-HCV 02/03/2013: not detected.
Fecal analysis on February 11, 2014: no worm eggs were found.
Treatment was carried out: mode 2, diet 10. Intravenously: glucose 5% -200 ml, ascorbic acid 5% -10 ml, analgin 50% - 2 ml, asparcam 20 ml. No. 5. Ceftriaxone 1.0 IM 2 times a day. Inside: tab. sotalol 80 mg 1 tab in the morning and evening, caps arbidol 0.1 1 caps 4 times a day, biomax 1 tab 1 time a day, caps azimycin 0.5 mg 1 tab 1 time a day, caps. Linex 1 caps 3 times a day, caps. mildronat 0.5 1 caps 2 times a day, susp. viferon 500000 units 2 suppositories 2 times a day per rectum.
RECOMMENDED:
21. Observation by the doctor of the unit according to the place of residence
22. Control performance of daily ECG monitoring after 3 months
23. Normalization of lifestyle.
24. Limit the intake of animal fats, easily digestible carbohydrates, increase the amount of vegetable fiber and vegetable fats in the diet.
25. Continue taking medications:
a. sotalol 80 mg - 1 tab. 2 times a day for 3 months
b. Mexicor 0.1 - 1 tab. 2 times
a
day
for
1
month has been under inpatient examination and treatment at the hospital therapy clinic of the Military Medical Academy since February 2016. with a diagnosis:
Cancer disease. Adenocarcinoma of the prostate, hormone-refractory form, T4 N1 Mx Gx C1 multiple distant foci in the bones of the skeleton. Cancer intoxication. Peritoneal carcinomatosis. Epithelial neoplasia of the sigmoid colon (2014). Polylymphadenopathy.
Chronic macrocytic hyperchromic anemia of moderate severity. Leukemoid reaction (neutrophilia 11.8*109/l, lymphocytosis 9.9*109/l). thrombocytosis 518*109/l
Ischemic heart disease. Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis. Complete blockade of the right leg of the bundle of His. Frequent supraventricular and ventricular extrasystole.
Hypertensive disease of the third stage. Medical normotension. The risk of cardiovascular complications is very high.
Chronic heart failure stage 2A, 4 functional class.
Bilateral hypostatic pneumonia in the lower lobes of both lungs, DN-1.
Type 2 diabetes mellitus, target HbAc<8.0%, decompensation. Diabetic distal symmetric polyneuropathy of the lower extremities of the sensory type.
cerebrovascular disease. Dyscirculatory encephalopathy of the third stage of mixed (diabetic, atherosclerotic, hypertensive) genesis.
Multinodular euthyroid goiter of the first degree.
Fibrosis of the liver of mixed origin. Liver cysts. Hepatocellular insufficiency of the 1st degree according to Child-Pugh.
Urolithiasis disease. Stones in the middle third of the right ureter. Chronic bilateral latent pyelonephritis without exacerbation. Secondary nephropathy of mixed (diabetic, atherosclerotic, hypertensive) genesis. Cysts of both kidneys. Chronic kidney disease C2 stage.
Bilateral sensorineural hearing loss
Discharged from the Military Medical Academy on February 02, 2016. Total treatment days were 4.
The final diagnosis was made on January 28, 2016. ICD code: C97
Total radiation dose 0.78 mSv.
Clinical outcome: improvement.
Complaints at admission: contact with the patient is impossible due to the severity of the condition, pronounced signs of discirculatory encephalopathy
Anamnesis of the disease: According to the submitted medical documentation, since 1982 he has been suffering from type 2 diabetes mellitus (with VVC, fasting hyperglycemia of 8.0 mmol/l was detected). Regularly followed the diet and the prescribed treatment, the blood sugar level did not exceed 8 mmol/l.
Coronary heart disease for more than 20 years, was repeatedly treated in a hospital. During the last 3 years, exertional angina pectoris was noted at the level of 2-3 functional class. At attacks took kardikt with positive effect.
Hypertension for 18 years. The maximum increase in blood pressure is up to 160/100 mm Hg, the minimum is 100/60 mm Hg. Didn't take therapy.
In 1993, TUR for prostate adenocarcinoma. In the future, there was an increase in PSA over 600 pg/ml (N<4). Registered with a urologist. Last inspection in 2014
2013 a neoplasm of the thyroid gland with metastasis to the lymph nodes of the neck was suspected. Consulted by an endocrinologist - multinodular euthyroid goiter of the 1st degree.
2013 - revealed polylymphadenopathy of the neck, incl. Virchow knot.
06/09/2014 - bilateral hilar pneumonia.
16.12.2014 - revealed an increase in ESR 36 mm/h, Leu 13.9*109/l, LF 60%, Hb 116g/l. This issue has not been investigated.
A real deterioration in the last weeks (according to the words of the accompanying daughter), when, against the background of relative well-being (he moved around the room on his own), weakness and fatigue began to increase sharply, subfebrile condition was noted, and he has not been getting out of bed for the past few days. Given the appearance of interruptions in the work of the heart, an ECG was performed, a paroxysm of atrial fibrillation was suspected. According to urgent indications, he was delivered to the GT clinic on a stretcher. Upon careful analysis of the ECG, it was determined that these ECG changes were the result of frequent supraventricular extrasystole against the background of sinus rhythm.
The patient was immediately reported to the management of the clinic. Considering the severity of the comorbid pathology, a decision was made to hospitalize the patient in the ICU.
Objectively at the time of admission: the condition is severe, prognostically unfavorable, due to severe comorbid, including oncological pathology in a patient of senile age.
The skin is dry, pale, tissue turgor is sharply reduced. palpable cervical lymph nodes, Virchow's node on the left, not soldered to the underlying tissues, dense. Pastosity of legs and feet. The level of consciousness is stun. The patient is exhausted very quickly during minimal intercourse. Answers questions and follows simple commands. Manifestations of encephalopathy of mixed genesis are expressed.
Hemodynamic parameters are stable. Hell 136/78 mmHg Art. Pulse = heart rate = 87 per minute. Rhythmic, symmetrical, synchronous, satisfactory filling, not tense. heart sounds are rhythmic, muffled, systolic murmur over the apex, weakening of the first tone.
The chest is of the correct form, symmetrical. the right half lags somewhat behind the left in the act of breathing
. Shortening of percussion sound from the level of the sixth rib on the right. In the same place, a sharp weakening of breathing is heard, up to its complete absence. On the left above the lower sections, there is a weakening of breathing and scattered moist fine bubbling rales.
The abdomen is not swollen. On palpation, soft, painless in all departments. On the anterior abdominal wall there is a postoperative scar from a median laparotomy. In the mesogastrium, a rounded formation is palpable, dense, not soldered to the underlying tissues, 7 x 7 cm, displaced and painless on palpation. peristalsis is heard. A digital examination revealed brown stools without admixture of blood. Tapping on the lower back is painless. CVP - 30 mm. The expressed dehydration, the phenomena of a respiratory alkalosis is defined. The rate of diuresis is reduced due to hypovolemia.
During hospitalization, stabilization of hemodynamics, respiratory function was achieved, the patient is discharged to the outpatient stage under the supervision of an oncologist at the polyclinic.
Results of laboratory researches:
Clinical blood test (hardware processing):
RBC
date , *1012/l
Hb
units.
Lake. *109/l
Tr.
109/L
HCT
PCT
E
%
B
%
lymph
%
mon
%
28.01.16
2.69
97
22.62
518
28.7
0.363
0
0
43.6
4.1
MCV,
Fl
MCH,
pg
MCHC,
g/l
RDW,
%
MPV,
Fl
PDW
%
Lf
%
M,
%
Lf,
109/l
M,
109/l
106.8
36.1
338
15.5
7.0
15.5
43.6
4.1
9.86
0.93
CBC (hardware processing):
RBC
date , *1012/ L
Hb
units
Lake. *109/l
Tr.
109/L
HCT
PCT
E
%
B
%
lymph
%
mon
%
01/31/16
2.54
87
20.64
369
27.2
0.269
0.6
0
39.0
4.7
MCV,
Fl
MCH,
pg
MCHC,
g/l
RDW,
%
MPV,
Fl
PDW
%
Lf
%
M,
%
Lf,
109/L
M,
109/L
101.7
34.3
320
15.8
7.3
15.8
39.0
4, 7
9.05
0.97
Clinical blood test (hardware processing): RBC
date
, *1012/l
Hb
units.
Lake. *109/l
Tr.
109/L
HCT
PCT
E
%
B
%
lym
%
mon
%
01.02.16
2.53
85
20.63
364
26.7
0.266
1.4
0.1
42.5
4.6
MCV,
Fl
MCH,
pg
MCHC,
g/l
RDW,
%
MPV,
Fl
PDW
%
Lf
%
M,
%
Lf,
109/l
M,
109/l
105.7
33.6
318
15.5
7.3
15.5
42.5
4.6
8.77
0.95
Urinalysis (hardware processing):
Date
Rel. dense
pH
Protein
Acetone
Glucose
Lake.
Erythrocytes
Epithelium
Cylinders
Urobil.
Bakt.
unchangeable
vyschel.
01/30/16
1030
5.5
1.0
neg
neg
neg
solid
solid
single
-
16
0
Urinalysis (hardware processing):
Date
Rel. dense
pH
Protein
Acetone
Glucose
Lake.
Erythrocytes
Epithelium
Cylinders
Urobil.
Bakt.
unchangeable
vyschel.
01/31/16
1025
5.5
neg
neg
neg
neg
80-100
10-15
1-2
1-3
16
1
Biochemical blood test from 01/28/2016:
Date
01/28/2016
31.01.2016
Norm indicators Units
Glucose
9.6
8.1
4.2-6.2
mmol
/
l
Urea
13.7
6.6
2.4-6.4
mmol/l
Creatinine
68
57
53-123
umol/ l
Bilirubin total.
26.5
11.7
6.8-26
umol/l
Total protein
59
46
63-87
g/l
ALP
109
30-120
U/l
ALB
25.6
35-53
g/l
ALT
19
10-50
U/l
AST
15
11-50
U/l
Cl-
102
104
mmol/l
K+
3.77
3.14
4-6
mmol /
Na+
133.1
133.4
130-150
mmol/l
Blood troponin T from 01/28/2016: weakly positive.
Results of instrumental studies:
ECG dated January 28, 2016: Sinus rhythm with a heart rate of 70 beats per minute. EOS is horizontal. AV block I degree. Complete blockade of the right leg of the bundle of His. Signs of diffuse disorders of repolarization processes.
ECG dated January 31, 2016: Sinus rhythm with a heart rate of 100 beats per minute. EOS is horizontal. AV block I degree. Complete blockade of the right leg of the bundle of His. Signs of diffuse disorders of repolarization processes.
X-ray of the organs of the chest cavity on January 29, 2016: on the chest radiograph in the horizontal position of the patient in the pleural cavities there is free fluid (a significant amount on the right). Signs of a small right-sided pneumothorax - the lung is compressed in the apical region by 2 cm. The lung pattern is strengthened and deformed due to predominantly interstitial changes - congestion, 2-sided congestive pneumonia. The roots of the lung are compacted, unstructured. The heart is not enlarged. The aorta is sealed. In the soft tissues of the neck on the right, a seal is determined in the form of a nodular formation measuring 35 cm in diameter. Conclusion: right-sided pneumothorax. Congestive 2-sided pneumonia, 2-sided hydrothorax. Lymph conglomerate. neck nodes on the right.
Radiography of the organs of the chest cavity on January 29, 2016: on the control radiograph of the chest in the horizontal position of the patient, the lungs were straightened, the amount of fluid in the right pleural cavity and congestion in the lungs decreased.
Ultrasound of the abdominal organs and kidneys dated January 29, 2016: Visualization is difficult due to severe intestinal pneumatosis. Near the upper pole of the right kidney there is a rounded hypoechoic formation 27 mm in diameter. Lymphadenopathy (mts?) of the upper mesenteric lymph nodes. Hyperplasia of the right adrenal gland. Mts in the region of the right adrenal gland. Cysts of the right kidney.
Treatment was carried out:
Mode 1, diet, drug treatment:
Drug
Dose
Method
1.
Ceftriaxoni 1.0
1.0 ml 2 times a day
IV
2.
Neotoni 1.0
1.0 ml 1 time a day
IV
3.
Quamatli 0.2
0.2 ml 2 times a day
IV
4.
Cytaflavini 20 ml
single IV
5.
Cerukali
2.0
single IV
6.
MgSo4
25% - 5.0
5.0 1 time per day
IV
7.
Kalii chloridi 4% - 30.0
30 each 0 1 time per day
IV
RECOMMENDED:
1. Observation by a urologist, oncologist at the place of residence. Addressing the issue of continuing treatment in a hospice setting, intravenous administration of albumin (protein maintenance doses)
2. Continue taking:
a. Diuver 5 mg in the morning
b. Cytoflavin 2 tablets in the morning and in the afternoon
c. Asparkam 1 tablet 3 times a day
d. Ranitidine 0.3 1 tablet 2 times a day
Military Medical Academy. CM. Kirov
Department of Hospital Therapy. V.N. Sirotinin
XVIII. DISCUSSION REPORT CASE
HISTORY №: ARCHIVE №:
SURNAME, FIRST NAME, PATRONY NAME:
Date of birth: full years: 50
Contingent: Pensioners of the Ministry of Defense of the Russian Federation
Inpatient treatment: Department of Hospital Therapy of the Military Medical Academy from: 21.04.2016 to: 25.04.2016 total days spent treatments: 4
Final diagnosis:
atherosclerosis of the aorta. Large focal myocardial cardiosclerosis with outcome in secondary dilated cardiomyopathy. Secondary mitral insufficiency of the 2nd degree, tricuspid insufficiency of the 2nd degree, secondary pulmonary hypertension of the 3rd degree. Frequent ventricular extrasystole, paroxysmal unstable ventricular tachycardia. Persistent form of atrial fibrillation. RFA of pulmonary veins and cava-tricuspid isthmus 04.2012; 07/30/2014 - RFA of arrhythmogenic zones of the left and right atria using a circular diagnostic electrode (Lasso) under conditions of Carto XP electroanatomical mapping. Paroxysm of atrial fibrillation from 04/21/2016. (tachysystolic variant, CHA2DS2VAS with 2.2% [2 points], EHRA grade 4, HAS-BLED 2 points), complicated by the development of arrhythmogenic shock, interstitial pulmonary edema,
Chronic heart failure stage 2B, 4-3 functional class.
Bronchial asthma, atopic, mild, intermittent course in the stage of stable remission
Urolithiasis, microliths of both kidneys, remission, without impaired renal excretory function. Secondary nephropathy due to chronic heart failure. Diffuse nephroangiosclerosis. Chronic kidney disease stage 3aA1.
Secondary chronic iron deficiency anemia of mild degree.
Chronic gastritis without exacerbation.
Alimentary obesity of the first degree, stable stage.
Intervertebral osteochondrosis of the cervical, thoracic and lumbar spine.
Varicose disease of the lower extremities without signs of venous insufficiency.
Hyperopia 0.5 D in both eyes.
Total radiation dose: 0.26 mSv
Clinical outcome: Dropped out with improvement
On admission:
Complaints: interruptions in the work of the heart during the last 2 hours. severe shortness of breath when walking (distance not less than 10 m), fatigue, severe general weakness.
History of the disease: Patient considers himself since 2008, when 3 weeks after suffering lacunar tonsillitis first developed paroxysm of atrial fibrillation, complicated by the development of pulmonary edema. A military hospital was hospitalized, where acute infectious-immune myocarditis was diagnosed, complex treatment was carried out. After discharge, the patient noted frequent attacks of palpitations (1-2 times a week), accompanied by severe general weakness, shortness of breath, dizziness. In view of this, in the period from 2008 to 2012, he was repeatedly hospitalized in various hospitals in St. Petersburg with paroxysms of atrial fibrillation (AF). The disease was complicated twice by the development of cardiogenic arrhythmic shock (2008 and 2009). In 2010, during the next hospitalization, thromboembolism of small branches of the pulmonary artery was diagnosed. On an outpatient basis, he received cordarone with an unstable effect. The active use of antiarrhythmic therapy was limited by the fact that against the background of intravenous administration of cordarone, the development of toxic hepatitis was noted with an increase in aminotransferases by more than 50 times (!), and when administered orally at a maintenance dose of 100 mg / day. - ALT level was within 2-3 upper limits of normal. The development of postmyocardial remodeling and dilatation of the left chambers of the heart (diffuse hypokinesia and myocardium, left ventricular ejection fraction 20%, dilatation of the anterior-posterior size of the left atrium 52 mm) did not allow the use of group 1C drugs for long-term continuous use. In 2012, a protracted paroxysm of AF developed. Against this background, 88 episodes of non-sustained ventricular tachycardia (up to 10 seconds) were recorded during daily ECG monitoring. On April 27, 2012, RF catheter isolation and catheter ablation of the cavatricuspid isthmus were performed at Almazov Federal Center for Emergencies under the conditions of CARTO 3 electroanatomical mapping using a circular diagnostic electrode. When performing a control endocardial electrophysiological study, ventricular arrhythmias were not provoked, data for the WPW syndrome were not obtained, sinus rhythm was maintained, cordarone therapy in combination with β-adrenoblockers (bisoprolol) was continued, but after three days on April 30, 2012, a hemodynamically significant paroxysmal AF requiring repeated electrical cardioversion. Despite the treatment, during 2012-2013, paroxysms of the tachysystolic form of AF continued to be recorded, clinically asymptomatic, which were stopped by intravenous administration of cordarone. In July 2014, against the background of another paroxysm of AF, cardiogenic pulmonary edema developed, which required electrical cardioversion for health reasons. For this reason, July 30, 2014 In the conditions of FGBU "FTsSKE named after V.A. Almazov" repeated radiofrequency catheter ablation of arrhythmogenic zones of the left and right atria was performed using a Lasso circular diagnostic electrode under conditions of CartoXP electroanatomical mapping. Carrying out this type of treatment made it possible to stabilize the patient's condition and stop using cordarone until March 2015 (on March 16, 2015, cordarone was resumed due to the development of recurrent episodes of atypical atrial flutter, which were stopped by stationary electrical cardioversion). At the next examination of cardiac surgeons-arrhythmologists of the Federal State Budgetary Institution "FCSKE named after V.A. Almazov", there were no indications for surgical treatment, it was recommended to continue monitoring and prophylactic administration of cordarone (according to the ECHO-ECG performed at that time, against the background of diffuse myocardial hypokinesia, there was a decrease in EF to 18 %). According to the patient, from the second half of 2015, edema in the legs began to increase, the abdomen increased in size, exercise tolerance decreased significantly, he began to get tired quickly, and shortness of breath developed with slight physical exertion. Associating deterioration of health with cordarone, the patient stopped taking it. During October-December 2015, the patient regularly took diuretics (furosemide, veroshpiron), ACE inhibitors, however, the state of health and condition progressively worsened during January: shortness of breath appeared in a horizontal position, difficulties arose when moving around the apartment, and therefore, for urgent medical reasons, he was hospitalized in the intensive care unit of the hospital therapy clinic. During the treatment with the use of Levosimendan (2 doses), there was an improvement in well-being. After discharge from CHT, a paroxysm of atrial fibrillation developed, which was stopped by electrical cardioversion at the Pokrovskaya hospital. During the same period, the patient was actively asked to join the waiting list for a heart transplant. On March 1, Levosimendan was re-introduced as planned. He followed the prescribed therapy at the outpatient stage and felt well. Despite this, at about 07:00 on April 21, 2016, the patient developed a paroxysmal atrial fibrillation, accompanied by a progressive increase in severe weakness, decrease in blood pressure. Hospitalized in the hospital therapy clinic.
SURVEYS: An. HD common 04/22/2016: Alkaline phosphatase 81.3 U/L; ALT 37.7 U/l; AST 29.0 U/l; GGT 162.9H u/l; LDH 224.9 u/l; Albumin 33.1 G/L; Total bilirubin 14.2 umol/l; Calcium 2.17 mmol/l; Cholesterol 5.99; Creatinine 161.7Humol/l; Glucose 9.61H mmol/l; Total protein 61.9L units; Urea 9.4H mmol/l; Direct bilirubin 3.2 umol/l
PTI 04/25/2016 40%
Chest X-ray dated 04/22/2016 On the survey radiograph of the chest organs in the lungs, moderately pronounced phenomena of stagnation. The roots of the lungs are moderately compacted due to the vessels of gravity. The sinuses are free. The heart is significantly expanded in diameter to the left with unevenness along the left contour, which is typical for an aneurysm.
Echo-CG on 25.04.2016: IVS 8-10 mm, GS 10 mm, LV ECL-63mm, LV ESR-55mm, EF(S)-22% EF (Tei) 28%, Vlzh 220/185 ml. UO 35 ml, LP-52×50×60mm, PP-45×64mm, RV-36mm, LV myocardial weight 323 g, IMM 191 g/m2. SDLA 50 mmHg Conclusion: eccentric myocardial hypertrophy. Fibrosis of the interventricular septum. Total hypokinesia of the myocardium of the left stomach. Dilatation of all cavities. Symptom of spontaneous pseudocontrasting of cavities of the 1st degree. The chords are shortened, compacted, limit the mobility of the mitral valves. Strengthening of the moderator bundle of the right ventricle. The aorta, fibrous rings of AK and MK, aortic crescents and mitral leaflets are sealed. Relative insufficiency of the mitral valve of the 1st degree, tricuspid valve of the II degree. (VC=6-7 mm), pulmonary hypertension of II degree. The pericardium is not changed. There is no effusion.
Discharged ahead of schedule according to the report in a satisfactory condition.
RECOMMENDED:
1. observe the regime of work and rest.
2. observation by a cardiologist (routinely consider prescribing the drug Uperio (Entresto) to the patient at the minimum therapeutic dose)
3. continue taking medications:
• Torasemide 0.01 to 1.5 tablets 1 time per day
• Diacarb 0.25 1 time per day
• Betaloc-ZOK 0.025 1 tab 1 time in the morning and 1/2 tab in the evening
• Coraxan 0.005 1 tab 2 times a day
• Trimetazidine 0.035 1 tab 1 time a day
• Cordaron 0.2 1 tab 1 time per day day
• Warfarin 2.5 mg 1.75 tab. in the evening
• Cytoflavin - 2 tablets in the morning and in the afternoon for 1 month
• Asparkam 1 tablet 3 times a day for the first 10 days of each
month
.
was on inpatient examination and treatment with a diagnosis (I 40.0):
Acute infectious-immune myocarditis with arrhythmias of the type of frequent ventricular premature beats, unstable paroxysms of atrial fibrillation. Heart failure of the first functional class.
Widespread osteochondrosis of the spine with radicular syndrome. Lumbalgia.
Days of treatment 18.
Complaints at admission: pronounced palpitations, interruptions in the work of the heart, dizziness, moderate general weakness, discomfort in the heart area.
Within a month, against the backdrop of a protracted episode of acute respiratory illness, he began to notice the daily appearance of palpitations, interruptions in the work of the heart, a long-lasting feeling of general weakness, fatigue, the appearance of constant discomfort in the heart, low-grade fever.
Results of instrumental studies:
ECG on January 30, 2014: P-0.12 s, QT-0.34 s, PQ 0.14 s, QRS 0.08 s. Heart rate 94 per minute. Sinus rhythm. Horizontal position of the electrical axis of the heart. Diffuse disturbance of repolarization processes. Frequent ventricular extrasystoles.
ECG on February 11, 2014: P-0.08 s, QT-0.32 s, P 0.08 s, PQ 0.12 s, QRS 0.09 s. Heart rate 96 per minute. Minor sinus tachycardia. Horizontal position of the electrical axis of the heart. Diffuse violation of repolarization processes. Indirect ECG signs of left ventricular hypertrophy. Negative dynamics in the form of T wave inversion in II, III, AVF, V6 and slight depression of the ST segment in II, III, AVF, V5-V6 leads. Single ventricular extrasystole.
ECG 02/15/2014: Sinus rhythm with a heart rate of 74 per minute. Horizontal position of the electrical axis of the heart. Diffuse violation of repolarization processes. Single ventricular extrasystoles.
Holter ECG monitoring on January 30, 2014: during the observation period, sinus rhythm was recorded with a heart rate of 61 to 155 beats per minute. During wakefulness, tachycardia was recorded with an average hourly heart rate of up to 155 per minute. The decrease in heart rate at night is adequate (circadian index 44%). Average heart rate (day/day/night) 76/85/59 per minute. Frequent solitary polymorphic ventricular extrasystoles (4217 in total), once as an episode of trigeminia, single polytopic supraventricular extrasystoles (total 196), periodically in the form of couplets (total 61), once as an episode of bigeminy, unstable runs of atrial fibrillation with a heart rate of up to 155 beats were registered. minute (total 43, maximum 34 complexes). At 7:30, with an increase in heart rate to 150 beats per minute, a horizontal depression of the ST segment up to 1.5 mm was recorded for 5 minutes.
ECHO-KG dated 07.02.2014 IVS=WS=10.5 mm, LV 56/38 mm, EF 56%, FU 28%, VR 80 ml, LA 40 mm, PP 40 mm, aorta 36 mm, aortic dilatation 21 mm, e/a 1.4 The myocardium is not thickened, the kinetics is not disturbed, the cavities are not enlarged, free. Aorta, valves, pericardium are not changed. Diastolic dysfunction of the rigid type. Regurgitation of the 1st degree on the tricuspid and mitral valves.
Ultrasound examination of the abdominal organs on 02/03/2014: liver, gallbladder, pancreas, spleen without pathology.
X-ray of the chest organs on January 28, 2014: no pathological changes were detected.
Radiography of the paranasal sinuses on January 28, 2014: thickening of the mucous membrane of the left maxillary sinus of the parietal nature.
Radiography of the paranasal sinuses on February 12, 2014: the paranasal sinuses were pneumotized.
ENT on February 11, 2014: the mucous membrane of the nasal cavity is hyperemic, edematous, there is no pathological discharge in the nasal cavity, the nasal septum is curved. Nasal breathing is moderately difficult. The external auditory canals are wide, free, there is no pathological discharge. ShR 6/6 meters, BP gray, contoured. The mucous membrane of the pharynx is hyperemic, the palatine tonsils are not enlarged, swallowing is free. In other organs of ENT organs without visible pathology. Diagnosis: ARVI by type of rhinopharyngitis, residual effects. Deviation of the nasal septum. Recommended: Rg SNP, washing the nasal cavity with saline solutions 3 times a day for 7 days.
Laboratory results:
General clinical blood test:
Date
Hb, units
Er., *1012/l
Leu., *109/l
Ht, %
ESR, mm/h
T,*109/l
E, %
B, %
Lf, %
M, %
Pya, %
Xia, %
31.01
147
4, 55
9.5
44.3
14
271
3
35
6
1
55
15.02
134
4.35
8.6
44.1
10
286
1
1
34
7
1
56
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
31.01
full
1025
light yellow
5.5
no
no
oxalate
no
no
no
0-1
no
0-2
0-1
Biochemical blood test:
Name
Unit of measure.
Norm
31.01
Urea
mmol/l
2.5-6.4
4.4
Glucose
mmol/l
4.2-6.4
4.94
Creatinine
mmol/l
0.05-0.12
0.09
O. protein
g/l
63-87
70
Albumin
g/l
30-55
48
globulins
g/l
17-35
28
Potassium
mmol/l
3.50-5, 10
4.47
Sodium
mmol/l
136-145
140.7
Chlorine
mmol/l
98-107
106
Triglycerides
mmol/l
0-2.3
1.7
Cholesterol
mmol/l
3.7-6.0
5.81
b- lipoproteins (LDL)
ED
350 - 650
600
LDL
mmol/l
1.9-4.4
3.31
VLDL
mmol/l
0.6-1.2
0.78
HDL
mmol/l
0.78-2.303
1.72
coefficient atherogenicity
units.
0.0-3.0
2.38
TSH
mIU/ml
0.3-4.0
1.73
T4 free
mg/dl
4.5-15
7.4
CPK
U/l
10-160
238
CPK-MB
U/ l
0-25
38.6
ALT
U/l
10-50
20
AST
U/l
11-50
51
CRP
mmol/l
3-10
22
Myocardial antibodies
titer
less than 1:10
1:40
Cardiotest (myoglobin, CPK-MB, troponin) 01/30/2014: positive.
Cardiotest (myoglobin, CPK-MB, troponin) 02/15/2014: negative
Biochemical blood test 02/05/2014: LDH 211 U/l (120-246), AST 30 U/l (11-50), CPK 350 U/ l (10-160), CPK-MB 27.7 U/l (0-25), fibrinogen 2.38 g/l (0-4). CRP 0.2,
Blood for microflora and determination of sensitivity to antibiotics (three times 31.01-04.02): no growth of microflora.
Microreaction with cardiolipin antigen 31.01.2014: negative.
AT-HIV 1.2 02/03/2014: not detected.
HBs, Anti-HCV 02/03/2013: not detected.
Fecal analysis on February 11, 2014: no worm eggs were found.
Treatment was carried out: mode 2, diet 10. Intravenously: glucose 5% -200 ml, ascorbic acid 5% -10 ml, analgin 50% - 2 ml, asparcam 20 ml. No. 5. Ceftriaxone 1.0 IM 2 times a day. Inside: tab. sotalol 80 mg 1 tab in the morning and evening, caps arbidol 0.1 1 caps 4 times a day, biomax 1 tab 1 time a day, caps azimycin 0.5 mg 1 tab 1 time a day, caps. Linex 1 caps 3 times a day, caps. mildronat 0.5 1 caps 2 times a day, susp. viferon 500000 units 2 suppositories 2 times a day per rectum.
RECOMMENDED:
26. Observation by the doctor of the unit according to the place of residence
27. Control performance of daily ECG monitoring after 3 months
28. Normalization of lifestyle.
29. Limit the intake of animal fats, easily digestible carbohydrates, increase the amount of vegetable fiber and vegetable fats in the diet.
30. Continue taking medications:
a. sotalol 80 mg - 1 tab. 2 times a day for 3 months
b. Mexicor 0.1 - 1 tab. 2 times a
day
1
month CM. KIROVA
XVIII. DISCUSSION REPORT CASE
HISTORY №: ARCHIVE №:
SURNAME, FIRST NAME:
FULL YEARS: 58
COPY: CHI
HAS BEEN TREATED IN: Department of Hospital Therapy of the Military Medical Academy
From: 10.05.2016 TO: 10.05.2016 TOTAL DAYS OF TREATMENT CARRIED OUT:
FINAL DIAGNOSIS: Ischemic heart disease. Atherosclerotic and large-focal post-infarction cardiosclerosis (2005, 2013), chronic aneurysm of the left ventricular apex. Severe arrhythmias: often recurrent hemodynamically significant persistent paroxysms of ventricular tachycardia from 05/10/2016. (stopped), paroxysmal atrial fibrillation (tachysystolic variant, CHA2DS2VASc 2.2% [2 points], EHRA class 2, HAS-BLED 2 points), outside paroxysm.
Angioplasty and stenting of the anterior interventricular artery (2013).
Stage III hypertension (normotension, risk of cardiovascular events IV)
Chronic heart failure of the 1st functional class
Gastroesophageal reflux disease. Distal erosive first degree reflux esophagitis. Superficial gastritis, erosive bulbitis.
Varicose veins of the lower extremities.
Solitary cyst of the left kidney
ICD code: [I47.2].
WORK CAPABILITY: restored
TOTAL RADIATION DOSE: 0.26 mSv
CLINICAL OUTCOME: Discharged with improvement
AT ADMISSION: Fell ill on 05/09/2016, around 21:00, when there was a feeling of heat all over the body and in the head, the pulse disappeared. Called an ambulance. A similar condition (with the development of pre-syncope states) is noted for the first time.
In history - a long course of hypertension, myocardial infarction in 2005 and 2013, angioplasty with stenting of the anterior interventricular artery in March 2013, paroxysmal atrial fibrillation, COPD, varicose veins of the lower extremities. He is periodically hospitalized due to the unstable course of angina pectoris in hospitals of the city, however, the patient does not describe anginal pain and reports that episodes of strong heartbeat served as the reason for hospitalization. The last hospitalization for this reason was in June 2013. Since that time, anginal pain and episodes of arrhythmias have not recurred. He has not received the prescribed therapy since March-April 2014. Tolerance to physical activity, while it was quite satisfactory. Working as a cardboard cutter work is associated with moderate (to intense) physical activity. He also notes an episodic increase in blood pressure up to 180/100 mm Hg. Art., which associates with changes in the weather. He considers 140/80 mm Hg to be working figures. Art. However, regular monitoring of blood pressure figures does not produce. A real deterioration in well-being developed on the night of May 10, 2016, when complaints that were not typical for the patient appeared, manifested by a sensation of "flushing to the head", pulsation in the temporal regions, a feeling of heat throughout the body, "lack of pulse" in the radial arteries. At the time of the arrival of the ambulance team, and after feeling better, against the background of ongoing treatment, there were again complaints of severe weakness, defocusing of vision, accompanied by syncope. The patient notes a three-time short-term loss of consciousness.
Past injuries, surgeries, diseases (dates, received treatment for them): angioplasty and stenting of the anterior interventricular artery in March 2013
Existing comorbidities (duration of the course, treatment received for them): COPD 0 st. Chronic bronchitis without exacerbation. Varicose veins of the lower extremities.
Heredity: father died at 59, mother at 50 . Doesn't know the reasons Bad habits:
smokes
1-2 packs of cigarettes a day
AT DISCHARGE: satisfactory condition. He was discharged ahead of schedule (according to the report), the goals of hospitalization were partially achieved - the patient maintains a stable sinus rhythm, normotension, 24-hour ECG monitoring was not performed against the background of antiarrhythmic therapy
RECOMMENDED: to observe the regime of work and rest.
Observation of a cardiologist, arrhythmologist, gastroenterologist of the polyclinic.
The patient has class IB indications for implantation of a cardioverter-defibrillator (presence of structural heart disease and spontaneous sustained ventricular tachycardia with hemodynamic presyncopal conditions) in a planned manner for secondary prevention of sudden death.
Coronary angiography in a planned manner, followed by a consultation with a cardiac surgeon to resolve the issue of coronary plasty (bypass surgery) and possible resection of the aneurysm with surgical remodeling (recovery) of the left ventricular
cavity omakor:
• Kordaron 200 mg - 1 tablet per day in the morning
• Bisoprolol 2.5 mg - 1 tablet per day in the morning
• Omacor - 1000 mg (1.0 g) in the morning.
Additionally, continue taking:
• Acetylsalicylic acid (Trombo ASS / Aspirin-cardio / Acecardol / Aspicor ...) 100 mg in the morning continuously
• Atrovastatin 20 mg in the morning continuously
• Omeprazole 20 mg in the morning for 1 month
• Phosphalugel - 1 dose at night for 1 month
FGDS
(control) after 1 month
Daily ECG monitoring after three days of taking the recommended antiarrhythmic therapy
Form 12_Un
. CM. KIROV
St. Petersburg, st. Academician Lebedeva, d.6 lit. H
DISCLAIMER No.
, born in 1972 was on inpatient examination and treatment at the hospital therapy clinic of the Military Medical Academy from May 30, 2016 to May 31, 2016 with a diagnosis of:
Hypertension of the first stage (arterial hypertension of the 2nd degree → drug normotension, the risk of cardiovascular complications is “high”) without signs of heart failure. Uncomplicated hypertensive crisis from May 30, 2016 (stopped on May 30, 2016). Initial manifestations of cerebrovascular accident in the form of astheno-neurotic syndrome.
Discharged from the Military Medical Academy on May 31, 2016 Total days of treatment 1
The final diagnosis was made on May 31, 2016 ICD code I-10
MES 291250
A certificate of incapacity for work No. ______________________ was issued from May 30, 2016 to May 31, 2016 as a continuation of the certificate of incapacity for work No. 229514825255 from May 26, 2016. The ability to work
was not restored, the appearance at the clinic on June 1, 2016.
Clinical outcome: improvement.
Complaints at admission: dizziness when moving and at rest, headache, discomfort when looking at a bright light, general weakness.
Anamnesis of the disease: he has been experiencing an increase in blood pressure since 2013, he consulted a general practitioner, there is no permanent treatment. Real deterioration since May 22, 2016, when during work he felt weakness, tachycardia, which disappeared on their own. He did not seek medical help. May 25, 2016 noted an increase in blood pressure up to 160/100 mm. rt. Art., felt a rapid heartbeat, weakness (did not take drugs). On May 26, 2016, he turned to the doctor on duty at polyclinic No. 97, he does not remember what was appointed, he independently took adenol and cinnarizine, noted a short-term improvement. On May 30, 2016, due to another increase in blood pressure to 160/110 mm Hg. Art. and the development against this background of a severe dull headache without a clear localization, nausea, lack of effect from taking adenol, called an ambulance team, delivered to the hospital therapy clinic of the VMA.
Treatment was carried out: bed rest, diet No. 10. Intravenous drip: Cytoflavin, glucose solution. Intramuscularly: analgin solution, metoclopramide solution. Inside: prestarium, phenibut, vinpocetine, aspirin.
The patient was admitted to the clinic due to the development of an uncomplicated hypertensive crisis, which was stopped in the hospital. According to the anamnesis, objective status, and the results of additional research methods, the presence of symptomatic arterial hypertension in the patient was excluded. Therapy for essential arterial hypertension at this stage can be monocomponent, represented by drugs that affect the RAAS. Discharged at his own request in a satisfactory condition under the supervision of a cardiologist at the place of residence.
Results of instrumental studies:
ECG 05/30/2016: sinus rhythm with a heart rate of 66 per minute. Normal position of the EOS. Hypertrophy of the myocardium of the left ventricle.
Echo-CG on May 30, 2016: IVS = WS = 11 mm, LV = 44/29 mm, LV V = 86/31 ml, VR = 55 ml, EF = 64%, FU = 35%, OTS = 0, 5 units, LVMM = 200 g, LVMI = 99 g/m2, LA = 38*43*53 mm, PP = 37*52 mm, RV = 24 mm, RV wall = 4 mm, Ao = 32 mm, open. AK = 17 mm, LA = 20 mm. Conclusion: Eccentric remodeling of the left ventricle. The kinetics is not broken. The cavities are not expanded. Aorta, valves, pericardium are not changed. Diastolic dysfunction of the rigid type. The minimum reverse blood flow to the MC and TC. Pulmonary blood flow is not changed.
Ultrasound of the abdominal organs on May 30, 2016: the liver is enlarged, the right lobe is 17.1 cm, the left lobe is 5.5 * 6.8 cm, echogenicity is not changed, the portal vein is 10.7 mm - not dilated, choledochus is 2 mm, intrahepatic bile ducts are not dilated. The gallbladder is irregular in shape, constriction in the middle third, length 8.1 cm, diameter 2.6 cm, smooth contours, wall 2 mm, heterogeneous, calculi, no polyps. The pancreas is located clearly, not enlarged, the contours are clear, even, the head is 26 mm, the body is 7 mm, the tail is 15 mm, echogenicity is increased, the structure is homogeneous. Right kidney: length 12.7 cm, width 4.6 cm, parenchyma 21 mm, PCL not dilated, no calculi. Left kidney: length 12.1 cm, width 5.6 cm, parenchyma 21 mm, PCL not dilated, no calculi. no pathology was detected in the projection of both adrenal glands. The spleen is not enlarged, length 8.5 cm, thickness 3.6 cm, the structure is homogeneous. Conclusion: ultrasound signs of hepatomegaly due to the right lobe, slight diffuse changes in the pancreas.
Ultrasound of the thyroid gland on May 30, 2016: located in a typical place, symmetrical, right lobe 1.9*1.5*5.1 cm, V = 6.9 cm3, left lobe 1.4*1.4*5, 1 cm, V = 4.8 cm3, isthmus 3.2 mm. The echostructure is homogeneous, echogenicity is not changed. Throughout the parenchyma of the right lobe, anechoic formations with clear, even contours with calcifications inside from 1 mm to 3.5 mm are determined. Throughout the parenchyma of the left lobe, similar formations are determined from 1.5 to 2 mm. in the lower third of the left lobe, an anechoic formation with clear, even contours with a diameter of 12.3 * 5.6 mm is determined. In the projection of the parathyroid glands - without pathological changes. Conclusion: ultrasound signs of thyroid cysts.
Consultation of an ophthalmologist on May 30, 2016: diagnosis: Hypertensive angiopathy of both eyes. At the time of examination, there were no data for stagnation of the optic discs.
Consultation of a neurologist on May 30, 2016: diagnosis: Initial manifestations of cerebrovascular accident in the form of astheno-neurotic syndrome. Recommendations are given (see below).
Laboratory results:
Clinical blood test (hardware processing): RBC
date
, *1012/l
Hb
units.
Lake. *109/l
Tr.
109/l
HCT
PCT
ESR, mm/h
E
%
B
%
limf
%
mon
%
p/i
%
s/i
%
05/30/16
4.92
160
7.13
224
46.5
0.190
-
1.8
0.4
27.0
6.5
-
64.3
Urinalysis (hardware processing):
Date
Rel. dense
pH
Protein
Acetone
Glucose
Lake.
Erythrocytes
Epithelium
Salts
30.05.16 g
1020
6.0
neg
neg
neg
0-1 in p/z
0-1-2 in p/z.
1-3 in p / sp.
negative
Biochemical blood test:
Indicators 30.05.16 g
Units
Indicators 30.05.16 g
Unit
Cholesterol
5.57
3.7-5.0
mmol/l
CPK
125.1
10-160
U/l
Glucose
5.1
4.2-6.2
mmol/l
CPK-MB
8.2
10-25
U/l
Urea
5.8
2.4-6.4
mmol/l
K+
4.9
4-6
mmol/l
Bilirubin total
4.2
6.8-26
umol/l
Na+
138
130-150
mmol/l
Total protein
71
63-87
g/l
Ca++
1.31
2-3
mmol/l
ALT
26
10-50
U/l
Cl
100
98-106
mmol/l
AST
21
11-50
U/l
Creatinine
78
53-123
umol/l
Indicators 31.05.16 g
K+
5.19
4-6
mmol/l
Na+
140.2
130-150
mmol/l
Analysis blood tests on May 30, 2016: troponin I - 0.0 ng/ml (norm 0-0.04).
RECOMMENDED:
31. Supervision by a cardiologist, internist, endocrinologist at the place of residence.
32. Normalization of lifestyle. General measures, including regular, moderate in intensity physical dynamic loads in the air, sufficient sleep and rest, the ability to switch to rest, smoking cessation, alcohol. Useful spa treatment.
33. Limit the consumption of animal fats, easily digestible carbohydrates, increase the amount of vegetable fiber, vegetable fats, foods containing an increased amount of potassium (dried apricots, raisins, prunes) in the diet. The basis of treatment is the consolidation of a rational lifestyle.
34. Control of the level of blood pressure.
35. Permanent intake (under the control of the pulse level, blood pressure):
• Perindopril 5 mg orally, ½ tablet in the morning.
• Vinpocetine 5 mg orally 1 tablet 3 times a day for 14 days.
36. Neurologist's recommendations:
• Perform magnetic resonance imaging of the head in a planned manner.
• Duplex scanning of brachiocephalic arteries in a planned manner.
DEPARTMENT OF HOSPITAL THERAPY
OF THE MILITARY MEDICAL ACADEMY
IM. CM. KIROVA
XVIII. CASE REPORT
№:
SURNAME, FIRST NAME, PATRONY NAME:
DATE OF BIRTH: FULL YEARS: 72
CAPACITY: Civilian personnel of the Ministry of Defense of the Russian Federation
WAS IN HOSPITAL TREATMENT In: Department of Hospital Therapy of the Military Medical Academy
From: 05/31/2016 TO: 06/03/2016 TOTAL DAYS PASSED 3
FINAL DIAGNOSIS:
Combined underlying disease:
1. Chronic rheumatic heart disease. Acquired heart disease in the form of a combined defect of the mitral valve. Commissurotomy (from 1975) for stenosis of the left atrioventricular orifice. Prosthetics of the mitral valve with a framed bioprosthesis Carpentier-Edwards PERIMOUNT Plus - 27 mm under the conditions of EC and HCP (dated May 21, 2015) for restenosis of the left atrioventricular orifice.
2. Ischemic heart disease. Atherosclerosis of the aorta and coronary cardiosclerosis. Atherosclerotic, post-infarction (from 2007) and rheumatic cardiosclerosis with rhythm disturbances as a permanent form of atrial fibrillation-flutter (CHA2DS2VASc 7 points, HAS-BLED 4 points, EHRA II). Weak sinus syndrome. PEX from 2015 (DDDR mode). Hypertension stage III (arterial hypertension of the 3rd degree, the risk of cardiovascular complications is "extremely high").
Complications:
Chronic heart failure stage IIa, 3→2 functional class. Secondary nephropathy of mixed (hypertonic, atherosclerotic) genesis.
Accompanying illnesses:
Cerebrovascular disease. Dyscirculatory disease stage III, mixed (post-stroke - stroke of the ischemic type from 2008, hypertensive, atherosclerotic) genesis. Diffuse-nodular goiter of the 1st degree. Autoimmune thyroiditis, hypothyroidism, in the phase of drug compensation (135 mcg of thyroxine). Peptic ulcer of the duodenum, remission. Chronic viral hepatitis (HCV) with a minimal degree of activity. Chronic biliary-dependent pancreatitis, remission phase. Angiolipoma of the left kidney. Divergent alternating strabismus with a Hirschberg deviation angle of 45 degrees. ICD code: [I50.0].
HOSPITAL LIST: a certificate of incapacity for work was issued No. from 31.05 to 03.06.2016.
WORK CAPABILITY: restored
TOTAL RADIATION DOSE: 0.06 mSv
CLINICAL OUTCOME: Dropped out with improvement
ON ADMISSION: Complaints of shortness of breath that occurs with little physical exertion (walking around the room), general weakness, swelling of the legs.
Anamnesis of the disease: at the age of 19, she had a sore throat, according to the patient - a severe course. Subsequently, at the age of 20, mitral heart disease was diagnosed. In 1975, a combined mitral heart disease was formed with a predominance of stenosis of the left atrioventricular orifice with clinical manifestations of cardiac decompensation, for which a commissurotomy was performed in the XUV-1 clinic in the same year. After the rehabilitation period, the patient's condition and well-being improved significantly, her ability to work was restored, she worked in the Military Medical Academy in responsible positions at the headquarters of the academy. According to the patient, at the age of about 60 years, hypertension was diagnosed with an increase in blood pressure to 180/100 mm Hg. Art., in connection with which she began to constantly take antihypertensive drugs - ACE inhibitors, CCBs. Against the background of ongoing therapy, blood pressure stabilized at the level of 130-140 / 70-80 mm Hg. Art. About 10 years ago, interruptions in the work of the heart with palpitations began to disturb - a paroxysmal form of atrial fibrillation of the tachy-brady type (SSSU) was diagnosed, at the same time a PEKS (DDDR) was installed. According to the milestone documents (discharge records from the clinics of the Military Medical Academy, where she was treated), there are indications that the patient was diagnosed with angina pectoris FC 2, and in 2007 she suffered a small focal myocardial infarction. In 2014, coronary angiography was performed at the XUV-1 clinic - the right type of myocardial blood supply, 20% stenosis of the mouth of the OA, 20% stenosis of the PAD. On 04/01/2016, Sorin Replay DR PEX was reimplanted with a base frequency of 60 per minute. But despite the ongoing therapy, the state of health progressively worsened, shortness of breath began to increase, general weakness, decreased exercise tolerance, swelling of the lower extremities occurred, and due to increasing circulatory failure against the background of restenosis of the left atrioventricular orifice, on May 21, 2015, a surgical intervention was performed in the XUV-1 clinic - mitral valve replacement with a Carpentier-Edwards PERIMOUNT framed bioprosthesis Plus - 27 mm under IR and HCP conditions. Rehabilitation treatment from June 4 to August 21 took place in the TUV-2 clinic. According to the discharge epicrisis, paroxysms of atrial fibrillation-flutter acquired a persistent character; in early 2016, the patient turned to cardiologists about the possibility of arresting atrial fibrillation-flutter and restoring sinus rhythm, but taking into account echocardiography data (significant atrial dilatation, a long history of the disease) from active restoration of the rhythm, it was decided to abstain, and tactics of heart rate control were chosen. The patient receives: xarelto 15 mg per day, lozap 25 mg 2 times a day, bisoprolol 7.5 mg per day, inspra 25 mg per day, torasemide 10 mg every other day. However, despite the ongoing therapy, during the last week she began to notice a significant decrease in exercise tolerance, difficulty moving within the apartment due to shortness of breath, an increase in swelling of the lower extremities, and therefore, according to urgent indications, due to an increase in manifestations of circulatory insufficiency, she was hospitalized in the ICU clinic of hospital therapy. 5 mg per day, inspra 25 mg per day, torasemide 10 mg every other day. However, despite the ongoing therapy, during the last week she began to notice a significant decrease in exercise tolerance, difficulty moving within the apartment due to shortness of breath, an increase in swelling of the lower extremities, and therefore, according to urgent indications, due to an increase in manifestations of circulatory insufficiency, she was hospitalized in the ICU clinic of hospital therapy. 5 mg per day, inspra 25 mg per day, torasemide 10 mg every other day. However, despite the ongoing therapy, during the last week she began to notice a significant decrease in exercise tolerance, difficulty moving within the apartment due to shortness of breath, an increase in swelling of the lower extremities, and therefore, according to urgent indications, due to an increase in manifestations of circulatory insufficiency, she was hospitalized in the ICU clinic of hospital therapy.
EXAMINATIONS:
• General blood test on May 31, 2016: leukocytes 6.12 10*9/l; erythrocytes 3.85 10*12/l; hemoglobin 127 g/l; hematocrit 36.4%; platelets 149 10*9/l.
• General blood test on 06/01/2016: leukocytes 5.84 10*9/l; erythrocytes 3.98 10*12/l; hemoglobin 130 g/l; hematocrit 37.7%; platelets 152 10*9/l.
• An. BH general 05/31/2016: ALT 58 U/l; AST 58 U/l; Total bilirubin 13.6 umol/l; Creatinine 76.0 umol/l; Glucose 5.6 mmol/l; Albumins 45.8 g/l; Urea 4.0 mmol/l.
• An. BH general 06/01/2016: ALP 68.3 U/l; ggt 98.7 U/l, calcium 2.23 mmol/l, cholesterol 3.7 mmol/l, glucose 4.73/l, total protein 62.1 g/l, potassium 4.87 mmol/l, sodium 138 .9 mmol / l, CRP 0, Rheumat. factor 2.8, glycated hemoglobin 5.4%.
• An. HD general 06/02/2016: Creatinine 86.9 µmol/l, Urea 5.8 mmol/l, Calcium 2.27 mmol/l.
• An. cr. for thyroid hormones. 06/01/2016: TSH 11.57 IU/ml, TG 48.7 IU/ml, T3 St. 0.50 ng/ml, T4 St, T4 total normal.
• Urinalysis general 06/01/2016: yellow color; specific gravity 1.011; reaction 7.0; leukocytes 3-2-4 Leu/uL ul; protein 0.08 g/l; erythrocytes 2-1-2 in p/sp ul; leach er. 2-3-2 in p / sp, epithelial cells 1-2-2 p / sp.
• X-ray (Chest) 03/23/2016: no pathological changes were detected.
• Ultrasound (Abdominal cavity) 03/22/2016: The liver is enlarged in size (right lobe 17.2 cm, left lobe 9.0 cm x 7.2 cm), inflection in the neck of the gallbladder, gallbladder wall 2.5 mm, heterogeneous, a hyperechoic formation with a diameter of 2.7 mm (polyp) is determined along the back wall in the bottom area, a pancreas of a heterogeneous structure, an additional lobule of the right kidney with a diameter of 17.7 mm is determined, in the middle third of the parenchyma a hyperechoic formation with a clear even contour with a diameter of 6 is determined, 2 mm.
• Fibrogastroduodenoscopy on 03/22/2016: The esophageal dentate line is 2 cm above the crura of the diaphragm, where there is longitudinal erosion with partial epithelialization. The socket of the cardia does not close completely; when straining, prolapse of the gastric mucosa and reflux of its contents are observed. The folds of the stomach are of medium caliber, tortuous, edematous, straighten out with intensive air supply. The mucosa is hyperemic. In the lumen there is mucus, a foamy liquid mixed with bile. The pylorus does not close completely, there is a reflux of duodenal contents. The mucous membrane of the duodenal bulb is hyperemic. Bile is passaged into the lumen of the duodenum. HP test is positive.
• ECG 05/31/2016: Atrial flutter rhythm, irregular form with conduction 5:1, 4:1 with HR 85, EOS horizontal position. Signs of left ventricular hypertrophy, violation of repolarization processes with the formation of negative T II, T III, V5-6.
• ECG 06/03/2016: Atrial flutter rhythm, irregular form with conduction 5:1, 4:1 with HR 85, EOS horizontal position. Signs of left ventricular hypertrophy, violation of repolarization processes with the formation of negative T II, T III, V5-6.
• EchoCG on May 31, 2016: MZHP15 mm; ZS LV 12 mm; KDR 43 mm; DAC 26 mm; EF 72%; LP 46x56x60 mm; mitral valve: prosthesis, Ve/Va 1.6, gradient 10.2; EDD of the pancreas 40 mm, anterior wall -5 mm, pressure in the pulmonary artery 34 mm Hg. Art. Conclusion: symmetrical myocardial hypertrophy. The kinetics is not broken, dilatation of the atria, the right ventricle. In the mitral projection - a prosthesis, the effective area is 2.4 cm2. Aorta, fibrous rings of AK and MK, aortic crescents are sealed. Regurgitation of the I degree on AK, MK and TK. The pericardium is changed.
• Ultrasound of the thyroid gland on 06/02/2016: in the middle lobe, an isoechoic formation with a hypoechoic rim 5.1x6.8 mm is determined, next to it is a hypoechoic formation with calcification inside 3.2 mm in diameter. Ultrasound signs of diffuse changes in the thyroid gland, nodes of the right lobe of the thyroid gland.
• Ultrasound (Abdominal cavity) 06/02/2016: The liver is enlarged in size (right lobe 17.5 cm, left lobe 5.4 cm x 9.5 cm), parenchymal bridge at the border of the body and the bottom of the gallbladder, gallbladder wall 2, 9 mm, heterogeneous, pancreas of heterogeneous structure, dimensions 31x10x17 mm, the spleen is not enlarged, the kidneys-CHLS are sealed. Conclusion: ultrasound signs of fatty hepatosis I-II degree, diffuse changes in the pancreas, thickening of the PCS of both kidneys.
• Radiography of the UGP on May 31, 2016: moderately pronounced phenomena of venous congestion. The roots of the lungs are moderately compacted due to the vessels. In the right pleural cavity, there is fluid up to the level of the 5th rib (account for the anterior segments). The heart is moderately dilated to the left. The aorta is sealed.
RECOMMENDED:
Observation of the cardiologist of the polyclinic.
1. Normalization of lifestyle. General measures, including regular, moderate in intensity physical dynamic loads in the air, sufficient sleep and rest, the ability to switch to rest. Useful spa treatment.
2. Limit the intake of animal fats, easily digestible carbohydrates, increase the amount of vegetable fiber, vegetable fats, foods containing an increased amount of potassium (dried apricots, raisins, prunes) in the diet. The basis of treatment is the consolidation of a rational lifestyle.
3. Control of the level of blood pressure.
4. Permanent intake (under the control of the pulse level, blood pressure):
• Micardis 40 mg - 1.5 tablets in the morning
• Bisoprolol 5 mg - 1 tablet in the morning
• Inspra 50 mg - 1 tablet in the morning
• Xarelto 15 mg - 1 tablet in the morning
•
Omacor 1.0 - 2 capsules in the morning
•
L-thyroxine 50 mcg - 1 tablet in the morning (TSH control 1 time in 2 months
) CM. KIROVA
XVIII. DISCUSSION REPORT CASE
HISTORY №:
SURNAME, NAME, PATRONYNIC NAME:
DATE OF BIRTH: FULL YEARS: 68
CAPACITY: Pensioners of the Ministry of Defense of the Russian Federation
WAS IN HOSPITAL TREATMENT IN: Department of Hospital Therapy of the Military Medical Academy
From: 06/02/2016 TO: 06/17/2016 TOTAL TREATMENT DAYS: 15
FINAL DIAGNOSIS:
Cryptogenic cirrhosis of the liver, Child-Pugh class C. Held intestinal bleeding from 05/24/2016.
Chronic rheumatic, coronary heart disease. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic, myocardial cardiosclerosis with arrhythmias and conduction disturbances according to the type of permanent atrial fibrillation (CHA2DS2-VASc 5 points, HAS-BLED 6 points), complete AV blockade, PEKS 2001, reimplantation 2013. in DDD mode (operation - VVI). Biological aortic valve prosthesis Edvards 25 (rheumatic combined defect) and coronary artery bypass grafting (one bypass) (15.01.2014).
Thromboembolism of the pulmonary artery from 03.05.2016. Pneumonia infarction of the right lung. Diffuse pneumofibrosis, pleurodesis of the right lung.
Chronic heart failure stage 2b, 4 functional class. Anasarca (bilateral hydrothorax, ascites, massive edema of the lower extremities) of mixed (hypoproteinemia, heart failure) genesis
Cholelithiasis. Gallbladder calculus.
Chronic biliary-dependent pancreatitis, remission phase.
Chronic gastroduodenitis, phase of unstable remission.
Secondary mixed (posthemorrhagic, iron deficiency) anemia of severe degree, hemotransfusion of one dose of erythrocyte suspension from 05/25/2016.
secondary nephropathy. Urolithiasis disease. Stones of the right kidney. Incomplete duplication of the left kidney. Simple cysts of both kidneys. Chronic latent bilateral non-obstructive secondary pyelonephritis, exacerbation phase. Chronic kidney disease С36А1 (40 ml/min/1.73 m2).
Absence of the right lobe (hemistrumectomy from 2000 for cancer), small cysts of the left lobe of the thyroid gland.
Cerebrovascular disease, encephalopathy of mixed (dyscirculatory, hepatic) genesis of the second stage.
Consolidated compression fracture, hemangioma of the body of the first lumbar vertebra.
Chronic combined hemorrhoids without exacerbation.
Fluid evacuation from the left pleural cavity: 03.6.2016 2400 ml, 14.6.2016 2400 ml, 16.6.2016 1600 ml.
ICD code: [I50.0 - 06/04/2016].
Sick leave: not issued
TOTAL RADIATION DOSE: 2.42 mSv
CLINICAL OUTCOME: Dropped out with chronicity ON ADMISSION
: Complaints of general weakness, shortness of breath with minor physical exertion, swelling of the legs.
In 1962, after suffering from a sore throat, aching pains and swelling of large joints appeared. He was treated in the city hospital of Tomsk for rheumatism with a positive effect. Before 1966 According to the patient, he regularly underwent prophylactic bicillin therapy. in 1966 entered the Sanitary and Hygienic Institute in Leningrad, from which he graduated in 1972. Since 1972 served in the army as an epidemiologist, finished his service in the Navy. According to the patient and according to the submitted medical milestone documents, the deterioration of health since the late 90s, in 2000. was treated at the VMHT clinic for chronic rheumatic heart disease, complete A-B blockade. In 2001, PEX was installed in DDD mode. In subsequent years, he was repeatedly treated in the clinics of the Military Medical Academy due to emerging paroxysms of tachycardia, and persistent atrial fibrillation was diagnosed. By 2013 progressively increased heart failure, troubled dyspnea, increased swelling of the lower extremities, at the same time, PEKS was reimplanted in the DDD/e mode of the patient, combined aortic heart disease with a predominance of insufficiency was verified, and on 15.01. also coronary angiography and arto-coronary bypass (one bypass). (There are no data on the results of coronary angiography.) But despite the aortic valve replacement, heart failure persisted, ejection fraction was 35%-28%, in 2014-2015. frequent hospitalizations in VMedA clinics. In the spring of 2016, despite the outpatient treatment, circulatory decompensation began to increase again, on May 11, 2016. by ambulance to the SZgmu named after I.I. Mechnikov with progressive heart failure. PE, infarction-pneumonia of the right lung was diagnosed, anticoagulant, antibacterial therapy was started, signs of hepatocellular insufficiency, anemic syndrome were noted. Against the background of taking warfarin (INR dated May 23, 2016 - 7.25) 05/24/2016 intestinal bleeding occurred, accompanied by milena, a decrease in hemoglobin levels to 62 g / l. An EGD was performed, but there were no signs of bleeding. It was decided to abstain from fibrocolonoscopy due to the severity of the patient's condition. Blood transfusion was performed twice, against the background of which on June 1, 2016. hemoglobin level 79 g/l. According to the discharge epicrisis dated 2.06. 2016 positive dynamics was achieved in the form of relief of peripheral edema, a positive x-ray picture from the lungs: a significant decrease in fluid in the pleural cavities. The patient continued to complain of shortness of breath with slight physical exertion and persistence of edema of the legs and feet, severe general weakness and sought medical help at the Military Medical Academy and, according to a report, was hospitalized at the hospital therapy clinic in the ICU for urgent medical reasons.
SURVEYS:
Laboratory data:
An. HD common 06/03/2016: Alkaline phosphatase 126.1 U/L; ALT 11.1 U/l; AST 21.3 U/l; CPK 52.4 U/l; GGT 72.6H u/l; LDH 149.1 u/l; Albumin 27.9LG/L; Total bilirubin 10.0 umol/l; Calcium 1.91L mmol/l; Cholesterol 2.28L; Creatinine 142.0H umol/l; Glucose 4.72 mmol/l; Magnesium 0.85 mmol/l; Iron 3.9L umol/L; Triglycerides 0.95 mmol/l; Total protein 53.2L units; Urea 12.2H mmol/l; Uric acid 506.1H umol/l, HBA%R 6.87%; LDL_R 1.61 mmol/l; ApA1R 138.13 mg/dl; ApoBR 47.32 mg/dl; Apbar 0.34
An. HD common 06/07/2016: Alkaline phosphatase 145.4HU/L; ALT 10.2LU/l; Amylase 100.0 u/l; AST 21.3 U/l; GGT 87.4H u/l; LDH 140.1 u/l; Albumin 29.3LG/L; Total bilirubin 7.2 umol/l; Cholesterol 2.51L; Creatinine 114.0 umol/l; Total protein 50.8L units; Urea 12.7H mmol/l; Direct bilirubin 2.6 umol/l, Lipa 59.23 U/l
An.BC total 06/09/2016: TRF-R 2.80 g/l
An.BC total 15.06.2016 Albumin 34.22L g/l, Globulins 16 g/l; Total beok 49.9 g/l
An.BCh general 15.06.2016 Alkaline phosphatase 119.5 U/L; ALT 9.5L U/l; ALT 17.0 U/l; GGT 87.5H u/l; LDH 136.3 u/l; Albumin 27.9L G/L, Globulins 23.8 g/L; Total bilirubin 8.6 umol/l; Calcium 1.96 mmol/l, Cholesterol 2.96L; Creatinine 154.4N µmol/l; Total protein 51.7L units; Urea 17.3H mmol/l; Direct bilirubin 3.5 umol/l, glucose 8.13 N mmol/l, HDL 0.85 mmol/l, magnesium 1.01 mmol/l, potassium 5.79 N mmol/l, sodium 129.1 L mmol/
l . blood test 02.06.2016 hemoglobin 71 g/l, hematocrit 20.9; Erythrocytes 2.79*1012/l, Leukocytes 7.32*109/l, Platelets 191*109/
l blood test 04.06.2016 hemoglobin 85 g/l, hematocrit 25.8; Erythrocytes 3.28*1012/l, Leukocytes 7.89*109/l, Platelets 252*109/l
About. blood test 09.06.2016 hemoglobin 85 g/l, hematocrit 26.5; Erythrocytes 3.86*1012/l, Leukocytes 6.45*109/l, Platelets 180*109/l, reticulocytes 11 ppm
Vol. blood test 14.06.2016 hemoglobin 76 g/l, hematocrit 23.3; Erythrocytes 3.08*1012/l, Leukocytes 5.72*109/l, Platelets 162*109/
l blood test 15.06.2016 hemoglobin 79 g/l, hematocrit 25.7; Erythrocytes 3.38*1012/l, Leukocytes 4.10*109/l, Platelets 222*109/
l urinalysis 14.06.2016 beat density 1025, protein 0.1 g/l, leu -4-5 in p/c, mucus 3, bacteria 4, oxalates 1, epithelium m.p. units in p/z
Coagulogram 02.06.2014 PTI 30%, fibrinogen 4.63 g/l, INR 2.17
Coagulogram 06/08/2014 PTI 81%, fibrinogen 5.24 g/l, INR 1.12
Coagulogram 14.06.2014 PTI 82%, fibrinogen 3.60 g/l, INR 1.11
Coagulogram 15.06.2014 PTI 83%, fibrinogen 4.10 g/l, INR 1.10
CA 19-9 86.8 U/ml (0-35), alpha-fetoprotein, PSA, free PSA, hCG, CA 15-3 - normal
Pleural fluid 06/03/2016: Cytosis 0.1*109/l, protein 12.0 g/l
Pleural fluid 06/14/2016: Cytosis 0.1*109/l, protein 1.1 g/l
Instrumental data:
FGDS 06/07/2016 - insufficiency of the rosette of the cardia, moderately pronounced atrophic changes in the mucosa of the esophagus, stomach and duodenum, pyloric insufficiency, secondary duodenitis.
FCC 06/01/2016 - mixed type dyskinesia with superficial atrophy, combined hemorrhoids. Organic pathology of the colon, incl. neo was not found.
Ultrasound of the OBP 06/06/2016 - fibrotic changes in the liver, limited ascites, cyst of the upper pole of the right kidney, incomplete doubling of the left kidney.
X-ray examination of the chest in 2 projections on 06/03/2016: increased lung pattern due to deforming pneumofibrosis. Fluid in the left pleural cavity at the level of the 5th rib, on the right at the level of the 6th rib (account for the anterior segments). On the right, at the level of the 4th rib, there is a uniform shadow with clear contours - encapsulated liquid. The roots of the lungs are moderately compacted due to the vascular component.
X-ray examination of the chest in 2 projections 06/06/2016 after fluid evacuation: on the left, the lungs are expanded, the amount of fluid has decreased to the level of the sinuses.
CT scan of the abdomen on 06/07/2016: indirect signs of liver cirrhosis. Diffuse decrease in liver density. Hepatosplenomegaly. Gallbladder calculus. CT picture of local thickening of the duodenal wall in the region of the major duodenal papilla. CT scan showing simple cysts in both kidneys. Stones of the right kidney. Free fluid around the liver, spleen and interstoma. Free fluid in both pleural cavities, more on the left. Changes in the diaphragmatic pleura on the right are probably post-inflammatory in nature. CT picture of a compression fracture of the body, hemangioma of the first lumbar vertebra.
ECHO-CG 06/03/2016: EF 62%, dilatation of the right ventricle, in the cavity of which the electrode is covered with a layer of fibrin. The LV myocardium is not thickened, there are no zones of local disturbance of kinetics. The aorta is sealed. In the projection of the valve - prosthesis without signs of dysfunction. The mitral cusps are sealed. Regurgitation on MK and TK of 1 degree. Pressure in the small circle - 40 mm Hg. The pericardium is compacted, there is no effusion. In the pleural cavities, the effusion is on the left up to the middle of the scapula, on the right up to the 8th rib.
ECG 03-16.06.2016 Rhythm of EKS with HR 60/min
CONSULTATIONS CARRIED OUT:
Gastroenterologist - I agree with the diagnosis of cryptogenic cirrhosis. Recommendations for correction of therapy are given.
THERAPEUTIC TREATMENT: Transfusions:
03.06.2016 albumin 10% - 4 doses,
06/03/2016 erythrocyte mass - 2 doses
06/06/2016 fresh frozen plasma - 2 doses
10.06.2016 albumin 10% - 4 doses
15.06.2016 albumin 10% - 2 doses
SURGICAL TREATMENT:
Evacuation of fluid from the left pleural cavity: 03.6.2016. 2400 ml, 14.6.2016 2400 ml, 16.6.2016 1600 ml
AT DISCHARGE: The patient has an extremely high cardiovascular, arrhythmogenic and hemorrhagic risk. The degree and severity of damage to the heart muscle does not determine the severity of the condition. The dominant is the pathology of the liver, manifested by the development of cirrhosis, hepatosplenomegaly and severe hypoproteinemia, which contributes to the development of significant edema, impaired coagulation, the threat of thrombo-hemorrhagic syndrome. The development of cirrhosis in a patient is indicated not only by structural changes in the liver, enlargement of the veins of the portal system, detected by ultrasound, but also by a significant decrease in protein-synthetic function, a decrease in the level of calcium and magnesium in blood plasma. Given the nature and extent of myocardial changes, the contribution of cardiac dysfunction to the development of cirrhosis is minimal, which allows us to consider cirrhosis as cryptogenic, and considering 10 points on the Child-Pugh scale, one can state decompensation of the course of cirrhosis without signs of portal hypertension (an EGD was performed, as a result of which no data were obtained on the presence of esophageal varicose veins). Therefore, cirrhosis of the liver is currently the main contribution to the severity of the patient's condition with the disease. Neoplastic process has not been proven. The results of the study of tumor markers with a positive result and an increase of more than two times Gl 19-9 Ag (86.8 U/l) may be determined by the presence of liver damage. cirrhosis of the liver is currently the main contribution to the severity of the condition of the patient with the disease. Neoplastic process has not been proven. The results of the study of tumor markers with a positive result and an increase of more than two times Gl 19-9 Ag (86.8 U/l) may be determined by the presence of liver damage. cirrhosis of the liver is currently the main contribution to the severity of the condition of the patient with the disease. Neoplastic process has not been proven. The results of the study of tumor markers with a positive result and an increase of more than two times Gl 19-9 Ag (86.8 U/l) may be determined by the presence of liver damage.
The main efforts are focused on normalizing the electrolyte and protein composition of the blood, stopping the threat of thrombo-hemorrhagic syndrome, reducing the severity of tissue hyperhydration, and hepatoprotective therapy.
RECOMMENDED: Observe the regime of work and rest.
Observation of a gastroenterologist at the place of residence
Complete protein nutrition.
Restriction of fluid intake (1 l / day)
If the condition worsens, hospitalization in the established order in a specialized hepatological department / hospice
Continue taking:
1. Ademetionine 400 mg - 2 tablets in the morning
2. Veroshpiron 25 mg - 2 tablets 3 times a day
3. Hepa- Merz - 1 powder in the morning
4. Torasemide 10 mg - 3 tablets in the morning
5. Perindopril 5 mg - 1/2 tablet in the morning
6.
Duphalac
-
30 ml each in the morning CM. KIROVA
XVIII. DISCUSSION REPORT
date: 06/29/2016 time: 10:45 CASE
HISTORY №:
SURNAME, NAME, PATRONYMIDITY:
DATE OF BIRTH: 06/11/1944 COMPLETE YEARS: 72
POSITION: Members of the families of retired and reserve officers of the Ministry of Defense of the Russian Federation
WAS IN HOSPITAL TREATMENT VMA therapy
FROM: 06/16/2016 TO: 06/30/2016 TOTAL DAYS OF TREATMENT: 14
FINAL DIAGNOSIS:
Coronary artery disease. Repeated non-Q-posterior-lateral with the transition to the apex myocardial infarction from 06/18/2016. Acute heart failure of the 2nd degree according to T. Killip. Severity class 2. Atherosclerosis of the aorta and coronary arteries, atherosclerotic and postinfarction cardiosclerosis (2006). Calcified aortic stenosis, stage B. (Sao 1.5 cm2). Toxic (polychemotherapy) myocardial dystrophy.
Stage III hypertension, the risk of cardiovascular complications is very high.
Nosocomial polysegmental pneumonia in the lower lobe of the left lung. Purulent endobronchitis. Resolved thromboembolism of segmental and subsegmental branches of the pulmonary artery and thrombosis of the portal vein. Diffuse pneumofibrosis. Multiple atelectasis of the lower lobe of the left lung. Respiratory failure of mixed (ventilation, restrictive, due to heart failure) genesis III degree. Extended mechanical ventilation (18.06-21.06.2016).
Heart failure II a stage.
Cancer disease. Colon cancer T3N0MO (surgical treatment from 01/27/2016). Condition after three courses of polychemotherapy with capecidabine. Cancer of the right breast 2010. T2N0M0 (mastectomy, 6 cycles of chemotherapy in 2010).
Mixed encephalopathy (dyscirculatory, dysmetabolic) of the third stage. Decompensation against the background of the underlying disease. metabolic myopathy.
Secondary nephropathy of mixed origin. chronic kidney disease. C3bA1 stage.
Chronic gastritis, remission. Chronic pancreatitis, remission. Colon diverticulosis.
Chronic combined hemorrhoids, without exacerbation.
Myoma of the uterus.
ICD code: [I26.9 - 06/21/2016].
TOTAL RADIATION DOSE: 6.86 mSv
CLINICAL OUTCOME: Eliminated with improvement
AT ADMISSION: About 15 years old, hypertension is diagnosed with an increase in blood pressure to 160-170/90-100 mm Hg. Art. maximum, usually while taking hypotensive blood pressure 130-140/80-70 mm Hg. Art. she did not resort to emergency medical services, she usually takes ACE inhibitors, b-blockers. During the same time, coronary heart disease is diagnosed, there are no clinical data for the development of angina pectoris, but according to the records in the medical book and the data of milestone medical documents, there are indications of a myocardial infarction suffered in 2006 (ECHO-KG was performed on June 1, 2016: local myocardial contractility and global are not disturbed, ejection fraction 66%, diastolic dysfunction of the left ventricle). Since 2010 The patient is diagnosed with cancer of the right breast, at the Research Institute of Oncology. N.N. Petrov underwent a right-sided mastectomy, a course of polychemotherapy and until 2015. health was quite satisfactory, but at the end of 2015. Colon cancer was diagnosed on 01/27/2016. the tumor was resected, then two months later, 3 courses of chemotherapy were performed, but since April of this year, she began to experience difficulty walking, muscle weakness, and since May 2016. difficulty in maintaining the head in a vertical position, then shortness of breath began to bother, on May 25, 2016, a CT scan of the chest and abdomen was performed: thrombosis of the branches of the right and left pulmonary arteries, thrombosis of the portal vein. May 26, 2016 She was hospitalized at the Propaedeutics Clinic for Internal Diseases, treated with Clexane and Eliquis, and was discharged on 10.06.2016. In connection with the deterioration of well-being during the last days in the form of an increase in shortness of breath, especially at night, she turned today to the CDC of the Military Medical Academy, where cardiac asthma, pulmonary embolism were suspected. The patient, for urgent medical reasons, was referred for hospitalization to the hospital therapy clinic.
Upon admission, the condition was regarded as severe, due to the increasing phenomena of respiratory failure. When performing angio-CT data for PE was not received. During the first day of stay, IVL was performed (NIV, support pressure 15 cm wg FiO2 30%), however, on the night of June 17-18, a loss of consciousness developed, accompanied by tachycardia, the development of hypotension, tachypnea, and clonic convulsions. The patient was transferred to a ventilator. During this period, the dynamics of the ECG shows transmural damage in the area of the lower wall with a transition to the side wall, the apex. By the time of development, these changes coincided with the time of impaired consciousness and developed against the background of relatively stable hemodynamics in the absence of signs of rhythm disturbance. Considering the increase in CPK (general), CPK-MB (these changes have been observed over the past 2 weeks), 3-fold increase in troponin levels. When performing MRI of the head, data on stroke were not obtained. Coronary angiography revealed a multiple stenosing lesion of the coronary bed with a pronounced collateral network. There were no signs of acute plaque ulceration.
The severity of the condition is due to the development of severe pulmonary heart failure, mutually potentiating each other. Dominant in the clinical picture were ventilation disorders, which were stopped only with the use of mechanical ventilation. Their genesis, most likely, is of a mixed nature: as a result of multiple courses of polychemotherapy, recurrent attacks of thromboembolism, muscle weakness developed that did not allow the patient to take a full breath on his own, diffuse pneumofibrosis with the development of pronounced restrictive changes (which manifests itself, among other things, in a significant increase in lung compliance) and decrease in the respiratory surface, as well as the presence of acute cardiovascular insufficiency, which aggravates the process of gas exchange in the alveoli, requiring constant maintenance of positive end-expiratory pressure. Damage to the heart is diffuse in nature with predominant damage to the lower wall. This damage contributes to some decrease in systolic function, however, diastolic disorders due to fibrosis of the heart muscle are leading in the development of heart failure.
During June 18-21, the patient received mechanical ventilation and inotropic support. Subsequently, after extubation, she was systematically transferred to IVL, insufflation with an oxygen flow. At present, the maximum possible compensation for pulmonary heart failure has been achieved. The optimal therapy was selected - normotension, respiratory rate less than 22/min, SaO2 when breathing atmospheric air 95-98%. Infrequent short-term episodes of acute respiratory failure are noted, well stopped by insufflation with an oxygen flow.
SURVEYS:
An. HD general 06/17/2016: Alkaline phosphatase 111.0 U/L; ALT 33.2 U/l; AST 52.2HU/l; CPK 152.8 U/l; GGT 57.2 u/l; LDH 285.5H u/l; Albumin 38.2 G/L; Cholesterol 4.27; Creatinine 72.6umol/l; CPK-MB 49.8H IU/L; Total protein 70.4 units; Urea 4.9 mmol/l
An. HD total 06/20/2016: Calcium 2.76H mmol/l; Magnesium 0.82 mmol/l
An. HD general 06/28/2016: Alkaline phosphatase 127.5 U/L; ALT 58.8HU/l; AST 62.0HU/l; CPK 213.0HU/l; LDH 197.8 u/l; Albumin 32.8 G/L; Total bilirubin 6.6L umol/l; Calcium 2.32 mmol/l; Cholesterol 4.98; Glucose 4.49 mmol/l; Total protein 61.8L units; Direct bilirubin 1.1 umol/l
An.BC total 20.06.2016: HBA%R 6.11%
An.BC total exp.lab. 06/18/2016: CK 124.81 u/l; CKMB 36.74 u/l
An.BH general ekp.lab. 06/19/2016: CK 429.64 u/l; CKMB 14.92 u/l
KShchS and Electrolytes 06/21/2016: pH 7.459; pCO2 34.4 mmHg; pO2 68.2 mmHg; sO2 96.2%; cGlu 8.8 mmol/L; cLac 1.8 mmol/l; ctBil 0 nmol/L; cK+ 3.6 mmol/L; cNa+ 141 mmol/l; cCa2+ 1.01 mmol/l; cCl 107 mmol/l; ctHb 116 g/dL
KShchS and Electrolytes 06/24/2016: pH 7.331; pCO2 51.4 mmHg; pO2 113 mmHg; sO2 98.7%; cGlu 5.6 mmol/l; cLac 0.8 mmol/l; ctBil 9 nmol/l; cK+ 4.4 mmol/l; cNa+ 140 mmol/l; cCa2+ 1.27 mmol/L; cCl 108 mmol/l; ctHb 122 g/dL
KShchS and Electrolytes 06/29/2016: pH 7.438; pCO2 43.0 mmHg; pO2 68.1 mmHg; BE(B) 4.6 mmol/l; cGlu 5.8 mmol/L; cLac 1.3 mmol/l; ctBil 2 nmol/l; cK+ 4.2 mmol/l; cNa+ 137 mmol/l; cCa2+ 1.06 mmol/L; cCl 101 mmol/l; ctHb 126 g/dL
Laboratory results: CBC
(hardware processing):
Date
RBC *1012/l
Hb units.
WBC. *109/l
Tr. 109/l
E %
B %
lymph %
mon %
neutral %
16.06.16
4.16
131
9.12
189
-
-
17.6
4.9
77.5
MCV, fl
MCH, pg
MCHC, g/l
HCT %
89.4
31.5
352
37.2
Date
RBC *1012/l
Hb u
WBC. *109/l
Tr. 109/L
E %
B %
lymph %
mon %
neu %
19.06.16
3.91
125
16.1
197
0.1
-
6.4
4.8
88.7
MCV, fl
MCH, pg
MCHC, g/l
HCT %
89.3
32.0
358
34.9
Date
RBC *1012/L
Hb units
WBC. *109/l
Tr. 109/l
E %
B %
lim %
mon % neu
%
23.06.16
4.1
120
6.6
126
1
-
23
8
68
MCV, fl
MCH, pg
MCHC, g/l
HCT %
ESR mm/h
91.2
29.2
358
37.5
38
Urinalysis
Date
Rel. dense
pH
Protein
Acetone
Glucose
Lake.
Erythrocytes
Epithelium
Color
06/17/16 g
1025
5.5
0.12 g/l
neg
neg
3-4-5 in p / c
-
-
Yellow.
20.06.16 g
1020
acidic
0.033 g/l
negative
negative
3-4 in p/c
-
3-5 in p/c
Yellow.
06/23/16 g
1025
7.5
0.12 g/l
neg
neg
3-4 in the r/c
-
3-5 in the r/c
Yellow.
Biochemical analysis of blood:
Indicators 16.06.16 g
Unit
of measurement 18.06.16 g
Unit
Cholesterol
4.74
3.7-5.0
mmol/l
D-dimmer
1.0
0-0.5
µg/ml
Glucose
5.8
4.2-6.2
mmol/l
Troponin I
0.34
0-0.11
ng/ml
Urea
3.5
2.4-6.4
mmol/l
ALT
50
10-50
U/l
Bilirubin total.
18.6
6.8-26
umol/l
AST
56
11-50
U/l
Bilirubin etc.
5.2
0-7
umol/l
Urea
7.3
2.4-6.4
mmol/l
Total protein
75
63- 87
g/l
Creatinine
99
53-123
umol/l
ALT
44
10-50
U/l
AST
58
11-50
U/l
Parameters 19.06.16 g
Unit
LDH
362
120-246
U/l
Creatinine
142
53-123
umol/l
Creatinine
99
53-123
umol/l
Glucose
10.3
4.2-6.2
mmol/l
Troponin I
0.01
0 -0.11
ng/ml
Urea
11.5
2.4-6.4
mmol/l
Cortisol
20.87
6.7-22.6
ug/dl
Total protein
69
63-87
g/l
SKMS
73.2
24- 195
U/l
AST
55
11-50
U/l
Creatine kinase
246.9
0-25
U/l
LDH
304
120-246
U/l
Indicators 23.06.16 g
Unit
Fibrinogen
3.8
2.76-4.71
g/l
Alkaline phosphatase
84.4
45-129
U/l
Prothrombin
102
80-130
%
ALT
45.0
11-50
U/l
AST
29.2
10-50
U/l
Indicators 20.06.16 g
CPK
unit
52.3
10-160
U/l
PTHIO
39.4
12-88
Pg /ml
CPK-MB
22.1
0-25
U/l
Magnesium
0.82
0.6-1.2
mmol/l
GGT
172.2
8-63
U/l
Calcium
2.76
2-2.7
mmol/l
Bilirubin total
18.6
6.8-26
umol/l
Prothrombin
87.8
80-130
%
Calcium
2.21
2-2.7
mmol/l
Fibrinogen
3.60
2.76-4.71
g/l
Creatinine
99
53-123
umol/l
Troponin I
0.22
0-0.11
ng/ml
Glucose
5.8
4.2-6.2
mmol/l
Magnesium
0.88
0.6-1.2
mmol/l
Total protein
75
63-87
g/l
Urea
3.5
2.4-6.4
mmol/l
Uric acid
250.7
150-420
umol/l
Prothrombin
120
80-130
%
Fibrinogen
4.72
2.76 -4.71
g/l
Troponin I
0.12
0-0.11
ng/ml
CT scan (06/23/2016) CT picture of atelectasis of the lower lobe of the left lung, against which pneumonic infiltration cannot be excluded. Narrowing of the lumen of the lower lobe and corresponding segmental bronchi on the left. Subsegmental atelectasis of the basal parts of the lower lobe of the right lung. Bilateral small hydrothorax.
On the survey radiograph (06/19/2016) in the intensive care unit, lying on the back, without holding the breath in the direct projection, an increase in the pulmonary pattern in both lungs due to the vascular component is visualized. A small hydrothorax on the left, the right sinus is free. There are no data for pneumonia. the shadow of the heart is not displaced.
MRI of the head (06/18/2016). There are no data for acute cerebrovascular accident. Picture of discirculatory encephalopathy.
Spirometry. (06/17/2016) A sharp violation of the ventilation capacity of the lungs by a restrictive type. VC -25%.
Coronary angiography dated 06/18/2016. Balanced type of KM. Diffuse lesion of the coronary arteries. Stenosis of the VTK-70% in pr./3, 80% - in the middle/3, subocclusion in the dist/3. OA-occlusion in the middle / 3. PLA- 60% in the middle / 3, at the top of the left ventricle. The RCA is occluded in the distal third, subocclusion of the IOC. Pronounced collateral network of the distal RCA from the LCA basin.
ECHO-KG from 06/18/2016. Symmetrical LV myocardial hypertrophy. There are no zones of local disturbance of kinetics. The cavities are not expanded. the aortic annulus is calcified, the calcification of the aortic crescents moderately stenosing the aortic valve. Pulmonary blood flow is not changed. Diastolic dysfunction of the first type. LV - 48x31 mm, MZHP - 12 mm, ZS - 11 mm, FV - 65%, FU-37%, UO-65 ml, Ao-30 mm, VAO-30mm, opening AK-15 mm, LP-37x15x48 mm, pp-36x47mm, RV= 2.5 mm.
ECG from 06/18/2016. Against the background of sinus tachycardia, subendocardial damage is noted in the lower lateral parts of the left ventricle. Further ECG without negative dynamics.
AT DISCHARGE: the patient is discharged in a relatively satisfactory condition; at present, the maximum possible compensation for pulmonary heart failure has been achieved. The optimal therapy was selected - normotension, respiratory rate less than 22/min, SaO2 when breathing atmospheric air 95-98%. Infrequent short-term episodes of acute respiratory failure are noted, well stopped by insufflation with an oxygen flow.
RECOMMENDED: Supervision by a therapist at the place of residence
Complete protein nutrition
Use of anti-decubitus systems (mattress) in bed
Planned expansion of the motor regimen under the supervision of a physician of the exercise therapy clinic, therapeutic exercises
Continue taking:
1. Eliquis (apixaban) 5 mg - 1/2 tablet 2 times a day
2. Bisoprolol 5 mg - 1 tablet in the morning
3. Perindopril 5 mg - 1 tablet in the morning
4. Mildronate 500 mg - 1 capsule in the morning and at lunchtime
5. Trimetazidine 35 mg - 1 tablet in the morning and afternoon
6. Piracetam 1000 mg - 1 capsule in the morning
7. Through a nebulizer: Ambroxol 1 ml + Berodual 1 ml + physiological solution of 0.9% NaCl 2 ml - inhaled 2 times a day
8. Breathing exercises 4 times a day for 15 minutes
9. Oxygen concentrator with a flow of 2-3 l / min during sleep and on demand.
DEPARTMENT OF HOSPITAL THERAPY
MILITARY MEDICAL ACADEMY
IM. CM. KIROVA
XVIII. DISCLAIMER DATE: 07/18/2016
time: 09:41
CASE HISTORY №: 39065 ARCHIVE
SURNAME
, NAME, PATRONYMIC: DATE
OF
BIRTH: 07/20/1954 FULL YEARS: 61
CAPACITY: Individual contract : 07/14/2016 TILL: 07/18/2016 TOTAL DAYS OF TREATMENT: 4
FINAL DIAGNOSIS: Community-acquired bilateral polysegmental pneumonia in the upper (S2, S3) lobe, middle lobe (S4), lower lobe (S8.9) of the right lung, in the upper (S3.4.5) lobe of the left lung, severe course. COPD IV degree. Bronchiectasis of the lungs, Bullous emphysema. Idiopathic fibrosing alveolitis (?) DN III.
sop.: Atherosclerosis of the aorta, coronary arteries. Atherosclerotic cardiosclerosis. Prolapse of the anterior leaflet of the mitral valve 1 degree. Hypertension stage I (AH - 1, risk - 3). CHF 1 st., 1 FC.
Peptic ulcer of the duodenum, remission. Chronic gastroduodenitis, remission.
Right kidney cyst.
DDZP, without exacerbation. ICD code: [J18 - 07/14/2016].
ASSOCIATED DISEASES: Atherosclerosis of the aorta, coronary arteries. Atherosclerotic cardiosclerosis. Prolapse of the anterior leaflet of the mitral valve 1 degree. Hypertension stage I (AH - 1, risk - 3). CHF 1 st., 1 FC.
Peptic ulcer of the duodenum, remission. Chronic gastroduodenitis, remission.
Chronic pancreatitis, remission. Right kidney cyst. Degenerative-dystrophic disease of the spine. Benign prostatic hyperplasia.
HOSPITAL LIST: does not work, does not need a l / n.
WORK CAPABILITY: -
TOTAL RADIATION DOSE:
CLINICAL OUTCOME: Dropped out with improvement
AT ADMISSION: EXAMINATIONS
:
KShchS and Electrolytes 07/14/2016: pH 7.360; pCO2 52.3 mmHg; pO2 159 mmHg; sO2 99.0%; cGlu 11.2 mmol/L; cLac 1.5 mmol/l; ctBil 9 nmol/l; cK+ 4.1 mmol/L; cNa+ 140 mmol/l; cCa2+ 0.82 mmol/l; cCl 100 mmol/l; ctHb 127 g/dL Chest X-ray on August 18, 2016
: pulmonary fields are emphysematous, pulmonary pattern with gross fibrous deformity, thickening of the bronchial walls in the root zones is observed. The roots of the lungs are compacted, fibrous deformed. Pleural cord at the level of the 3rd rib on the right. The diaphragm is flattened with pleurodiaphragmatic adhesions. The heart is not dilated, the aorta is sealed. Expansion of a pulmonary artery is noted. CONCLUSION: R-picture of COPD.
EP on 07/18/2016: VC 1.88 l (44%), FVC 1.67 l (40%), FEV1 0.74 l (22%), Tiffno index 51% - violations of pulmonary function by mixed type, pronounced .
CONSULTATIONS CARRIED OUT:
THERAPEUTIC TREATMENT:
SURGICAL TREATMENT:
CONSERVATIVE TREATMENT:
AT DISCHARGE:
RECOMMENDED: 1. Compliance with a diet with limited salt intake, control of blood pressure at home.
2. Carrying out an additional examination in a specialized pulmonology department:
- performing sanitation and diagnostic fibrobronchoscopy with the study of washing water for atypical cells and Mycobacterium tuberculosis;
- conducting videothoracoscopy with biopsy of intrathoracic lymph nodes and lung tissue (according to indications);
- repeated CT scan of the chest;
- implementation of the quantiferon test for the final exclusion of the tuberculous nature of pneumonia.
3. Continue taking drugs:
-foradil-combi
-spiriva-
-ambroxol, 30 mg per day, 2-3 weeks.
4. Acquisition of a portable oxygen inhaler, oxygen therapy at home.
5. Observation by a pulmonologist at the place of residence.
DEPARTMENT OF HOSPITAL THERAPY
OF THE MILITARY MEDICAL ACADEMY
IM. CM. KIROVA
XVIII. DISCUSSION REPORT
date: 08/15/2016 time: 10:28
ILLNESS HISTORY No.: 40926 ARCHIVE No.:
SURNAME, NAME, PATRONYMIC
DATE OF BIRTH: 12/04/1998 FULL YEARS: 17
CAPACITY: Recruits (applicants)
WAS AT THE DEPARTMENT hospital therapy VMA
FROM: 08/12/2016 TO: 08/15/2016 TOTAL DAYS OF TREATMENT: 3
FINAL DIAGNOSIS: Main disease: Type 1 diabetes mellitus. ICD code: [E10.1].
Complications: Diabetic ketoacidosis dated August 12, 2016. Diabetic precoma dated August 12,
2016. Concomitant diseases: Acute respiratory disease like acute tonsillopharyngitis (from August 9, 2016), mild severity, period of early convalescence. ICD code: [E10.1].
CLINICAL OUTCOME: Ext. translation (1 Department of Therapy of Advanced Doctors)
AT ADMISSION: Severe condition, lethargic, emaciated, pronounced smell of acetone from the mouth.
Given the identified signs of acute respiratory disease in the convalescence stage, the patient was isolated and treated in the ICU.
EXAMINATIONS:
Complete blood count on August 12, 2016 (17:36) Leukocytes 9.5 x109/l; er. 5.53x1012/l, Hb 168g/l, neutroph. 86%, lymph. 11%, monocytes 2%, platelets 198x109/l.
Complete blood count August 12, 2016 (16:04) Leukocytes 10.1x109/l; er. 6.06x1012/l, Hb 178g/l, platelets 59x109/l.
Complete blood count 08/13/2016 Leukocytes 9.22x109/l; er. 4.81x1012/l, Hb 145g/l, platelets 167x109/l.
Complete blood count August 14, 2016. Leukocytes 5.6 x 109/l; er. 4.8 x 1012/l, Hb 147 g/l, platelets 120 x 109/l.
Biochemical blood test dated 08/12/2016 (16:16): glucose 37 mmol/l.
Biochemical blood test dated August 12, 2016 (18:19): glucose 35.9 mmol/l, total protein 79 g/l, albumin 47.5 g/l, urea 9.1 mmol/l, creatinine 104 µmol/l, total bilirubin 8.0 µmol /l, amylase 48 U/l, ALT 38 U/l, AST 12 U/l, GGTP 44 U/l, ALP 106 U/l. LDH 183 U/l, CPK MV 0, CPK total. 91 U/l. prothrombin 97%, INR 1.01, fibrinogen 3.22 g/l;
Biochemical blood test dated August 13, 2016 (09:38): glucose 11.0 mmol/l, urea 8.0 mmol/l, creatinine 73 µmol/l, potassium 3.85 mmol/l, sodium 134.9 mmol / l.
Biochemical blood test dated 08/14/2016 (07:00): glucose 16.0 mmol/l, urea 4.9 mmol/l, creatinine 93 µmol/l.
Glycemic fluctuations on August 14, 2016: at 07:00 - 16.0 mmol / l, at 12:00 - 15.3; at 15:00 - 16.7; at 17:00 - 14.8.
KShchS and Electrolytes 08/12/2016 (17:27): pH 7.06; pCO2 8.2 mmHg; pO2 145.3 mmHg; sO2 97.2%; cK+ 4.96 mmol/l; cNa+ 140.3 mmol/L; cCa2+ 1.11 mmol/l; cCl 111 mmol/l; pH(T) 7.065; pCO2(T) 8.11 mmHg; pO2(T) 142.9 mmHg;
KShchS and Electrolytes 08/12/2016 (21:01): pH 7.21; pCO2 10.6 mmHg; pO2 125.0 mmHg; sO2 97.7%; cK+ 4.13 mmol/l; cNa+ 145.2 mmol/L; cCa2+ 0.90 mmol/L; cCl 115 mmol/l; pH(T) 7.218; pCO2(T) 10.3 mmHg; pO2(T) 121.3 mmHg;
KShchS and Electrolytes 08/13/2016 (15:01): pCO2 32.4 mmHg; pO2 28.1 mmHg; cK+ 3.4 mmol/l; cNa+ 138 mmol/l; cCa2+ 0.41 mmol/l; cCl 104 mmol/l; pH(T) 7.297; pCO2(T) 32.0 mmHg; pO2(T) 27.5 mmHg;
KShchS (vein) and electrolytes 14.08.2016 (12:22): pCO2 35 mmHg; pO2 38 mmHg; K+ 3.86 mmol/l; Na+ 132.6 mmol/l; Ca2+ 0.96 mmol/l; Cl 98 mmol/l; pH(T) 7.38; pCO2(T) 33.6 mmHg; pO2(T) 35.5 mmHg.
General analysis of urine 12.08.2016 sol-yellow, beats. weight 1.024, rec. acidic, protein 0.3, sugar (+), Acetone bodies (+++), fresh erythrocytes 3-4-5 in p.z., leukocytes 0-1-2 in p.z.
Urinalysis 13. 08. 2016 (15-03) yellow, slightly cloudy, beats. weight 1.020, rec acidic, protein 0.3, sugar (28 mmol/l), Acetone bodies (3.9 mmol/l), trace erythrocytes, leukocytes neg.
Urinalysis on August 14, 2016 (12-26): yellow, clean, beats. weight 1.005, acidic reaction, protein neg., sugar more than 55 mmol/l, acetone bodies 7.8 mmol/l, erythrocytes neg., leukocytes neg.
X-ray of the chest on August 12, 2016: chest without pathological changes.
ECG on August 12, 2016, August 14, 2016: sinus rhythm with a heart rate of 74 per minute, without pathology.
Endocrinologist's consultation on August 12, 2016: type 1 diabetes mellitus, target level of glycated hemoglobin is less than 6.5%. Diabetic ketoacidosis from 08/12/2016 Diabetic precoma from 08/12/2016
Ophthalmologist's consultation 08/12/2016: healthy
ENT consultation 08/12/2016: acute tonsillopharyngitis.
Consulted by an infectious disease specialist on August 13, 2016: acute respiratory disease, period of early convalescence.
CONSULTATIONS CARRIED OUT:
Consulted by an endocrinologist, ophthalmologist, ENT, infectious disease specialist. Recommendations taken into account in therapy
THERAPEUTIC TREATMENT: Diet 9a. Until 17:00 short-acting insulin s / c: at 09:00 - 10 units, at 13:00 - 16 units, at 15:00 - 16 units. From 17:00 short-acting insulin through an infusomat 6 units/hour. Infusion therapy (sodium chloride 0.9% + potassium chloride 4%), depending on the hydrobalance, up to 1.5 l / day. Ribavirin 800 mg/day Heparin 2500 units 4 times a day. Vitamins B 1 and B 6.
AT DISCHARGE: From the submitted medical documentation and from the words of the patient, it is known that during the last 2.5 months he noted a decrease in body weight by 10 kg. During this period of time, he did not notice thirst, dry mouth, did not seek medical help. On 08/09/2016, he felt a sore throat when swallowing, in connection with which he turned to the medical center of the VKA named after. V.F. Mozhaysky in the village. Lekhtusi, where he received topical treatment for three days (antiangin spray, vasoconstrictor drops in the nose, lubrication of the pharynx with Lugol's solution). On the background of the ongoing treatment, there was no improvement in well-being. On August 12, 2016, in the morning he felt severe weakness, dizziness, in connection with which he was taken to the VKA polyclinic, where the patient fell. There was a decrease in blood pressure to 50/0 mm Hg. Dexamethasone 12 mg was administered intravenously. An ambulance was called, which revealed BP 120/80 mmHg, blood glucose 30 mmol/l. Sol was administered intravenously. NaCl 0.9% - 500 ml. He was taken to the admission department of the Military Medical Academy, where hyperglycemia 37 mmol/l, leukocytosis 10.9*109/l, hemoconcentration (hematocrit 51.8, hemoglobin 178 g/l), ketonuria (+++), glucosuria ( +), proteinuria (0.3 g/l). For further examination and treatment, he was hospitalized in the ICU of the hospital therapy clinic.
General condition of moderate severity. Consciousness is clear. The position is active. Oriented in place, space and time. Skin and visible mucous membranes of normal color and moisture. Body temperature 36.9 C. Reduced nutrition (BMI 17.3 kg/m2). Lymph nodes are not enlarged, painless. The thyroid gland is not palpable. Osteo-articular system without visible pathology. There are no peripheral edema.
Cardiovascular system: The pulse is the same on both hands, rhythmic, 70 beats/min., Normal filling and tension. The borders of the heart are not expanded. Heart sounds are clear, no murmurs. BP: 120/75 mmHg
Respiratory system: Chest of the correct form, symmetrical, evenly participates in the act of breathing. Breathing frequency 14-16 in 1 minute. Auscultatory: vesicular breathing is heard over all fields of both lungs, side respiratory sounds are not heard.
Digestive system: The oral mucosa is clean. The tongue is clean and moist. The abdomen is of normal shape, soft, painless. The edge of the liver is not palpated. The size of the liver according to Kurlov: 9 x 8 x 7 cm.
Urinary system: tapping on the lumbar region is painless on both sides, urination is not disturbed.
Nervous system: focal neurological symptoms are not detected.
Fluid balance (from 09.00 to 17.00): parenteral 500 ml, liquid food drunk and eaten 2000 ml, diuresis 2500 ml.
The general condition of moderate severity, due to newly diagnosed diabetes mellitus type I, ketoacidosis and precoma from 08/12/2016.
Dynamic monitoring of glycemic and electrolyte metabolism, acid-base state is carried out.
Positive dynamics is noted in the form of normalization of the general condition and blood gas composition.
RECOMMENDED: continuation of therapy in a
specialized
endocrinology
department CM. KIROVA
XVIII. DISCUSSION REPORT CASE
HISTORY №: 40482 ARCHIVE №:
SURNAME, FIRST NAME, PATRONYMIC
DATE OF BIRTH: 04/02/1948 FULL YEARS: 68
CAPACITY: Pensioners of the Ministry of Defense of the Russian Federation
WAS IN HOSPITAL TREATMENT In: Department of Hospital Therapy of the Military Medical Academy
From: 08/04/2016 TO: 08/17/2016 TOTAL DAYS OF TREATMENT: 13
FINAL DIAGNOSIS: Cryptogenic cirrhosis of the liver, class C on the Child-Pugh scale, severe hypoproteinemia.
Chronic rheumatic, coronary heart disease. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic, myocardial cardiosclerosis with arrhythmias and conduction disturbances according to the type of permanent atrial fibrillation (CHA2DS2-VASc 5 points, HAS-BLED 6 points), complete AV blockade, PEKS 2001, reimplantation 2013. in DDD mode (operation - VVI). Biological aortic valve prosthesis Edvards 25 (rheumatic combined defect) and coronary artery bypass grafting (one bypass) (15.01.2014).
Diffuse macrofocal pneumofibrosis (PE, infarction-pneumonia of the right lung from 05/03/2016), pleurodesis of the right lung.
Chronic heart failure stage 2b, 4 functional class. Anasarca (continuously recurrent left-sided middle hydrothorax, encysted right-sided interlobar hydrothorax, ascites, massive edema) of mixed (hypoproteinemia > heart failure) genesis ICD code: [I50.0].
Cholelithiasis stage III. Chronic calculous cholecystitis without exacerbation, gallbladder calculus.
Chronic biliary-dependent pancreatitis, remission phase.
Chronic gastroduodenitis, phase of unstable remission.
Diabetes mellitus type 2, HbAc 7.8 mmol/l (05.08.16). target level less than 8.0%
Secondary iron deficiency anemia of moderate severity.
secondary nephropathy. Urolithiasis disease. Stones of the right kidney. Incomplete duplication of the left kidney. Simple cysts of both kidneys. Chronic latent bilateral non-obstructive secondary pyelonephritis, exacerbation phase. Chronic kidney disease C3aA1 (59 ml / min / 1.73 m2).
Absence of the right lobe (hemistrumectomy from 2000 for cancer), small cysts of the left lobe of the thyroid gland, euthyroidism
Cerebrovascular disease, encephalopathy of mixed (dyscirculatory, hepatic) genesis of the second stage.
Consolidated compression fracture, hemangioma of the body of the first lumbar vertebra.
Chronic combined hemorrhoids without exacerbation.
Chronic microcytic hypochromic anemia of mixed (iron deficiency, posthemorrhagic, chronic diseases) severe genesis.
Manipulations
04.08.2016 - catheterization of the right subclavian vein
on 08/07/2016. - catheterization of the left subclavian vein,
08/08/2016. - change of the catheter of the left subclavian vein, removed on 08/16/2016.
08/05/2016 - infusion of 400 ml of 10% albumin solution on
08.08.2016. - infusion of 400 ml of 10% albumin solution
on 08/10/2016. - infusion of 300 ml of 10% albumin solution and 2 doses of fresh frozen plasma (520 ml) on
08/11/2016. – blood transfusion of 2 doses of erythrocyte suspension (270 ml + 280 ml) on
August 14, 2016. - infusion of 400 ml of 20% albumin solution
08/04/2016 - puncture of the left pleural cavity, evacuation of 1300 ml of transudate
on August 10, 2016. - puncture of the left pleural cavity, evacuation of 2900 ml of transudate on
August 12, 2016. - puncture of the left pleural cavity, evacuation of 1950 ml of transudate on
August 15, 2016. - puncture of the left pleural cavity, evacuation of 1900 ml of transudate
TOTAL RADIATION DOSE: 0.09 mSv
CLINICAL OUTCOME: Dropped out with improvement ON ADMISSION
: Complaints on admission to general weakness, shortness of breath, aggravated by slight physical exertion, swelling of the lower extremities
In 1962, after suffering from a sore throat, aching pains and swelling of large joints appeared. He was treated in the city hospital of Tomsk for rheumatism with a positive effect. Before 1966 According to the patient, he regularly underwent prophylactic bicillin therapy. in 1966 entered the Sanitary and Hygienic Institute in Leningrad, from which he graduated in 1972. Since 1972 served in the army as an epidemiologist, finished his service in the Navy. According to the patient and according to the submitted medical milestone documents, the deterioration of health since the late 90s, in 2000. was treated at the VMHT clinic for chronic rheumatic heart disease, complete A-B blockade. In 2001, PEX was installed in DDD mode. In subsequent years, he was repeatedly treated in the clinics of the Military Medical Academy due to emerging paroxysms of tachycardia, and persistent atrial fibrillation was diagnosed. By 2013 progressively increased heart failure, troubled dyspnea, increased swelling of the lower extremities, at the same time, PEKS was reimplanted in the DDD/e mode of the patient, combined aortic heart disease with a predominance of insufficiency was verified, and on 15.01. also coronary angiography and arto-coronary bypass (one bypass). (There are no data on the results of coronary angiography.) But despite the aortic valve replacement, heart failure persisted, ejection fraction was 35%-28%, in 2014-2015. frequent hospitalizations in VMedA clinics. In the spring of 2016, despite the outpatient treatment, circulatory decompensation began to increase again, on May 11, 2016. by ambulance at the North-Western State Medical University named after I.I. Mechnikov with progressive heart failure. PE, infarction-pneumonia of the right lung was diagnosed, anticoagulant, antibacterial therapy was started, signs of hepatocellular insufficiency, anemic syndrome were noted. Against the background of taking warfarin (INR dated May 23, 2016 - 7.25) 05/24/2016 intestinal bleeding occurred, accompanied by melena, a decrease in hemoglobin levels to 62 g / l. An EGD was performed, but there were no signs of bleeding. It was decided to abstain from fibrocolonoscopy due to the severity of the patient's condition. Blood transfusion was performed twice, against the background of which on June 1, 2016. hemoglobin level 79 g/l. According to the discharge epicrisis dated June 2, 2016. positive dynamics was achieved in the form of relief of peripheral edema, a positive x-ray picture from the lungs: a significant decrease in fluid in the pleural cavities, but after being discharged from the hospital, he spent only a few days at home and due to increasing edema, severe general weakness, shortness of breath was again hospitalized in the ICU of the hospital therapy clinic, where he was treated from June 2, 2016 to 17 06. 2016. As a result of the examination, analysis of the data obtained, the diagnosis was established: Cryptogenic cirrhosis of the liver, class C on the Child-Pugh scale. Chronic rheumatic, coronary heart disease. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic, myocardial cardiosclerosis with rhythm and conduction disturbances by the type of constant was again hospitalized with shortness of breath in the ICU of the hospital therapy clinic, where he was treated from June 2, 2016 to June 17, 2016. As a result of the examination, analysis of the data obtained, the diagnosis was established: Cryptogenic cirrhosis of the liver, class C on the Child scale -Drink. Chronic rheumatic, ischemic heart disease. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic, myocardial cardiosclerosis with rhythm and conduction disturbances by the type of constant was again hospitalized with shortness of breath in the ICU of the hospital therapy clinic, where he was treated from June 2, 2016 to June 17, 2016. As a result of the examination, analysis of the data obtained, the diagnosis was established: Cryptogenic cirrhosis of the liver, class C on the Child scale -Drink. Chronic rheumatic, coronary heart disease. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic, myocardial cardiosclerosis with rhythm and conduction disturbances by the type of constant2nd form of atrial fibrillation (CHA2DS2-VASc 5 points, HAS-BLED 6 points), complete AV blockade, PEX 2001, reimplantation 2013. in DDD mode (operation - VVI). Biological aortic valve prosthesis Edvards 25 (combined rheumatic defect) and coronary artery bypass grafting (one bypass) (15.01.2014). Thromboembolism of the pulmonary artery from 05/03/2016. Pneumonia infarction of the right lung. Diffuse pneumofibrosis, pleurodesis of the right lung. Chronic heart failure stage 2b, 4 functional class. Anasarca (bilateral hydrothorax, ascites, massive edema of the lower extremities) of mixed (hypoproteinemia, heart failure) genesis. Cholelithiasis. Chronic calculous cholecystitis without exacerbation. Gallbladder calculus. Chronic biliary-dependent pancreatitis, remission phase. Chronic gastroduodenitis, phase of unstable remission. Secondary mixed (posthemorrhagic, iron deficiency) anemia of severe degree, hemotransfusion of one dose of erythrocyte suspension from 05/25/2016. secondary nephropathy. Urolithiasis disease. Stones of the right kidney. Incomplete duplication of the left kidney. Simple cysts of both kidneys. Chronic latent bilateral non-obstructive secondary pyelonephritis, exacerbation phase. Chronic kidney disease С36А1 (40 ml/min/1.73 m2). Absence of the right lobe (hemistrumectomy from 2000 for cancer), small cysts of the left lobe of the thyroid gland. Cerebrovascular disease, encephalopathy of mixed (dyscirculatory, hepatic) genesis of the second stage. Consolidated compression fracture, hemangioma of the body of the first lumbar vertebra. Chronic combined hemorrhoids without exacerbation. Secondary mixed (posthemorrhagic, iron deficiency) anemia of severe degree, hemotransfusion of one dose of erythrocyte suspension from 05/25/2016. secondary nephropathy. Urolithiasis disease. Stones of the right kidney. Incomplete duplication of the left kidney. Simple cysts of both kidneys. Chronic latent bilateral non-obstructive secondary pyelonephritis, exacerbation phase. Chronic kidney disease С36А1 (40 ml/min/1.73 m2). Absence of the right lobe (hemistrumectomy from 2000 for cancer), small cysts of the left lobe of the thyroid gland. Cerebrovascular disease, encephalopathy of mixed (dyscirculatory, hepatic) genesis of the second stage. Consolidated compression fracture, hemangioma of the body of the first lumbar vertebra. Chronic combined hemorrhoids without exacerbation. Secondary mixed (posthemorrhagic, iron deficiency) anemia of severe degree, hemotransfusion of one dose of erythrocyte suspension from 05/25/2016. secondary nephropathy. Urolithiasis disease. Stones of the right kidney. Incomplete duplication of the left kidney. Simple cysts of both kidneys. Chronic latent bilateral non-obstructive secondary pyelonephritis, exacerbation phase. Chronic kidney disease С36А1 (40 ml/min/1.73 m2). Absence of the right lobe (hemistrumectomy from 2000 for cancer), small cysts of the left lobe of the thyroid gland. Cerebrovascular disease, encephalopathy of mixed (dyscirculatory, hepatic) genesis of the second stage. Consolidated compression fracture, hemangioma of the body of the first lumbar vertebra. Chronic combined hemorrhoids without exacerbation. blood transfusion of one dose of erythrocyte suspension from 05/25/2016. secondary nephropathy. Urolithiasis disease. Stones of the right kidney. Incomplete duplication of the left kidney. Simple cysts of both kidneys. Chronic latent bilateral non-obstructive secondary pyelonephritis, exacerbation phase. Chronic kidney disease С36А1 (40 ml/min/1.73 m2). Absence of the right lobe (hemistrumectomy from 2000 for cancer), small cysts of the left lobe of the thyroid gland. Cerebrovascular disease, encephalopathy of mixed (dyscirculatory, hepatic) genesis of the second stage. Consolidated compression fracture, hemangioma of the body of the first lumbar vertebra. Chronic combined hemorrhoids without exacerbation. blood transfusion of one dose of erythrocyte suspension from 05/25/2016. secondary nephropathy. Urolithiasis disease. Stones of the right kidney. Incomplete duplication of the left kidney. Simple cysts of both kidneys. Chronic latent bilateral non-obstructive secondary pyelonephritis, exacerbation phase. Chronic kidney disease С36А1 (40 ml/min/1.73 m2). Absence of the right lobe (hemistrumectomy from 2000 for cancer), small cysts of the left lobe of the thyroid gland. Cerebrovascular disease, encephalopathy of mixed (dyscirculatory, hepatic) genesis of the second stage. Consolidated compression fracture, hemangioma of the body of the first lumbar vertebra. Chronic combined hemorrhoids without exacerbation. Chronic latent bilateral non-obstructive secondary pyelonephritis, exacerbation phase. Chronic kidney disease С36А1 (40 ml/min/1.73 m2). Absence of the right lobe (hemistrumectomy from 2000 for cancer), small cysts of the left lobe of the thyroid gland. Cerebrovascular disease, encephalopathy of mixed (dyscirculatory, hepatic) genesis of the second stage. Consolidated compression fracture, hemangioma of the body of the first lumbar vertebra. Chronic combined hemorrhoids without exacerbation. Chronic latent bilateral non-obstructive secondary pyelonephritis, exacerbation phase. Chronic kidney disease С36А1 (40 ml/min/1.73 m2). Absence of the right lobe (hemistrumectomy from 2000 for cancer), small cysts of the left lobe of the thyroid gland. Cerebrovascular disease, encephalopathy of mixed (dyscirculatory, hepatic) genesis of the second stage. Consolidated compression fracture, hemangioma of the body of the first lumbar vertebra. Chronic combined hemorrhoids without exacerbation. Consolidated compression fracture, hemangioma of the body of the first lumbar vertebra. Chronic combined hemorrhoids without exacerbation. Consolidated compression fracture, hemangioma of the body of the first lumbar vertebra. Chronic combined hemorrhoids without exacerbation.
The examination was carried out with oncological alertness. As a result of the treatment, including intravenous transfusion of albumin, fresh frozen plasma, erythrocyte mass, evacuation of fluid from the pleural cavity, a total of 6400 ml, drug correction, some stabilization of the patient's condition was achieved and the patient was discharged home under the supervision of a polyclinic doctor. In June, he was again hospitalized in the hospital. I.I. Mechnikov, no discharge documents were presented. Due to the growing general weakness, edematous syndrome, shortness of breath, today he applied for medical help to the 1st admission department and was sent for treatment to the hospital therapy clinic.
EXAMINATIONS:
Laboratory data:
About. blood test 04.08.2016 hemoglobin 76 g/l, hematocrit 25.0; Erythrocytes 3.83*1012/l, Leukocytes 7.20*109/l, Platelets 250*109/
l blood test 16.08.2016 hemoglobin 85 g/l, hematocrit 27.2; Erythrocytes 3.97*1012/l, Leukocytes 6.56*109/l, Platelets 240*109/l, reticulocytes 22 ppm
Vol. urinalysis 12.08.2016 beat density 1010, protein traces, leu -25-15 in p / z, fungi 3, bacteria 4, oxalates 1, epithelium m.p. units in p / s
Nechiporenko test 08/16/2016: E 1.0 * 106 / l, Lei 3.75 * 106 / l
An. BH total 08/05/2016: Fer 9.30 ng/ml; Lipa 47.55 U/l
An. HD total 08/08/2016: Albumin 28.6LG/L; Creatinine 175.1H umol/l; Glucose 6.20 mmol/l; Total protein 51.4L units; Urea 17.6H mmol/l
Alkaline phosphatase 126.1 U/L; ALT 11.1 U/l; AST 21.3 U/l; CPK 52.4 U/l; GGT 72.6H u/l; LDH 149.1 u/l; Albumin 27.9LG/L; Total bilirubin 10.0 umol/l; Calcium 1.91L mmol/l; Cholesterol 2.28L; Creatinine 142.0H umol/l; Glucose 4.72 mmol/l; Magnesium 0.85 mmol/l; Iron 3.9L umol/L; Triglycerides 0.95 mmol/l; Total protein 53.2L units; Urea 12.2H mmol/l; Uric acid 506.1H umol/l, HBA%R 6.87%; LDL_R 1.61 mmol/l; ApA1R 138.13 mg/dl; ApoBR 47.32 mg/dl; ApBAR 0.34
An. HD general 08/09/2016: Alkaline phosphatase 139.0HU/L; ALT 10.6LU/l; Amylase 81.8 u/l; AST 17.2r U/l; CPK 23.4r U/l; GGT 47.3ru/l; LDH 158.7ru/l; TRF-R 2.80 g/l
An. HD total 08/10/2016: Albumin 26.3LG/L; Calcium 1.89L mmol/l; Creatinine 172.6Humol/l; Total protein 42.9L units; Urea 18.4H mmol/l
An. HD general 11.08.2016: Lipa 64.20 U/l, Amylase 73.6 u/l; Albumin 30.7 G/L;
An. HD total 08/12/2016: Calcium 1.99L mmol/l
An. BH general 15.08.2016 Albumin 35.1L Globulins 17.4 g/l; Total bilirubin 8.6 umol/l; Calcium 2.18 mmol/l, Cholesterol 2.96L; Creatinine 153.5N µmol/l; Total protein 52.5L units; Urea 11.0H mmol/l; Direct bilirubin 3.5 umol/l, glucose 8.13 N mmol/l, HDL 0.85 mmol/l, potassium 3.4 N mmol/l, sodium 130.1 L mmol/l
Coagulogram 08/05/2016: PROTHROMBIN % 73%; PROTHROMBIN INR 1.20 INR; PROTHROMBIN sec 13.6 sec; FIBRINOGEN according to CLAUS 3.8 g/L; APTT 46.9 sec; APTT r 1.5
Coagulogram 08/11/2016: PROTHROMBIN % 68%; PROTHROMBIN INR 1.25 INR; PROTHROMBIN sec 14.2 sec; APTT FAILED sec; APTT r FAILED; FIBRINOGEN 4.24 g/L
Oncomarkers 08/05/2016: CA 19-9 86.8 units / ml (0-35), alpha-fetoprotein, PSA, free PSA, hCG, CA 15-3 - norm
Pleural fluid 08/12/2016: Cytosis 0.9 *109/L, protein 0.02 g/L
Pleural fluid 08/15/2016: Cytosis 0.4*109/L, protein 13 g/L
Serological tests for syphilis, HIV, HBsAg, anti-HCV 08/05/2016: negative.
Instrumental data:
FGDS 06/07/2016 - insufficiency of the rosette of the cardia, moderately pronounced atrophic changes in the mucosa of the esophagus, stomach and duodenum, pyloric insufficiency, secondary duodenitis.
FCC 06/01/2016 - mixed type dyskinesia with superficial atrophy, combined hemorrhoids. Organic pathology of the colon, incl. neo was not found.
CT scan of the abdomen on 06/07/2016: indirect signs of liver cirrhosis. Diffuse decrease in liver density. Hepatosplenomegaly. Gallbladder calculus. CT picture of local thickening of the duodenal wall in the region of the major duodenal papilla. CT scan showing simple cysts in both kidneys. Stones of the right kidney. Free fluid around the liver, spleen and interstoma. Free fluid in both pleural cavities, more on the left. Changes in the diaphragmatic pleura on the right are probably post-inflammatory in nature. CT picture of a compression fracture of the body, hemangioma of the first lumbar vertebra.
ECHO-CG 06/03/2016: EF 62%, dilatation of the right ventricle, in the cavity of which the electrode is covered with a layer of fibrin. The LV myocardium is not thickened, there are no zones of local disturbance of kinetics. The aorta is sealed. In the projection of the valve - prosthesis without signs of dysfunction. The mitral cusps are sealed. Regurgitation on MK and TK of 1 degree. Pressure in the small circle - 40 mm Hg. The pericardium is compacted, there is no effusion. In the pleural cavities, the effusion is on the left up to the middle of the scapula, on the right up to the 8th rib.
Ultrasound of the OBP 12.08.2016 - fibrotic changes in the liver, limited ascites, cyst of the upper pole of the right kidney, incomplete doubling of the left kidney, ascites
X-ray examination of the chest on 08/04/2016: increased lung pattern due to deforming pneumofibrosis. Fluid in the left pleural cavity at the level of the 4th rib. On the right, at the level of the 4th rib, there is a uniform shadow with clear contours - encapsulated liquid. The roots of the lungs are moderately compacted due to the vascular component.
X-ray examination of the breast 11.08.2016 after fluid evacuation: on the left, the lungs were expanded, no fluid was found.
ECG 04-17.08.2016 Rhythm of EKS with HR 60/min
AT DISCHARGE: Patient of extremely high cardiovascular, arrhythmogenic risk. The degree and severity of damage to the heart muscle determines the severity of the condition in part. The dominant is the pathology of the liver, manifested by the development of cirrhosis, hepatosplenomegaly and severe hypoproteinemia, which contributes to the development of extremely severe edema, impaired coagulation, and the threat of thrombo-hemorrhagic syndrome. The development of cirrhosis in a patient is indicated not only by structural changes in the liver, enlargement of the veins of the portal system, detected by ultrasound, but also by a significant decrease in protein-synthetic function, a decrease in the level of calcium and magnesium in blood plasma. Given the nature and extent of myocardial changes, the contribution of cardiac dysfunction to the development of cirrhosis is minimal, which allows us to consider cirrhosis as cryptogenic, and considering 10 points on the Child-Pugh scale, one can state decompensation of the course of cirrhosis without signs of portal hypertension (an EGD was performed, as a result of which no data were obtained on the presence of esophageal varicose veins). Therefore, cirrhosis of the liver is currently the main contribution to the severity of the patient's condition with the disease. Neoplastic process has not been proven. The results of the study of tumor markers with a positive result and an increase of more than two times Gl 19-9 Ag (86.8 U/l) may be determined by the presence of liver damage. cirrhosis of the liver is currently the main contribution to the severity of the condition of the patient with the disease. Neoplastic process has not been proven. The results of the study of tumor markers with a positive result and an increase of more than two times Gl 19-9 Ag (86.8 U/l) may be determined by the presence of liver damage. cirrhosis of the liver is currently the main contribution to the severity of the condition of the patient with the disease. Neoplastic process has not been proven. The results of the study of tumor markers with a positive result and an increase of more than two times Gl 19-9 Ag (86.8 U/l) may be determined by the presence of liver damage.
The main efforts are focused on normalizing the electrolyte and protein composition of the blood, stopping the threat of thrombo-hemorrhagic syndrome, reducing the severity of tissue hyperhydration, and hepatoprotective therapy.
Discharged in a relatively satisfactory condition under the supervision of doctors of the clinic
RECOMMENDED:
➢ Observe the regime of work and rest.
➢ Observation of a therapist, gastroenterologist at the place of residence
➢ Regular control of body weight!!! With an increase in body weight of more than 3 kg (edema) - hospitalization in the gastroenterological department
➢ Continue taking:
1. Ademetionine 400 mg - 2 tablets in the morning
2. Veroshpiron 25 mg - 2 tablets 4 times a day
3. Furosemide 40 mg - 2 tablets each in the morning and 1 tablet in the afternoon
4. Eufillin 150 mg - 1 tablet 2 times a day
5. Dufalac - 30 ml in the morning
6. Asparkam 1 tablet 3 times a day
7. Ferrum Lek 5%-2 ml - 2 ml (100 mg) intramuscularly daily 2 weeks
8. Retabolil 5%-1ml intramuscularly 1 time in 10 days №3
MILITARY MEDICAL ACADEMY
Clinic of hospital therapy
Discharge summary from the case history № 86
was examined and treated in the hospital therapy clinic of the Military Medical Academy from 24.12.2009 to 12.01. 2010
DIAGNOSIS:
CHD: stable exertional angina 3 FC. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis. Paroxysmal form of atrial fibrillation, out of paroxysm.
Hypertension III degree. (AH 2, CVE risk is extremely high). NK 2a st., 3 FC.
Cerebrovascular disease. Acute cerebrovascular accident of the ischemic type in the basin of the right middle cerebral artery from December 2009. Dyscirculatory encephalopathy of the 3rd stage of mixed (atherosclerotic, hypertensive) genesis in the form of scattered neurological symptoms, vestibulopathic and unexpressed psychoorganic syndromes.
Osteochondrosis of the thoracic spine with pain syndrome.
Cholelithiasis. Chronic calculous cholecystitis without exacerbation.
Omission of the right kidney 1 degree.
Varicose disease of the lower extremities, CVI-2st.
Phenomena of initial cataract in both eyes. Severe angiosclerosis of the retina. Initial macular degeneration of both eyes.
Upon admission, she complained of periodic pressing pains in the region of the heart, of varying duration, that occur after climbing to the 2nd floor, stopping on their own after the cessation of physical activity; periodic heartbeats, interruptions in the work of the heart; episodic increase in blood pressure up to 180\90 mm Hg, episodic dull aching headache without clear localization with an increase in blood pressure; pain in the spine, aggravated by physical exertion, unsteady gait, hearing and vision loss during the last month, memory loss, fatigue.
Results of instrumental studies:
X-ray of the chest organs No. 195 dated 12/25/09: on a chest radiograph and on fluoroscopy in the lungs without focal and infiltrative changes. Moderate diffuse emphysema, at the level of the 2nd rib on the left, areas of limited pneumofibrosis 1.5 * 1.0 cm are determined. The roots are structural, not expanded, free fluid in the pleural cavity is not determined. The diaphragm is flattened on the left, the costophrenic sinus is obliterated on the left. The heart is slightly dilated to the left. The aorta is compacted and deployed.
X-ray of the thoracic spine No. 2681 dated 11/17/09. in 2 projections - physiological kyphosis is enhanced (senile round back). Osteochondrosis in the mid-thoracic region with a decrease in the height of the discs, osteochondral sclerosis and marginal exophytes in direct projection up to 0.1 cm.
On ECG No. 176 dated 06.11.09. and 26.12.09. sinus rhythm is recorded with a heart rate of 65 per 1 minute, the EOS is deflected to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His). Left ventricular hypertrophy.
ECHO-KG from 01/08/2010: The cavities are not enlarged, free, the myocardium is not thickened, the kinetics is not disturbed, the aorta is sealed, the walls are thickened, calcification of the aortic crescents. Sealing, calcification of the mitral valve leaflets. Regurgitation of the 1st degree on the TC and MC, valvular on the aortic and pulmonary valves. Pulmonary blood flow is not disturbed. The pericardium is not changed
. Ultrasound of the OBP dated 11.01.2010. Multiple gallbladder calculi with a diameter of up to 10 mm., The right kidney is located 3 cm below its usual location. Visceroptosis.
FVD dated December 27, 2009. conclusion in hand.
CT scan of the head dated December 30, 2009. - conclusion on hand
Results of laboratory tests:
Clinical blood test (automatic processing):
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
MCHC, g/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
26.12.
113
3.62
5.1
326
25
2
1
46
7
1
43
11.01.
116
3.84
5.4
319
30
1
40
6
3
47 Complete
urinalysis (automatic processing):
Date
U.weight
Reak
Protein
Sach
Cylinder
Leu
Er.neiz
Urobil
26.12
1020
6.0
-
-
No
-
-
-
Biochemical blood test:
Name
Unit of measure.
Norm
25.12.2009
11.01.10
AST
U/l
11-50
20
ALT
U/l
11-50
16
CPK
U/l
10-160
68.6
O. bilirubin
mmol/l
6.8-26
8.4
Creatinine
mmol/l
0.05-0.12
0.12
Potassium
mmol/l
3.5-5.1
4.21
4.14
Serum iron
mmol/l
10.5-25
9.47
Total protein
g/l
64-83
70.8
72.7
glucose
mmol/l
3.9-6.2
5.57
F-50, HBsAg, HCV, RW: negative.
Examination of feces on December 26, 2010: no pathology, I/g were not detected.
Consulted by a neurologist. The diagnosis is specified, recommendations are given.
Consulted by an ophthalmologist. The diagnosis is specified, recommendations are given. A prescription for reading glasses has been issued.
Endoscopic examination of the gastrointestinal tract was not performed due to the patient's condition.
Treatment was carried out: regimen, diet, noliprel-forte, cordarone, aspicor, cytoflavin, rudotel, gliatilin, phezam, mildronate.
Discharged home in a satisfactory condition under the supervision of medical specialists of the clinic. A temporary disability sheet was not issued.
Recommended:
1. Supervision by a neurologist, a cardiologist.
2. Continue taking:
• Tab. Noliprel 1 tab. in the morning all the time.
• Tab. Thrombo ASS 0.05 1 tab. in the morning all the time.
• Tab. Preductal MB 1 tab. 2 times a day all the time.
• Tab. Gliatilin 0.4 1 tab. 3 times a day from 11 to 20 January 2010
• Caps. Phezam 2 caps. morning and afternoon from 11 to 20 January 2010.
• Quinax - 2 drops in each eye 4 times a day for 1 month.
• Actovegin 20% - 250ml intravenously 1 time per day for 2 weeks, starting from 20.01.10.
• Tanakan 1 tab 2 times a day from January 20 to February 20, 2010.
3. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
4. Limit the intake of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
5. Repeated hospitalization according to indications.
MILITARY MEDICAL ACADEMY
Clinic of hospital therapy
Discharge summary from the case history No. 1033
was examined and treated at the clinic of hospital therapy of the Military Medical Academy from 06.11.2009 to 20.11.2009.
DIAGNOSIS:
coronary artery disease, stable angina pectoris 3 FC. Atherosclerotic cardiosclerosis. Atherosclerosis of the aorta and coronary arteries. Paroxysmal form of atrial fibrillation, paroxysm of atrial fibrillation from 08.11.09. stopped medically on 08.11.09.
Hypertension III degree. (AH 2, CVE risk is extremely high). NK 2a st., 3 FC.
Dyscirculatory encephalopathy of the 3rd stage of mixed (atherosclerotic, hypertonic) genesis with a predominant lesion in the vertebrobasilar basin. Syndrome of intellectual-mnestic disorders.
Osteochondrosis of the thoracic spine with pain syndrome.
Cholelithiasis. Chronic calculous cholecystitis without exacerbation.
Omission of the right kidney 1 degree.
Varicose disease of the lower extremities, CVI-2st.
Upon admission, she complained of periodic pressing pains in the region of the heart, of varying duration, that occur after climbing to the 2nd floor, stopping spontaneously after the cessation of physical activity; periodic heartbeats, interruptions in the work of the heart; episodic increase in blood pressure up to 180\90 mm Hg, pain in the spine, aggravated by physical activity, weight loss by 5 kg during the year, memory loss, fatigue.
Results of instrumental studies:
X-ray of the chest organs No. 2590 dated 09.11.09: on the chest radiograph and on fluoroscopy, the lung fields are emphysematous, at the level of the 2nd rib on the left, areas of limited pneumofibrosis 1.5 * 1.0 cm are determined. The roots are structural, not expanded, the diaphragm is flattened, free fluid in the pleural cavity is not determined. The heart is slightly dilated to the left. The aorta is compacted and deployed.
X-ray of the thoracic spine No. 2681 dated 11/17/09. in 2 projections - physiological kyphosis is enhanced (senile round back). Osteochondrosis in the mid-thoracic region with a decrease in the height of the discs, osteochondral sclerosis and marginal exophytes in direct projection up to 0.1 cm.
On ECG No. 2487 dated 06.11.09. and 08.11.09. sinus rhythm is recorded with a heart rate of 90 per 1 minute, EOS is deflected to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His). Left ventricular hypertrophy.
ECHO-KG: The cavities are not enlarged, free, the myocardium is not thickened, the kinetics are not disturbed, the Aorta is sealed, the walls are thickened, calcification of the aortic crescents. Sealing, calcification of the mitral valve leaflets. Regurgitation of the 1st degree on the TC and MC. Pulmonary blood flow is not disturbed. The pericardium is not changed
by ultrasound of the OBP. Multiple gallbladder stones up to 10 mm in diameter, the right kidney is located 3 cm below its usual location.
Laboratory results:
Clinical blood test (automatic processing):
Date
Hb, units
Er., *1012/l
Leuk., *109/l
MCHC, g/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
09.11.
119
4.06
6.4
29.4
40
1
40
5
64
13.11.
116
3.74
5.9
31.0
34
2
1
31
4
3
59
Urinalysis (automatic processing):
Date
W.w
Reak
Protein
Sach
Cylind
Lei
Er.neiz
Urobil
29.10
1020
5.9
-
-
No
-
-
3.2
Biochemical blood test:
Name
Unit of measure.
Norm
09.11.2009
AST
U/l
11-50
23.5
ALT
U/l
11-50
16.4
CPK
U/l
10-160
64.3
Cholesterol
Mmol/l
3.7-6.0
5.78
Triglycerides
Mmol /l
0 - 2.37
Creatinine
mmol/l
0.05-0.12
0.11
Potassium
mmol/l
3.5-5.1
4.54
Serum iron
mmol/l
10.5-25
9.2
Total protein
g/l
64-83
68.3
Other blood tests: prothrombin 88%, fibrinogen 3.5 g/l,
F-50, HBsAg, HCV, RW: negative
Examination of feces on 11/13/2009: no pathology, I/g were not detected
Endoscopic examination of the gastrointestinal tract was not performed due to the patient's condition.
Treatment was carried out: regimen, diet, noliprel-forte, cordaron, aspicor, zovirax, cytoflavin, rudotel, gliatilin, phezam, mildronate.
Discharged home in a satisfactory condition under the supervision of medical specialists of the clinic. A temporary disability sheet was not issued.
Recommended:
1. Observation by a neurologist, cardiologist
2. Continue taking:
• Tab. Noliprel 1 tab. in the morning. (or noliprel-forte ½ tab. in the morning).
• Tab. Thrombo ASS 0.05 1 tab. in the morning.
• Tab. Preductal MB 1 tab. 2 times a day all the time.
• Caps. Cytoflavin 1 caps. 2 times a day for 1 month.
• Tab. Gliatilin 0.4 1 tab. 3 times a day for 2 months.
• Caps. Phezam 2 caps. morning and afternoon for 2 months.
3. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
4. Limit the intake of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
Form 12_Un.VmedA-2010 GT
CLINIC OF HOSPITAL THERAPY VmedA
them. CM. KIROV
St. Petersburg, st. Academician Lebedeva, d.6 lit. H
DISCHARGE STATEMENT No. 17520 has
been under inpatient examination and treatment at the BMX clinic since 16.03.17. to 03/24/17, the hospital therapy clinic of the Military Medical Academy from 03/24/17. on 04/11/17 with a diagnosis:
Disseminated intravascular coagulation syndrome, consumption phase from 03/23/17, stopped. Parietal thrombosis of the ascending, descending sections and aortic arch, parietal thrombus of the right atrium. Secondary pulmonary hypertension of the 2nd degree, mixed (vascular and postcapillary) genesis.
Widespread phlebothrombosis of the femoral-popliteal segment on the right and left of unknown age.
Submassive thromboembolism of the branches of the pulmonary artery (on the right: in the anterior trunk of the pulmonary artery A2, A3, subsegmental A5, A8, trunk thrombosis A9-10; on the left, thrombosis of the subsegmental branches A1 + 2, A8, A5; GENEVA 6 points). Infarction-pneumonia S1, S3, S8-9-10 of the right lung, S4, S5, S9 of the left lung. Bronchiolitis S1/2, S8 of the left lung, S6, S8, S9 of the right lung, without respiratory failure.
Coronary artery disease. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic and large-focal post-infarction (from 2007) cardiosclerosis with impaired conduction by the type of complete blockade of the left leg of the bundle of His. Relative insufficiency of the mitral and tricuspid valves of the second degree. Chronic left ventricular apex aneurysm with massive parietal thrombosis. Infrarenal aneurysm of the abdominal aorta with parietal thrombosis.
Hypertension stage III. The risk of cardiovascular complications is extremely high.
Chronic heart failure stage IIB, IV functional class. Bilateral middle hydrothorax, in the regression phase, mixed edema (heart failure, hypoproteinemia) genesis.
Fibrosis of the liver of mixed (cardiac, dysmetabolic) genesis. Hypoproteinemia. cytolysis syndrome. Syndrome of violation of pigment metabolism.
Neoplasm of the terminal part of the common bile duct.
Secondary nephropathy of mixed (atherosclerotic, hypertensive, dysmetabolic) genesis. Urolithiasis without exacerbation (nephrolitectomy on the left, 1989). Solitary cyst of the left kidney (Bosniak I). Accessory renal arteries on both sides. Chronic kidney disease C2A1 stage. Urinary tract infection of unspecified localization.
Manipulations:
Bladder catheterization 16.03.17.
Catheterization of the right subclavian vein from 16.03.17. to
03/26/17 Catheterization of the right internal jugular vein on 03/26/17
Puncture of the pleural cavity on March 24, 2017 (700 ml evacuated on the right, 1100 ml on the left), 03/27/2017 (800 ml evacuated on the right, 1000 ml on the left).
Plasma infusion 24.03.17 1000 ml, 28.03.17 1000 ml.
Albumin infusion 03/25/17 300 ml, 03/27/17 300 ml, 04/05/17. 200 ml.
ICD code: [I26.0 - 03/24/2017].
Discharged from the Military Medical Academy on April 11, 2017 Total days of treatment 26
The final diagnosis was made on March 24, 2017 ICD code I-26
Disability certificate was not issued
Work capacity was not restored, visit to the clinic on April 12, 2017
Clinical outcome: improvement .
SURVEYS:
ECG from 03/24/2017: sinus tachycardia with a heart rate of 106 per minute. EOS is deflected to the left. PBLNPG. Cicatricial changes in the anterior septal region. Diffuse disorders of repolarization.
ECG dated April 10, 2017: sinus rhythm with a heart rate of 72 per minute. EOS is deflected to the left. PBLNPG. 1st degree AV block.
Echo CG from 24.03.2017: IVS=12mm, AP=12mm, LV=47/43, EF=24%, LA=11mm, RA=58x54mm, RV=29mm, RV wall=5mm, SPLA =50 mm, LA=25 mm.
Severe dilatation of both atria. Against the background of total hypokinesia, akinesia of the anterior, lateral wall, septum, in the apical sections with the formation of a chronic aneurysm in the apex. Massive thrombosis is noted in the aneurysm cavity, without signs of flotation. Fibrosis of the IVS. The aorta is sealed, its walls are thickened. Aortic and mitral fibrous rings, aortic crescents, mitral leaflets. Regurgitation on MK and TK of the 2nd degree, on AK - valvular regurgitation. Moderate increase in pressure in a small circle. The pericardium is not changed, there is no effusion.
In the sinuses on both sides, the accumulation of fluid, on the right up to the level of the 7th rib, on the left up to the 5th rib along the paravertebral line.
X-ray of the OGK 28.03.17. The lungs are straightened, the fluid in the pleural cavities is at the level of the sinuses. On the right, against the background of a diffusely enhanced pulmonary pattern, a rounded shadow with fairly clear contours is determined in the supradiaphragmatic sections, a small amount of fluid in the horizontal interlobar fissure. On the left, at the level of the 5th rib, a small triangular shadow with clear contours is determined. The roots of the lungs are moderately compacted due to the vessels, structural. The shadow of the heart is expanded in diameter. The aorta is sealed. Signs of a heart attack-pneumonia on the right.
Control X-ray OGK 03.04.17. there is an increase in congestion in the lungs, expansion of the cardiac shadow, smoothness of the arcs.
Ultrasound of the OBP 27.03.17. diffuse changes in the liver and pancreas, chronic cholecystitis, violations of the rheology of bile.
CT scan of the abdomen, 23.03.17. CT picture of bilateral PE. Signs of an aneurysmal protrusion of the apex of the left ventricle with the presence of thrombotic masses. Thrombotic masses in the right atrium. Interstitial infiltration of both lungs - as a manifestation of thromboembolism of small branches of the pulmonary artery. Signs of infarction-pneumonia in the lower lobe of both lungs. Bilateral middle hydrothorax. Aneurysmal expansion of the infrarenal abdominal aorta. accessory renal arteries. Decreased density of the liver. Signs of thickened bile. Changes in the head of the pancreas near the OBD require dynamic observation. Signs of chronic pancreatitis.
CT control of the OGK, abdomen on 04/05/17. Bilateral thromboembolism of the branches of the pulmonary arteries. Signs of an aneurysmal protrusion of the apex of the left ventricle with the presence of thrombotic masses. Thrombotic masses in the right atrium. Atherosclerosis of the aorta, coronary arteries. CT signs of interstitial changes in S1, S3 of the right lung, in S4, S5, S9 of the left lung - a manifestation of thromboembolism of small branches of the pulmonary artery. Signs of bronchiolitis in S1+2, S8 of the left lung, S6, S8, S9 of the right lung. Signs of infarction-pneumonia in S8, S9, S10 of the right lung. Lung parenchymal infiltrate in S9 of the left lung (inflammatory genesis? pneumofibrosis? neo?). Free fluid in both pleural cavities.
A picture of preneurysmatic expansion of the infrarenal abdominal aorta. Accessory renal arteries on both sides (developmental variant). Diffuse decrease in the density of the liver. Signs of thickened bile. Signs of changes in the terminal part of the common bile duct - changes, probably of a neoplastic nature, an enlarged regional lymph node - between the wall of the duodenum and the head of the pancreas. Signs of chronic pancreatitis. Left kidney cyst.
Clinical blood test dated 03/24/2017: leukocytes - 9.71*109/l, erythrocytes - 4.17*1012/l, hemoglobin -118 g/l, platelets -180*109/l, HCT - 37.1% .
Clinical blood test dated April 10, 2017: leukocytes - 6.13*109/l, erythrocytes - 3.92*1012/l, hemoglobin - 113 g/l, platelets - 152*109/l, HCT - 36.2% , ESR 9mm/hour
Urinalysis:
Date
Rel. dense
pH
Protein
Acetone
Glucose
Cyl. p/sp
10.04.17
1010
5.5
0.16g/l neg
.
5.5
Leukocytes, p/sp.
Erythrocytes, p/zr
Epithelium, MVP p/z
Salt
Bakt.
Bile pigments
Mucus
3-4-4
5-4-5
oxalates
-
2
Biochemical blood test dated March 24, 2016: urea 8.5 mmol/l, glucose - 4.9 mmol/l, creatinine - 98 mmol/l, total protein - 59 g/l, albumin 24.6 g/l. , ALT 93 U/l, total bilirubin 221 µmol/l, straight. bilirubin 176.9 µmol/l, potassium 3.32 mmol/l, sodium 137.9 mmol/l, fibrinogen 4.04 g/l, INR 1.52 prothrombin 49%.
Biochemical blood test dated March 29, 2016: urea 15.8 mmol/l, creatinine -113 mmol/l, total protein - 65 g/l, albumin 34 g/l, potassium 4.9 mmol/l, sodium 139, 3 mmol/l, fibrinogen 2.5 g/l, INR 2.01 prothrombin 33%.
Biochemical blood test dated April 10, 2016: urea 7.4 mmol/l, creatinine -78 mmol/l, total protein - 62 g/l, albumin 32.8 g/l, total bilirubin 133.5 µmol/l , straight. bilirubin 97.7 µmol/l, potassium 2.9 mmol/l, sodium 137.6 mmol/l, fibrinogen 1.39 g/l, prothrombin 74%.
The patient was admitted by internal transfer from the clinic of naval surgery with a diagnosis of transfer of "PE", the phenomena of multiple organ failure, the leading of which at the time of admission were decompensation of cardiopulmonary insufficiency, liver failure. Upon admission, a syndrome of disseminated intravascular coagulation was diagnosed, which is currently stopped. Among the reasons for the development of jaundice, suprahepatic mechanism was assumed (hemolysis as a source excluded when examined by a hematologist), hepatic mechanism (autoimmune, cryptogenic, viral, toxic nature), which were not confirmed during the examination. As part of the differential search, the patient underwent a CT scan of the chest and abdomen in the angio mode on April 5, 2017, which revealed signs of changes in the terminal part of the common choledochus, probably neoplastic character, enlarged regional lymph node between the wall of the duodenum and the head of the pancreas. In the diagnosis, it was planned to exclude a neoplastic process.
The patient categorically refused to be transferred to a surgical hospital in the presence of relatives and witnesses.
Discharged to the clinic at the place of residence under the supervision of a cardiologist, gastroenterologist, oncologist.
Recommended
• Hospitalization in an oncology hospital to determine the nature of changes in the terminal part of the common choledochus, to make a decision on further treatment tactics.
• CT angiography images dated April 5, 2017 handed out
• Continue taking:
1. Xarelto 15 mg 1 r / day
2. Torasemide 10 mg 1 r / day
3. Lisinopril 10 mg ½ tab. 2r/day
4. Ursoliv 250 mg 1 caps 3r/day for 3 months
5. Spironolactone 25 mg 2 tab. 1 time / day
6. Omeprazole 20 mg 1 caps 2 times a day for 2 weeks.
7. Phlebodia 0.6 1 caps 2 times a day
8. Bisoprolol 5 mg ½ tab 1 time in the morning.
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
Discharge summary No. 963
was examined and treated at the hospital therapy clinic
from August 30 to September 13, 2010 with a diagnosis of
hypertension stage III. (AH 2, CVE risk is extremely high).
IHD: stable exertional angina 3 FC. Atherosclerotic cardiosclerosis. Atherosclerosis of the aorta and coronary arteries. Persistent form of atrial fibrillation. CHF 2a st., 3FC. Cerebrovascular disease. Dyscirculatory encephalopathy of the 3rd stage of mixed (atherosclerotic, post-stroke (December 2010), hypertensive) genesis in the form of diffuse neurological symptoms, vestibulopathic and unexpressed psychoorganic syndromes. Osteochondrosis of the thoracic spine with pain syndrome. Cholelithiasis. Chronic calculous cholecystitis without exacerbation. Diffuse nephroangiosclerosis of mixed (atherosclerotic, hypertensive, dysmetabolic) genesis. CKD stage 3, chronic renal failure stage 1a. Omission of the right kidney 1 degree. Varicose disease of the lower extremities, superficial form. HVN-2st. Primary cataract in both eyes. Severe angiosclerosis of the retina. Initial macular degeneration of both eyes.
Upon admission, she complained of periodic pressing pains in the region of the heart, of varying duration, shortness of breath that occurs after climbing to the 1st floor, stopping on its own after the cessation of physical activity; periodic heartbeats, interruptions in the work of the heart; episodic increase in blood pressure up to 180/90 mm Hg, episodic dull aching headache without clear localization with an increase in blood pressure; pain in the spine, aggravated by physical exertion, unsteady gait, hearing loss and vision loss during the last month, memory loss, fatigue.
Results of instrumental studies:
Ultrasound of the OBP from 09/01/2010. Multiple gallbladder stones up to 12 mm in diameter, the right kidney is located 3 cm below its usual location. Visceroptosis. Ultrasound signs of nephrosclerosis.
Ultrasound of the thyroid gland No. 1067 dated 10.09.2010. Conclusion: a cyst of the right lobe of the thyroid gland, the volume of the gland is at the upper limit of normal.
X-ray of the chest organs No. 1766 dated 09/01/10: on the chest radiograph and on fluoroscopy in the lungs without focal and infiltrative changes. Moderately expressed diffuse emphysema, diffuse pneumofibrosis. The roots are structural, not expanded, free fluid in the pleural cavity is not determined. The diaphragm is flattened on the left, the costophrenic sinus is obliterated on the left. The heart is slightly dilated to the left, "hanging". The aorta is compacted, elongated and deployed.
On ECG No. 1815 dated 08/30/10. sinus rhythm is recorded with a heart rate of 65 per 1 minute, the EOS is deflected to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His).
On ECG No. 1846 dated 06.09.10. sinus rhythm is recorded with a heart rate of 78 per 1 minute, the EOS is deviated to the left, bifascicular blockade (blockade of the anterior branch of the left leg and complete blockade of the right leg of the bundle of His). No negative momentum.
ECHO-KG from 09/06/2010: The cavities are not enlarged, free, the myocardium is not thickened, the kinetics is not disturbed, the aorta is sealed, the walls are thickened, calcification of the aortic crescents. Sealing, calcification of the mitral valve leaflets. Regurgitation of the 1st degree on the TC and MC. Pulmonary blood flow is not disturbed. The pericardium is not changed. Without dynamics with ECHO-KG from 01/08/2010.
Holter ECG monitoring (against the background of therapy) dated 09/01/2010: during the observation period, the following rhythms were recorded: pacemaker migration through the atria, 4 prolonged episodes of atrial fibrillation, tachysystolic form (11:10-11:28; 13:58) -15:45; 18:20-19:28; 23:41-00:50) and many short episodes of atrial fibrillation lasting up to 2 minutes, 5 short episodes of atrial flutter, turning into atrial fibrillation. Heart rate from 52 to 166 in 1 minute. The decrease in heart rate at night is adequate. Average heart rate 81/89/69 in 1 minute. Single ventricular extrasystoles were registered (22 in total); ultra-frequent supraventricular extrasystoles (total 4632), periodically aberrant, paired, group, bi- and trigeminy type. Against the backdrop of atrial fibrillation,
Monitor observation of Holter ECG (against the background of therapy) dated 09.09.2010: during the observation period, migration of the pacemaker through the atria was recorded, many short episodes of atrial flutter-fibrillation, normosystolic form, were recorded. Heart rate from 52 to 116 in 1 minute. The decrease in heart rate at night is adequate. Average heart rate 81/89/69 in 1 minute. Registered single ventricular extrasystoles (total 12); frequent supraventricular extrasystoles (total 1562), periodically paired, group, bi- and trigeminy type. Against the background of atrial fibrillation, tachysystole, ST segment depression up to 2 mm is recorded.
Daily monitoring of blood pressure (against the background of therapy) from 09/01/2010: Mean systolic blood pressure during the day and mean diastolic blood pressure during the day are within the normal range, mean systolic blood pressure at night is characteristic of mild labile hypertension. At night, systolic blood pressure paradoxically rises (nightpicker), diastolic blood pressure does not decrease enough (nondipper). The variability of systolic and diastolic blood pressure during the day is increased, at night the variability of systolic and diastolic blood pressure is within the acceptable range. 3 episodes of hypotension in systolic blood pressure up to 94 mmHg were registered. (time index 6%), and 2 episodes of hypotension in diastolic blood pressure up to 48 mm Hg. (time index 23%). There is an increase in the average pulse blood pressure, the magnitude and speed of the morning rise in diastolic blood pressure.
The results of laboratory examination:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
Ht, %
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
31.08
123
3.94
5.2
37.6
32
269
1
34
11
1
53
09.09
121
3.83
5.2
37.0
30
309
5
50
6
1
38
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MVP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
31.08
clear
1010
yellow
6.5
no
no
no
-
-
no
0-3
-
4-8
1-2
09.09
clear
1010
yellow
5.5
no
no
no
2
-
no
2-5
-
8-15
0-2
Biochemical blood test:
Name
Unit. rev.
Norm
31.08
09.09
Creatinine
µmol/l
53-124
101.1
urea
mmol/l
2.5-6.4
9.3
glucose
mmol/l
3.9-6.2
5.7
potassium
mmol/l
3.5-5 .1
4.9
4.6
sodium
mmol/l
136-145
141.8
139.3
total cholesterol
mmol/l
3.7-6.0
9.56
8.93
triglycerides
mmol/l
0-2.37
0.7
o. bilirubin
mmol/l
6.8-26
7.1
Total protein
g/l
63-87
74.6
albumin
g/l
30-55
43.5
ALT
U/L
8.4-53.5
16.1
AST
U/L
7-39.7
15.5
Amylase
U/L
28-100
68.7
prothrombin index
%
70-120
102
Fibrinogen
mg/dl
200-400
408
Creatinine clearance according to the Cockcroft-Gault formula = 31 ml/min. GFR by MDRD = 47.5ml/min/1.73m2
Endoscopic examination of the gastrointestinal tract was not performed due to the patient's condition.
Treatment was carried out: regimen, diet, noliprel, cordarone, aspicor, cytoflavin, actovegin, tanakan, phenibut, amitriptyline, movalis, piracetam, betaserc.
Discharged home in a satisfactory condition under the supervision of medical specialists of the clinic. A temporary disability sheet was not issued.
Recommended:
1. Supervision by a neurologist, a cardiologist.
2. Continue taking:
• Tab. Noliprel ½ tab. in the morning all the time.
• Tab. Kordaron 0.2 1 tab. morning and evening for 1 month, then ½ tab. in the morning constantly
• Tab. Thrombo ASS 0.05 1 tab. in the morning all the time.
• Tab. Amitriptyline 25mg ½ tab. 2 times a day for 1 month
• Tab. Lucetam 0.8 1 tab. morning 1 month
• Tab. Preductal MB 1 tab. 2 times a day all the time.
• Quinax - 2 drops in each eye 4 times a day for 1 month.
• Tanakan 1 tab 2 times a day until September 30, 2010.
3. Observe the drinking regime of 1-1.5 l / day; restriction of the use of table salt (no more than 3 g per day).
4. Limit the intake of animal fats, increase the amount of vegetable fiber, vegetable fats, foods containing a high content of potassium (dried apricots, raisins, prunes) in the diet.
5. Re-hospitalization after 3 months or earlier according to indications.
This block includes a number of mental disorders grouped together on the basis of the presence of clear etiological factors, namely, the cause of these disorders was brain disease, brain injury or stroke, leading to cerebral dysfunction. Dysfunction can be primary (as in diseases, brain injuries and strokes that directly or selectively affect the brain) and secondary (as in systemic diseases or disorders when the brain is involved in the pathological process along with other organs and systems).
Dementia [dementia] (F00-F03) is a syndrome caused by damage to the brain (usually chronic or progressive) in which many higher cortical functions are impaired, including memory, thinking, orientation, understanding, counting, learning ability, speech and judgment. Consciousness is not obscured. Cognitive decline is usually accompanied, and sometimes preceded, by deterioration in control of emotions, social behavior, or motivation. This syndrome is noted in Alzheimer's disease, in cerebrovascular diseases, and in other conditions that primarily or secondarily affect the brain.
If necessary, an additional code is used to identify the underlying disease.
Form 12_Un.VMedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, Suvorovsky pr. 63 tel. (812) 577-11-35
DISCUSSION REPORT CASE
HISTORY No. 657 ACCORDING TO ARCHIVE No. _________
She was hospitalized (in the day hospital mode)
in the hospital therapy clinic
from September 22, 2014 to September 26, 2014. Departed from VMA "26" 09 2014
Total days of treatment 5
The final diagnosis was established on 25.09.2014. ICD code I 11.9
Hypertensive disease stage II (normotension, the risk of cardiovascular complications is “high”). Aortic atherosclerosis without heart failure.
Polyposis of the large intestine.
A disability certificate was not issued.
The ability to work is not impaired.
Total radiation dose 0.26 mSv
Clinical outcome: discharge.
The results of laboratory studies in dynamics:
General clinical analysis of blood:
Date
Hb, units.
Er., *1012/l
MCH
fl
Leuc., *109/l
Ht
%
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
22.09
133
4.91
27.1
6, 2
44.5
8
349
5
22.1
10.3
1
60
Biochemical blood test: Urinalysis:
Name
Unit of measure.
Norm
22.09
Indicator
22.09
Creatinine
Mkmol/l
53-124
115.2
Color Yellow
Cholesterol
Mmol
/l
3.7-6.0
6.13
Transparency
trans.
Triglycerides
mmol/l
0-2.37
0.87
Specific. Weight
1020
PSA
mmol/l
up to 4
1.34
Protein (g/l)
no
Glucose
mmol/l
4.2-6.4
5.39
Sugar
No
Fibrinogen
g/l
2-4
3.67
Leukocytes in p/s
1-2-3
Potassium
mmol/l
4.0-6.0
4.46
pH
6.0
Urea
mmol/l
3.0-8.4
6.5
Results of instrumental studies:
ECG on September 22, 2014: Sinus rhythm, 74 beats. Normal position of the EOS. Partial violation of intraventricular conduction.
Ultrasound of the abdominal organs on September 22, 2014: Liver: right lobe - 13.2 cm, left - 5.7 cm, echogenicity is not changed, the vessels are not dilated. Portal vein less than 13 mm. The pancreas is located clearly, hyperechoic, the contours are clear, even. The gallbladder of the correct form, not enlarged. The PCL is not dilated; in the right kidney, the sinus is divided by a hypoechoic band. The spleen is not changed. Conclusion: Diffuse changes in the pancreas. Doubling of the right kidney.
ECHO-KG from 23.09.2014: MZHP-9.9mm, ZS-10.5mm, KDR LV-56.1mm, KSR LV-38.8mm, PV-58%, FU-31%, LP-32× 37×46mm, PP-37×46mm, RV-28mm, E/A=1.1 LV myocardial mass 267 g, IMM 136 g/m2. The walls of the aorta are sealed. The myocardium is slightly eccentrically hypertrophied. The cavities of the heart are free, not dilated. Global LV systolic function was preserved. Zones of local violation of contractility were not identified. Type I diastolic dysfunction. The valves are intact. Doppler examination revealed no pathology. Pericardium without features.
24-hour Holter ECG monitoring on September 23, 2014: during the observation period, sinus rhythm was recorded with a heart rate of 63 to 130 per minute, the decrease in heart rate at night was insufficient. Average heart rate 78/82/70 in 1 minute. Single supraventricular extrasystoles were registered (23 in total). When performing the planned load, the heart rate reached 130 and 123 in 1 minute, while the patient noted dizziness. No ischemic changes in the ST segment were detected.
Daily monitoring of blood pressure from 09/23/2014: Mean blood pressure 137/97 mm Hg. Art. during the day and 126/91 mm Hg. Art. at night. Daytime mean systolic BP is characteristic of mild labile hypertension, while nighttime BP is characteristic of mild stable hypertension. At night, systolic and diastolic blood pressure decrease insufficiently (nondipper). Episodes of hypotension were not registered.
X-ray of the chest organs No. 859 dated September 22, 2014: in the lungs without focal and infiltrative changes. The roots of the lungs are fibrously compacted, not expanded. Heart - aortic configuration due to the enlarged left ventricle. The aorta is enlarged and thickened.
Spirometry dated 09/25/2014: VFL within normal limits.
Spirometry (test with bronchodilator) from 09/25/2014: test with salbutamol: bronchodilation coefficient was 1.6%, which corresponds to the physiological variability of the bronchial lumen.
Fibrocolonoscopy dated 09/24/14: perianal skin is not changed. On digital examination, the tone of the rectal sphincter is normal. In the anus area, collapsed hemorrhoids and moderately tense internal hemorrhoids with inflamed mucosa above them are determined. The distal end of the fibrocolonoscope was inserted into the rectum, where 2 hyperplastic polyps on a wide base 0.3-0.4 cm in diameter were detected in the ampulla. At 15 cm in the upper ampullar part, a half-dip on a narrow base with a diameter of 0.5 cm. In the distal part of the sigmoid colon (23-25 cm), a polyp on a long stalk 2.0x2.5 cm (biopsy). In the descending colon - multiple (4) polyps on a narrow and wide base from 2 to 0.5 cm. In the region of the splenic angle, a polyp on a short stalk 1 cm (biopsy). Endoscopic electroexcision of polyps is recommended.
Conclusion: colon polyposis. Exacerbation of internal hemorrhoids.
Biopsy material (FCC dated September 24, 2014): in progress.
Recommended:
9. Observation by a therapist, gastroenterologist at a polyclinic at the place of residence.
10. consultation of a surgeon to resolve the issue of surgical intervention for intestinal polyposis.
11. taking the drug: rosuvastatin 10 mg, 1 tab. in the evening for a long time.
12. with an increase in blood pressure above 140/90 mm Hg. Art. taking capoten sublingually 25 mg.
September 26, 2014.
Form 12_Un.VmedA-2010 GT
MILITARY MEDICAL ACADEMY
CLINIC OF HOSPITAL THERAPY
St. Petersburg, st. Academician Lebedeva, d.6 lit. H
Discharge Statement No. 42260
has been hospitalized at the Clinic for Hospital Therapy of the Military Medical Academy since 06.09.17. on 09/21/17 with a diagnosis of
idiopathic fibrosing alveolitis, mural form. Metatuberculous changes in the lungs. Chronic subcompensated cor pulmonale. Respiratory failure II st.
GERD. Erosive reflux esophagitis. Erosive gastritis. Acute gastric (steroid erosion) bleeding from September 11, 2017. Acute severe post-hemorrhagic anemia.
Newly diagnosed diabetes mellitus (HbA1c 11.4%, target level <7.5%), diabetic ketosis from 09/06/2017, stopped on 09/08/2017.
Stage II hypertension, normotension during therapy, the risk of cardiovascular complications is "very high". Atherosclerotic cardiosclerosis. Chronic heart failure II A Art., 3 functional class.
Secondary nephropathy (hypertonic, atherosclerotic dysmetabolic) of mixed genesis of the only right kidney (nephrectomy of the left kidney in 2004). Chronic disease of the only right kidney C 3B (GFR 34 ml/min/1.73 m2).
Obesity 1 degree, alimentary-constitutional genesis.
Manipulations: catheterization of the central vein on the left 09/06-09/2017
catheterization of the central vein on the right 09/09/2017
transfusion of fresh frozen plasma (240+250 ml) 09/11/2017
transfusion of erythrocyte suspension (310+310+310 ml) on September 11, 2017; 280 ml (14.09.2017)
Category: individual agreement (citizen of the Republic of Belarus)
ICD code: [J 84.1 - 06.09.2017].
Discharged from the Military Medical Academy on September 20, 2017. A total of 15 days of treatment were carried out.
The final diagnosis was made on September 06, 2017. No certificate of
incapacity for work was issued . Ability to work was
not restored, observation / continued treatment / in a specialized pulmonology hospital was recommended
. Clinical outcome: improvement.
Medical history: The patient has a long history of hypertension (over 32 years). Since March 2017, he has been noted the appearance of an unmotivated unproductive cough and shortness of breath with moderate physical exertion. When seeking medical help, this condition was initially regarded as a reaction to taking ACE inhibitors, which were canceled without a positive effect. In the future, she noted an increase in shortness of breath, a decrease in tolerance to physical exertion and an increase in coughing to hacking. In the period from 03 to 14 August, she was in the clinic of GT VMedA, where idiopathic pulmonary fibrosis was verified. Chronic subcompensated cor pulmonale. DN 1-2 tbsp. After starting to take methylprednisolone at a dose of 30 mg/day, she noted an increase in exercise tolerance, complete relief of cough. Deterioration has been noted since the end of August 2017, when she noted the appearance of a rare cough, increased dyspnea to the level of rest, increased dryness in the mouth, the appearance of unmotivated thirst, a rapid increase in general weakness and fatigue. The above circumstances served as the basis for seeking medical help.
On admission September 06, 2017 complaints of severe general weakness (inability to stand), mixed dyspnea at rest, aggravated with minimal physical exertion, moderate cough with mucopurulent sputum of moderate volume, dry mouth and thirst, dry skin, periodic swelling of the legs to the lower thirds of the legs .
The general condition was regarded as severe, due to severe hyperglycemia (blood glucose 47 mmol/l, urinary ketosis, metabolic acidosis in arterial blood is compensated by respiratory alkalosis), severe hypoalbuminemia (23 g/l) and hypoproteinemia (46 g/l), severe hypoperfusion of peripheral tissues against the background of hypovolemia (CVP negative. BP with a tendency to hypotension 90-105 / 50-70 mm Hg, tachycardia up to 115 / min, signs of acute damage to a single kidney, oliguria), respiratory failure (RR 28-36 / min; SaO2 when breathing atmospheric air 86%, against the background of insufflation with an oxygen flow of 5 l / min 95%), expressed by general muscle weakness.
On the background of the therapy on September 11, vomiting with small flakes of hematin appeared, with FGDS, diapedetic bleeding from the surface of the mucosa and single small erosions of the stomach drew attention. Considering a significant decrease in hemoglobin to 60 g/l (including against the background of hemodilution due to active infusion therapy in the previous days in the treatment of hyperglycemia) and hypocoagulation, a single-group transfusion was performed [A2B (IV) Rh (-) neg. Kell (-) neg. dCĉēē] blood, plasma, albumin.
In the course of the treatment, stabilization of hemodynamics was achieved at the level of normotension, sinus normosystole, respiratory failure was subcompensated (when breathing atmospheric air → SaO2 95-98%), glycemia compensation (6.0-10.0 mmol/l), kidney function was compensated (diuresis adequate water load without additional stimulation), hypoperfusion and hypovolemia were stopped, the severity of general weakness was partially reduced. At the control CT scan of the lungs (on the arms) there are signs of subtotal damage by idiopathic fibrosing alveolitis.
Currently, he does not need further stay in the intensive care unit and intensive care unit. Further treatment under the supervision of a pulmonologist.
The patient is shown to continue GCS therapy in the amount of 4.5 tablets of methylprednisolone per day (in the morning, under the cover of antacids and secretolytics), oxygen therapy on an ongoing basis through a concentrator, breathing exercises with PEEP, nebulizer therapy (Berodual 10 drops, Ambroxol 20 drops, physical therapy). r 1 ml - 2 times a day), measures to normalize the nutritional status, support carbohydrate metabolism, and activate the patient. A further systematic reduction in the dose of metipred is possible in the regimen of 0.5 tablets per week. The use of efferent therapy methods is currently unlikely due to the high risk of bleeding, hypoalbuminemia. Examination by a pulmonologist in dynamics.
EXAMINATIONS: CBC
:
Date
HGB
HCT
RBC
WBS
PLT
P
S/I
E
L
M
ESR
myel
meta
06.09
144
0.400
5.35
12.2
82
08.09
122
0.357
4.33
7.9
83
1
85
1
8
5
16
11.09
60
0.178
2.13
8.1
76
6
82
5
6
9
12.09
84
0.236
2.89
8.6
84
6
79
9
2
6
1
3
13.09
72
0.212
2.59
10.4
129
1
74
6
4
3
1
4
16.09
85
0.245
3.02
12.9
125
18.09
103
0.299
3.62
13.1
101
1
90
4
4
6
_
_
_
_
_ .
Protein
pH
Lake.
Epithelium
Cylinders
Salts
Mucus
Bacteria
Mushrooms
06.09
St. yellow.
1.015
neg.
sour
0-1 in p/
z 2-2-4
-
-
-
07.09
light yellow
1.015
0.23
sour
7-8-9 in p / sp
4
4
2
08.09
light yellow
1020
0.13
acid.
6-3 in p/zr
Hyal.0-1
2
Biochemical blood tests:
Test name
06.09
09.09
11.09
12.09
15.09
17.09
Units of measurement
Glucose
27.93
12.2
11.25
8.4
6.24
5.14
mmol/l
Urea
25
15.9
22.5
12.8
mmol/l
Creatinine
133
92
132
76
µmol/l
Total protein
49
43
43
50.8
42
g/l
Albumins
23
27
33.8
35
g/l
A/G
1.16
1.71
17
4.8
Units
Globulins
2.1
16
1.99
7.3
g/l
Potassium
5.4
5.02
4.9
4.14
3.82
mmol/l
Sodium
131
128
135
135.4
mmol/l
Chlorine
107
110
mmol/l
bilirubin
20
Coagulogram
Name of test
08.09.17.
09/11/2017
09/12/2017
APTT, s
73.9
49
Prothrombin time, s
9.6
11
13
PTI, %
132
103
78
INR
0.85
0.97
1.15
Fibrinogen, g/l
4.68
3.7
2.73
ECG dated 09/06/2017: sinus tachycardia with a heart rate of 110 per minute. EOS is deflected to the left. Indirect signs of hypertrophy of both ventricles, right atrium. Diffuse disorders of repolarization.
Echo of CG from 09/06/2017: IVS=13mm, WS=10mm, LV=41/25, EF=69%, LA=44x46x48 mm, RA=52x56mm, RV=22mm, RV wall=5mm, SDLA =40 mm, LA=23 mm. Visualization is significantly difficult. Dilatation of both atria. Concentric hypertrophy of the LV myocardium. There are no zones of local disturbance of kinetics. The aorta, aortic and mitral fibrous rings are sealed. Regurgitation on MK and TK of 1 degree. Moderate increase in pressure in a small circle. The pericardium is not changed, there is no effusion. In the left sinus, accumulation of fluid up to the level of the 9th rib in the region of the sinus.
X-ray of the OGK 06.09.17. in direct and left lateral projections: lung fields of increased transparency without focal changes. Figure with large-mesh deformity due to pneumofibrosis more pronounced in the middle and lower sections. The diaphragm is raised and flattened. Free fluid in the pleural cavities is not determined. The roots are structural, not expanded. The heart is expanded in diameter to the left due to the left parts of the Aorta is sealed.
CT OGK - on hand.
Recommended
• Observation of a pulmonologist and endocrinologist with correction in the dynamics of therapy. rehabilitation activities.
• SaO2 control (>95%). With a decrease of less than 95%, oxygen therapy with an oxygen flow of 3-5 l / min is indicated, a mandatory consultation with a pulmonologist.
• Control of sugar levels before meals, glycated hemoglobin after 3 months.
• Active verticalization and expansion of the motor regimen
• Breathing exercises with positive PEEP 2 times a day
• ENT consultation in a planned manner
• Continue taking:
1. Rabeprazole 20 mg 1 r / day. in the morning
2. Almagel A - 1 tsp. 40 minutes before meals
3. Verapamil SR 240 mg 1 r / day. in the morning
4. Candesartan 16 mg ½ tab. in the evening
5. Long-acting insulin (Lantus) - 30 U subcutaneously at 22:00
6. Insulin of which action (Actrapid) subcutaneously before meals according to blood glucose level:
less than 6 mmol / l - do not do
6-8 mmol / l - 4 U
8-10 mmol / l - 6 U
10-12 mmol / l - 8
units 7. Ursoliv 250 mg 1 caps 3 times / day for 3 months
8. Nebulizer therapy (berodual 10 drops, ambroxol 20 drops, fisr-r 1 ml - 2 times a day)
9. Methylprednisolone 4 mg - 4.5 tab. 1 time / day, crush the tablets, drink with breakfast, drink jelly. Dose reduction by 0.5 tab. 1 time per week up to a maintenance dose of 2 tablets
10.
Veroshiron 25 mg - 2 tablets in
the
morning CM. KIROV
VMAB 0000 0000 5SPO
XVIII. DISCUSSION REPORT
Date: 07.11.2017 Time: 10:23
CASE HISTORY No.: 46354 ARCHIVE No.: 46354-2017
CAPACITY: Military service pensioners
STATED IN THE HOSPITAL TREATMENT IN: Hospital Therapy Clinic of the Military Medical Academy
From: 28.09.2017 TO: 07.11.2017 TOTAL DAYS OF TREATMENT: 40
FINAL DIAGNOSIS: Nosocomial recurrent bilateral congestive pneumonia in the lower lobes of both lungs, severe course (Klebsiella pneumonia, Acinetobacter baumanii, Acinetobacter baumanii, , Candida spp.). Diffuse endobronchitis. Respiratory failure 2→1 degree.
Stage III hypertension (arterial hypertension of the 2nd degree → high normal, the risk of cardiovascular complications is “very high”). Uncomplicated hypertensive crisis from September 28, 2017, was stopped by medication on September 28, 2017. Ischemic heart disease. Atherosclerosis of the aorta and coronary arteries, cerebral vessels. Atherosclerotic and postinfarction (AMI 2014, 2015) cardiosclerosis. Balloon angioplasty and stenting of the PMA and RCA from 2014, OA from 2015. Rhythm disturbances by the type of paroxysmal atrial fibrillation (EHRA-IIa, CHA2DS2VASc-4, HAS-BLED-2), outside paroxysm and conduction by the type of complete blockade of the right legs of the bundle of His.
Bronchial asthma of moderate severity, mixed genesis, hormone-dependent, stable course. Chronic obstructive pulmonary disease, predominantly emphysematous type, in remission. Gon's foci on the right. Compensated chronic pulmonary heart of mixed (bronchopulmonary, thoraco-diaphragmatic) genesis. Chronic heart failure stage IIA, 4 functional class. Small bilateral hydrothorax, hydropericardium. Cardiac fibrosis of the liver with protein-synthetic deficiency.
Secondary nephropathy of mixed (atherosclerotic, hypertensive, nephritic, dysmetabolic) genesis. Acute kidney injury from October 6, 2017. Stopped on October 8, 2017. Urinary tract infection (Klebsiella pneumonia, Enterobater cloacae, Candida spp). Diverticulosis, bladder formation. Conditions after subtotal resection of prostate adenoma. Prostate hyperplasia, bladder neck sclerosis, kidney cysts, bladder diverticulum. Functioning epicystostomy (02.08.2017). Forming bedsores of both heel areas.
Organic brain disease of dyscirculatory genesis with cognitive impairment and episodes of confusion.
Degenerative-dystrophic disease of the thoracic and lumbar spine. Spondylarthrosis. Osteochondrosis of the lumbar with L2-L5. Compression uncomplicated stable fracture of the L1 vertebral body (of unknown age) with pain and radicular syndromes. Chronic pancreatitis. OD - age-related cataract. OS - open-angle glaucoma. Artifakia.
Manipulations: Catheterization of the right subclavian vein 06.10.2017
Transfusion of albumin solution 200 ml 5% on 10/07/2017, 200 ml 20% on 10/23/2017; 100 ml 20% 25.10.2017 100 ml 20% 10/27/2017; 100 ml 20% 28.10.2017
Transfusion of fresh frozen plasma 600 ml on October 25, 2017; 980 ml 10/27/2017, 880 ml 10/30/2017
Puncture of the pleural cavity and evacuation of the effusion on the right 650 ml (10/31/2017), on the left 700 (11/01/2017)
ICD code: [I50 - 10/07/2017].
CLINICAL OUTCOME: Dropped out with chronicity (VMA SAINT PETERSBURG)
ON ADMISSION: From the anamnesis it is known that he considers himself ill since the age of 38, when he was first diagnosed with bronchial asthma, of mixed genesis, hormone-dependent, for which he currently uses the Symbicort inhaler - a total of 5 doses per day and polycortolone 2 mg / day.
For more than 5 years he has been suffering from hypertension, to control the level of blood pressure he constantly takes prestarium 5 mg / day.
Coronary heart disease debuted in 2014 with myocardial infarction. In the same year, balloon angioplasty and stenting of the posterior interventricular branch and the right coronary artery were performed (no medical documentation provided). In June 2015, “non-Q myocardial infarction in the lateral wall area” was diagnosed again, balloon angioplasty and stenting of the circumflex artery were performed. On July 30, 2017, a paroxysmal form of atrial fibrillation, ventricular extrasystole of the 5th grade, transient SA blockade of the 2nd degree was diagnosed, for which cordarone 200 mg per day was prescribed with a clear positive effect. Long-term chronic cystitis, prostate adenoma. On August 2, 2017, a suprapubic cystostomy was performed, so far urination through a catheter.
The reason for admission was the appearance on September 28, against the background of relative well-being, of severe headache without clear localization against the background of an increase in blood pressure to 170 and 100 mm Hg. Art., which was regarded as a "hypertensive crisis" and was the reason for hospitalization in the clinic of hospital therapy of the Military Medical Academy for urgent indications. Complaints at admission to severe weakness, fatigue, shortness of breath with little physical exertion, discomfort behind the sternum that occurs with little physical exertion, pain in the lumbar region, aggravated by a change in body position, dry cough.
Upon admission, the general condition was regarded as of moderate severity. BMI 22.9 kg/m2. Hypoproteinemic edema in the lower part of the body. Signs of a decrease in muscle mass and strength, which led to limited movement in bed. Hemodynamics is labile with fluctuations from 170/80 mm Hg. up to 95/60 mm Hg Pulse (a.radialis) uniform, rhythmic; frequency 60-74 per minute; filling is satisfactory; not tense; the vascular wall outside the pulse wave is not palpated; the apex beat is not palpable; pathological properties of the apex beat are not determined; pathological pulsations were not detected. The boundaries of relative cardiac dullness are expanded by 1.5 cm outward from the left mid-clavicular line; the boundaries of the vascular bundle are not displaced. Heart sounds are muffled, rhythmic, at the top there is a short systolic murmur. The shape of the chest is correct; respiratory movements of the chest are symmetrical; respiratory rate 15 per minute; the ratio of inhalation and exhalation: normal; no respiratory rhythm disturbances were found. Percussion in the symmetrical parts of the chest is determined by a clear pulmonary sound, dulled over the areas of the sinuses; auscultatory breathing is hard, weakened in the projection of dullness of percussion sound, a moderate amount of dry rales scattered throughout all fields of the lungs is heard. The tongue is moist, with a whitish coating. Abdomen of the usual form, painless; no peritoneal symptoms. The kidneys are not palpable; urinary catheter in the lower third of the abdomen along the white line. blunted over areas of sinuses; auscultatory breathing is hard, weakened in the projection of dullness of percussion sound, a moderate amount of dry rales scattered throughout all fields of the lungs is heard. The tongue is moist, with a whitish coating. Abdomen of the usual form, painless; no peritoneal symptoms. The kidneys are not palpable; urinary catheter in the lower third of the abdomen along the white line. blunted over areas of sinuses; auscultatory breathing is hard, weakened in the projection of dullness of percussion sound, a moderate amount of dry rales scattered throughout all fields of the lungs is heard. The tongue is moist, with a whitish coating. Abdomen of the usual form, painless; no peritoneal symptoms. The kidneys are not palpable; urinary catheter in the lower third of the abdomen along the white line.
EXAMINATIONS:
Results of instrumental studies:
ECG on September 28, 2017: Sinus rhythm with HR=67 beats/min. Sharp deviation of EOS <α=-60. Blockade of the anterior-superior branching of the LNPH. Blockade of the right leg of the bundle of His. Signs of hypertrophy of the right departments. Diffuse disorders of repolarization processes. It is impossible to exclude the presence of cicatricial changes in the lower wall.
ECG from 03, 06, 07, 09, 14, 20, 22, 25, 26-31.10.2017, 01-05.11.2017 - without significant dynamics.
Echo-KG 02.10.2017:
Index
Value
Index
Value
Left ventricle
IIV
1.7
cm
EDV (2D)
69
ml
WD
1.0
cm
EDV/ST
42
ml/m2
EC
5.2
cm
ED (2D)
25
ml
EC/St
3.2
cm/m2 EC
/St
15
ml/m2
EC/height
3.2
cm/m
EDV/MMLV
ml/g
WT
0.37
u.
LVML
280
g
VMVS
2.2
cm
LVMI (LVML/ST)
171
g/m2 VE
1.9
cm
LVML
/height
173
g/m FR
3.5
cm
LVML
/height2.7
76
g/m2 FU
function
33%
EF 61%
EF(2D) 63%
UV 44 ml
Right ventricle
EDR1 base(4s)
1.9
cm
Ex. Trakt1
3.6
cm
KDR2
avg(4s)
2.6
cm Tract2
3.4
cm
ERA3 length
7.3
cm
Left atrium LA LA
diameter
3.8
cm LA
volume
51
ml
LA volume/St
31
ml/m2
Right atrium RA
diameter (4C)
3.7
cm
IVC diameter
1.7
cm
Aorta and pulmonary artery
Aortic annulus
2.2 cm
Ascending Ao
3.0
cm
Aortic
arch
2.8
cm
Pulmonary
artery
1.5
cm
C.
Valsalva
3.3
cm
_
_
_
Ve/Va 1.4
Regurgitation 0-1
U/e' TC
Aortic valve
Vmax m/s 1.22
dP mmHg
Regurgitation 0
Pulmonary
Vmax m/s 1.2
dP mmHg
Regurgitation 1
Conclusion: Eccentric LV hypertrophy. Degree: sharp. Hypertrophy of the pancreas. Degree: insignificant. Dilatation of the right ventricle. Degree: insignificant. Focal changes in the heart were not detected. atherosclerosis of the aorta. The pericardium is without pathological changes. Degenerative changes in the aortic and mitral valves.
Daily monitoring of blood pressure from 10/11/2017: Average blood pressure during the day 132/69 mm Hg. Art., at night 128/69 mm Hg. Art.
Holter ECG monitoring on October 11, 2017: During the observation period, sinus rhythm was recorded with a heart rate of 45 to 69 per minute. Average heart rate (day/night) 55/50 per minute. The following rhythm and conduction disorders were registered: single ventricular extrasystoles (219 in total), single supraventricular extrasystoles (193 in total), paired supraventricular extrasystoles (3 in total). Ischemic infidelityniya of the ST segment is not revealed.
Ultrasound of the abdominal organs dated October 11, 2017: The liver is not enlarged, the right lobe is 12.8 cm, the left lobe is 6.8 cm * 6 cm, the echogenicity is not changed, the portal vein is 11.8 mm, the choledochus is 4.7 mm, intrahepatic passages are not expanded. The gallbladder was of regular shape, length 4.4 cm, diameter 3.3 cm, smooth contours, wall 2.23 mm, a hyperechoic heterogeneous formation with a diameter of 4.7 x 6 mm was located along the anterior wall. The pancreas is located clearly, not enlarged, the head, body, tail 25.6 mm, the contours are clear, uneven, the structure is heterogeneous, the echogenicity is increased. The spleen is not enlarged, length 9.5 cm, thickness 3.7 cm, homogeneous structure. The right kidney: length 10.2 cm, width 5.3 cm, parenchyma 17 mm, PCL not expanded, compacted, in the parenchyma in the middle third a cyst with a diameter of 26.5 x 28 mm is located, in the lower pole a cyst with a diameter of 38.4 x 32 mm. Left kidney: length 10 cm, width 4.9 cm, homogeneous parenchyma 14 mm, PCL not expanded, compacted, a cyst 27 mm in diameter is located in the middle third of the parenchyma. Conclusion: Gallbladder polyp? Violation of the rheology of bile. Diffuse changes in the pancreas. Consolidation of PCLS of both kidneys. Cysts of both kidneys.
Ultrasound of the pelvic organs dated October 06, 2017: Conclusion: Ultrasound - signs of chronic cystitis, bladder diverticula. Bladder formation? Condition after subtotal resection of prostate adenoma.
X-ray of the organs of the chest cavity on September 29, 2017: On the survey R-gram of the chest in the vertical position of the patient in the conditions of the ICU. The roots of the lungs are compacted, contain calcified lymph nodes of the bronchopulmonary group. In the lower individual of the right lung, an area of compaction of the lung tissue with fairly clear contours is determined. A small amount of fluid in the right pleural cavity is not excluded. The heart is horizontal. The aorta is sealed.
X-ray examination of the chest from 07.10.2017: On the plain chest X-ray in direct projection in intensive care, in the supine position, without holding the breath, a hypoventilation area is determined in the left lung in the upper sections; pulmonary pattern is enhanced. The roots of the lungs are structural, not expanded. The shadow of the mediastinum is shifted to the left, due to the left parts of the heart. The aorta is sealed. The dome of the diaphragm is even, clear on both sides. Sinuses: free on the right, impossible to assess on the left.
X-ray examination of the chest from 09.10.2017: On the survey R-gram of the chest in the position of the patient sitting on the bed in the conditions of the ICU against the background of diffuse pneumofibrosis, moderately pronounced phenomena of venous congestion are noted. No focal changes were found in the lungs. The roots are moderately compacted due to the vessels. In the pleural cavities an integral amount of fluid. The heart is located horizontally, moderately expanded in diameter to the left. The aorta is calcified.
X-ray examination of the chest from 10/23/2017: On the survey R-gram of the chest in the position of the patient lying in bed in the conditions of the ICU, congestion in the lungs increased. The amount of fluid in the pleural cavities increases with a tendency to encystation. Pneumonic infiltration in the lower parts of the lungs.
X-ray examination of the chest from 10/30/2017: On the control survey R-gram of the chest in the horizontal position of the patient in the conditions of the ICU without holding the breath, there is a pronounced negative trend with a significant increase in the amount of encapsulated fluid, especially on the right and subtotal infiltration of the right lung of an uneven nature, which does not exclude abscess formation . Pleural empyema?
X-ray examination of the chest from 11/01/2017: On the control survey R-gram of the chest in the horizontal position of the patient in the ICU without holding the breath after the evacuation of fluid from the pleural cavities, the lungs are straightened. The amount of fluid in the pleural cavities decreased to the level of the sinuses. Pleural bands are more pronounced on the right. Strengthening of the lung pattern due to the interstitial component.
Fibrobronchoscopy on 10/06/2017: Conclusion: endoscopic picture: 1) deformation of the lumen of the middle third of the trachea due to compression from the outside 2) Deformation of the right main bronchus and left bronchus due to compression from the outside along the medial wall. 3) Chronic diffuse deforming endobronchitis, exacerbation.
Fibrobronchoscopy on October 24, 2017: Conclusion: 1) endoscopic picture of deformation of the tracheal lumen in the middle third (compression from the outside); 2) deformation of the trachea and bronchi of II degree; 3) Deformation of the right main bronchus and the right bronchus due to compression from the outside along the medial wall. 4) Chronic diffuse deforming endobronchitis. Positive dynamics in comparison with the Study of 10/06/17 in the form of a decrease in the degree of mucosal hyperemia.
Fibrobronchoscopy on October 27, 2017: diffuse erosive endobronchitis. Manipulations: sanitation; irrigation of the mucosa with a solution of Colistin.
Radiography of the lumbar spine dated October 03, 2017: On spondylograms of the lumbar spine in 2 projections in the horizontal position of the patient in the intensive care unit, static disturbances in the form of straightening of the physiological lordosis and displacement of the L3 bodies posteriorly by 0.7 cm and L5 anteriorly by 0.9 cm (stair listez). Reducing the height of the body L1 with wedge-shaped deformation of it due to a compression fracture. Osteochondrosis L2-3, L3-4, L4-5 motor segments with symptoms of spondylosis. diffuse osteoporosis.
CT scan of the chest dated September 29, 2017: CT picture of interstitial changes in the lungs of a congestive nature. CT picture of interstitial changes in the lungs of a congestive nature. CT picture of COPD (emphysema, signs of bronchitis, pneumofibrotic changes). Gon's foci, calcified lymph nodes of the right bronchopulmonary group, calcifications along the pleura on the right - posttuberculous changes. A small amount of fluid in the pleural cavity and pericardial cavity. Degenerative-dystrophic changes in the thoracic spine, mixed replacement hydrocephalus.
CT scan of the chest dated October 31, 2017: CT picture of COPD (emphysema, signs of bronchitis, pneumofibrotic changes). Foci of Gon, metatuberculous changes in the lymph nodes of the mediastinum. Subsegmental atelectasis. CT picture of fluid in both pleural and pericardial cavities. Degenerative-dystrophic changes in the thoracic spine.
MRI of the brain dated October 12, 2017: MR signs of dyscirculatory encephalopathy
Results of laboratory tests:
Clinical blood test (hardware processing):
Date
Hemoglobin
Erythrocytes
Leukocytes
Platelets
n/
a s/a
Eosin.
Lymph.
Mon.
ESR
29.09.17
135
4.2
6.7
200
-
65
4
21
10
6
06.10.17
129
4.09
8.5
234
07.10.17
124
3.92
18.7
211
08.10.17
138
4.32
13.9
202
09.10.17
119
3.75
13.4
221
3
85
1
6
5
3
10.10.17
106
3.33
11.5
201
2
78
1
13
6
2
11.10.17
124
3.83
11.1
243
4
69
-
16
11
3
12.10.17
122
3.87
8.7
168
1
60
1
22
14
5
20.10.17
117
3.65
13.5
210
2
74
2
11
11
9
_
_
_
_ 5
195
10/21/17
110
3.43
9.5
195
10/22/17
120
3.80
13.4
224
10/23/17
115
3.67
9.9
205
10/24/17
101
3.19
8.0
163
9
71
5
10
5
7
10/25/17
104
3.38
9.3
164
10
56
2
27
4
5
_
_
_
_
_
_
_
_
_
_
10/27/17
125
3.93
11.1
185
6
66
2
18
8
4
10/28/17
101
3.23
9.3
164
10/29/17
113
3.69
10.4
197
31.10.17
89.3
2.9
7.9
126
4
72
18
6
9
01.11.17
101
3.21
7.4
130
2
76
16
5
6
02.11.17
95
3.06
4, 7
118
2
82
2
12
1
7
05.11.17
103
3.33
13.8
105
Urinalysis (hardware processing):
Date
Rel. Density
pH
Protein
Acetone
Glucose
Lake.
V
p
/ z
Er
Epithelium
Salts
Bacteria
Fungi
Cylinders
_
_
_
_
_
_
Neg
all
03.10.17
1.015
7.0
0.27
neg
neg
100
-
Single
Phosphates
4
10/09/17
1.006
5.0
0.08
neg
neg
10-12
1-2
oxalates
3
10/12/17
1015
7.0
0.09
neg
neg
70
1010
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
5.0
0.35
1.5
neg
15-20
2-3
4
4
hyaline
10/24/17
1.015
5.0
0.34
traces
neg
100
-
2-3
All p/sp
10/25/17
1.015
5.0
0.27
traces
neg
10-12
-
1-2
2
3
10/26/17
1.015
5.0
0.23
neg
12-14-16
not
from
1-2-1
oxalates
3
4
10/27/17
1.005
5.0
0.18
neg
neg
100
Fresh
unchanged
Means.
Quantity
4
4
10/28/17
1.005
5.0
traces
neg
neg
40-50
12-20
4-5
oxalates
2
4
10/31/17
1.015
5.0
0.25
neg
neg
9-10
7-8
single
completely
1
Hyaline
0-1
01.11.17
1.005
5.0
0.24
neg
neg
12-15
10-12
2-4
completely
02.11.17
1.015
8.5
0.16
traces
Neg
100
entirely
Biochemical blood test:
Norm
Unit
29.09
02.10
03.10
06.10
07.10
08.10
09.10
11.10
12.10
16.10
Total protein
64-83
g/l
45
40
49
44.7
43.4
44.9
Albumin
35-53
g/l
29.9
26.6
32.3
25.5
25.1
26.3
Cholesterol
3.7-5.0
mmol/ l
3.24
3.38
2.82
Triglycerides
0-1.7
mmol/l
0.63
HDL
0.78-2.3
mmol/l
1.02
LDL
1.9-4.4
mmol/l
1.93
VLDL
0.6-1.2
mmol/l
0.29
Glucose
4.2-6.2
mmol/l
4.95
7.4
7.5
8.1
4.3
4.34
Urea
2.4-6.4
mmol/l
2.1
7.1
7.4
8.9
6.3
5.8
Creatinine
53-123
umol/l
58
133
82
70.6
71.4
Bilirubin total
6.8-26
umol/l
14.3
18.5
16.4
18.5
Bilirubin e.g.
<5
umol/l
9.9
10.6
ALT
10-50
U/l
12.9
18.1
21
18
14.5
13.9
AST
11-50
U/l
30.9
37.4
48
42
10.7
23.8
LDH
120-246
U/l
520.7
CPK
10-160
U/l
51.77
42.1
CPK-MB
0.00-25.00
U/l
12.43
8.0
Alkaline phosphatase
30-120
U /l
113.7
125.5
Amylase
<100
U/l
46
D-Dimer
<500
Ng/ml
2994.92
TSH
0.34-5.60
ulU/ml
1.85
T3
2.50-3.90
Pg/mL
2.04
K
3.60-5.40
Mmol/l
4.26
4.06
4.12
4.0
Na
136-154
Mmol
/l
129.8
120.3
124.4
125.7
Ca++
2-3
Mmol/L
1.25
RW neg
neg
P-50 neg
neg
HbsAg
neg
neg
AntiHCV
neg
neg
Troponin
I
<0.01
ng/ml
<0.01
<0.01
<0.01
<0.01
Continued biochemical blood test
Norm
Unit
20.10
21.10
22.10
23.10
24.10
25.10
26.10
27.10
28.10
29.10
Total protein
64-83
g/l
43
41
38
38.7
37.5
40.6
37.5
40
47
Albumin
35-53
g/l
26.9
26.8
24.0
23.8
19.9
23.8
21.7
27.2
28.1
Cholesterol
3.7-5.0
mmol/l
2.64
1.51
1.77
Glucose
4.2-6.2
mmol/l
4.15
4.9
4.4
4 .4
5.97
Urea
2.4-6.4
mmol/l
2.6
1.7
2.0
3.1
2.9
3.9
3.3
Creatinine
53-123
umol/l
61.8
44
45
49
56
42
48
CPK
10-160
U/l
24.9
Bilirubin total.
6.8-26
umol/l
7.3
11.4
ALT
10-50
U/l
10
7.2
AST
11-50
U/l
25
17.3
K
3.60-5.40
Mmol/l
3.08
3.2
3 .5
3.57
3.5
Na
136-154
Mmol/l
124.5
128.7
132.4
127.7
133
Ca++
2-3
Mmol/l
2.09
Continued biochemical blood test
Norm
Unit
31.10
01.11
02.11
03.11
05.11
Total protein
64-83
g/l
40.2
39.7
50.4
50
Albumin
35-53
g/l
22, 5
21.8
27.5
Cholesterol
3.7-5.0
mmol/l
1.63
Glucose
4.2-6.2
mmol/l
4.28
5.3
Urea
2.4-6.4
mmol/l
3 .0
5.3
9.7
Creatinine
53-123
umol/l
53
60.8
48
CPK
10-160
U/l
Bilirubin total
6.8-26
umol/l
9.8
ALT
10-50
U/l
AST
11-50
U/l
K
3.60-5.40
Mmol/l
3.39
3.67
Na
136-154
Mmol/l
132.3
135, 3
Ca++
2-3
Mmol/l
2.05
2.24
Acid-base state of blood:
Date
Sample
pH
pCO2
pO2
BE
pO2/FiO2
Na
K
Ca
Cl
06.10
Arter.
7.48
34.3
73.8
2.0
3.51
110.6
2.88
0.56
74
07.10
Arter.
7.50
31.7
71.2
1.0
2.30
111.3
3.46
0.85
80
08.10
Venous.
7.42
40.2
37.8
1.5
113.4
3.29
0.84
77
09.10
_
7.42
37.4
51.3
-0.7
119.5
3.73
0.85
88
10.10
Venous.
7.46
29.4
48.7
-3.4
128.9
2.54
0.34
94
21.10
Venous.
7.41
39.2
49.8
-0.3
131.1
2.98
0.80
97
21.10
128.7
3.2
102
22.10
Venous.
7.42
35.0
55.7
-2.1
132.4
3.5
0.71
100
23.10
Arter.
7.41
37.1
92.5
-1.4
2.98
129.5
3.7
1.14
100
25.10
Venous.
7.41
39.3
50.5
0.0
128.4
2.88
0.70
96
26.10
Venous.
7.37
44.0
36.1
0.2
123.8
3.73
1.19
95
27.10
_
7.38
41.3
41.5
-0.9
122.7
3.02
0.92
92
28.10
_
7.42
44.1
40.6
4.0
126.4
2.6
1.08
93
29.10
_
7.36
38.4
42.4
-4.2
129.9
2.05
86
30.10
Venous.
7.46
45.1
43.8
7.8
128.4
2.66
0.86
90
31.10
Venous.
7.45
41.1
61.1
4.1
130.1
2.85
0.54
89
01.11
Venous.
7.38
52.5
51.3
5.9
133.2
2.72
0.68
92
02.11
Venous.
7.58
22.1
56.3
-1.3
133.9
2.66
0.42
99
02.11
Venous.
7.59
29.1
45.1
6.2
132.4
4.49
1.13
98
05.11
Venous.
7.41
45.7
48.9
4.2
3.81
0.93
99
Coagulogram
Date
APTT
PTI, %
INR
Fibrinogen, g/l
29.09
1.04
119
0.92
5.02
06.10
1.25
33
2.2
4.1
07.10
1.14
68
1.27
3.59
08.10
No coagulation
36
2.03
5.52
09.10
4.32
103
0.99
4.09
11.10
4.94
93
1.05
3.46
16.10
1.03
85
1, one
No
coagulation
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
34
2.03
3.68
27.10
60
1.33
5.35
28.10
1.62
64
1.32
3.4
02.11
1.37
58
1.4
2.7
03.11
1.7
75
1.19
2.51
05.11
2 ,2
56
1.4
1.9
C-reactive protein from 09.10.2017: 33.86 mg/l (norm 0-5.0 mg/l), from 11.10.2017: 11.45 mg/l (norm 0-5.0 mg /l), dated October 27, 2017: 96.37 mg/l (norm 0-5.0 mg/l); dated 02.11.17: 110.18 mg/l.
PSA from 10/11/2017: 0.05 ng/mL (norm 0.00-4.00).
Procalcitonin from 10/07/2017: 0.648 ng/ml (normal 0-0.1 ng/ml, more than 0.1 ng/ml - possible bacterial infection, more than 0.5 ng/ml - high risk of sepsis, from 10/23/2017: 0.074 ng/ml, dated October 26, 2017: 0.13 ng/ml
Proteinogram dated October 11, 2017: albumin 51.53% (norm 55.8-65), α-1 6.0% (norm 2.2 -4.6); α-2 14.06% (normal 8.2-12.5); β 11.85% (7.2-14.2); γ 16.56% (11.5-18 ,6).
Sputum culture results (received at FBS dated 06.10.2017): 1. Acinetobacter baumanii (sensitive to ampicillin, amikacin, gentamicin, levofloxacin, trimethoprim/sulfamethaxazole, cefepime, ciprofloxacin; intermediate to meronem); 2. Escherichia coli (sensitive to amikacin, intermediate to gentamicin, meronem); 3. Klebsiella pneumonia (resistance to all antibacterial drugs).
Sputum culture dated October 24, 2017 (received with FBS): 1. Klebsiella pneumonia; 2. Enterococcus faecalis. 3. Yeast-like fungi of the genus Candida. Supplement to culture: Klebsiella pneumonia produces carbapenemase: NDM metallo-betalactamase. It is sensitive to tetracycline, tigecycline, colistin, fosfomycin, to the bacteriophage Klebsiella polyvalent.
Urine culture results dated October 27, 2017: Klebsiella pneumonia (sensitive to amikacin, gentamicin, tobramycin; intermediate sensitivity to imipenem and meropenem). Addition: revealed the growth of Enterobater cloacae, sensitive to tigecycline.
The results of blood culture from 10/27/2017: growth of Staphylococcus epidermidis was obtained.
Biochemical examination of the pleural fluid (right pleural cavity) on 10/31/17: total protein 20 g/l, ALT 10 units/l.
Biochemical examination of the pleural fluid (left pleural cavity) on 10/31/17: total protein 21 g/l, ALT 7 U/l.
COURSE OF THE DISEASE IN THE CLINIC OF HOSPITAL THERAPY:
On the part of the main organs and systems (cardiovascular, respiratory systems), the patient was compensated during the first day, the therapy selected at the previous stages of treatment was adjusted within the framework of the underlying and concomitant diseases. Stabilization of hemodynamics was confirmed during daily monitoring of ECG and blood pressure. During the examination with ultrasound of the abdomen and small pelvis, a polyp of the gallbladder, a violation of the rheology of bile, diffuse changes in the pancreas, thickening of the CHLS and cysts of both kidneys, as well as signs of chronic cystitis, diverticulum (formation?) Of the bladder, condition after subtotal resection of the adenoma prostate. At the initial X-ray examination of signs of hydrothorax, infiltrative changes were not detected. However, CT revealed a picture of congestive interstitial changes in the lungs against the background of COPD (pulmonary emphysema, signs of bronchitis, pneumofibrotic changes). Gon's foci, calcified lymph nodes of the right bronchopulmonary group, calcifications along the pleura on the right - posttuberculous changes. A small amount of fluid in the pleural cavity and pericardial cavity. Degenerative-dystrophic changes in the thoracic spine, as well as mixed replacement hydrocephalus of the brain. In order to clarify the nature of changes in the spine due to pain vertebrogenic syndrome, an x-ray examination of the chest was performed, which revealed static disturbances in the form of straightening of physiological lordosis and displacement of the bodies L3 posteriorly by 0.7 cm and L5 anteriorly by 0.9 cm (staircase listhesis). Reducing the height of the body L1 with wedge-shaped deformation of it due to a compression fracture. Osteochondrosis L2-3, L3-4, L4-5 motor segments with symptoms of spondylosis. diffuse osteoporosis. In blood tests, the decrease in the level of protein, urea, and cholesterol was explained not only by alimentary reasons, but also by a decrease in catabolic processes.
From the moment of admission, the clinical picture was dominated by pain syndrome caused by vertebrogenic pathology (degenerative-dystrophic disease of the thoracic and lumbar spine. Spondylarthrosis. Osteochondrosis of the lumbar spine with L2-L5. Compression uncomplicated stable fracture of the L1 vertebral body (of unknown age) with pain and radicular syndromes) against the background of neurological deficit. Due to severe pain and radicular syndromes, the patient is constantly in a forced horizontal position on the back, which increases the risk of developing vicarious complications: congestive pneumonia, thromboembolic catastrophes, soft tissue necrosis, progression of constipation events. Consulted by a neurologist (“Acute lumbodynia, possibly of vertebral origin. Cerebrovascular disease. stage II encephalopathy with vertebrobasilar insufficiency and moderate cognitive impairment”) and an orthopedist. The ongoing therapeutic measures, according to the principle of reasonableness and sufficiency, were aimed not only at the secondary prevention of life-threatening precedents, but also at improving the quality of life. Flupirtine, a non-opioid centrally acting analgesic, is used as a symptomatic therapy for pain syndrome; it was decided to refrain from NSAIDs (taking into account the high risk of nephrotoxicity and bleeding). In addition, the patient was examined by the Chief Specialist of the Military Medical Academy for physical therapy, and a course of exercise therapy was started. but also improve the quality of life. Flupirtine, a non-opioid centrally acting analgesic, is used as a symptomatic therapy for pain syndrome; it was decided to refrain from NSAIDs (taking into account the high risk of nephrotoxicity and bleeding). In addition, the patient was examined by the Chief Specialist of the Military Medical Academy for physical therapy, and a course of exercise therapy was started. but also improve the quality of life. Flupirtine, a non-opioid centrally acting analgesic, is used as a symptomatic therapy for pain syndrome; it was decided to refrain from NSAIDs (taking into account the high risk of nephrotoxicity and bleeding). In addition, the patient was examined by the Chief Specialist of the Military Medical Academy for physical therapy, and a course of exercise therapy was started.
On October 06, 2017, during a planned round of the ward, attention was drawn to the patient's drowsiness, does not respond to sound and tactile stimuli, and reacts to pain impulses. Due to a sharp increase in neurological deficit, a high risk of developing hypostatic, aspiration pneumonia, the need for dynamic monitoring of vital functions, as well as in order to eliminate and prevent life-threatening conditions, the patient was transferred to the ICU.
In the ICU, a neurologist ruled out stroke, diagnosed Parkinson's syndrome, which was successfully compensated by PK-Merz injections, as well as congestive pneumonia in the basal parts of the lungs. Performed FBS (deformation of the lumen of the middle third of the trachea due to compression from the outside, deformation of the right main bronchus and left bronchus due to compression from the outside along the medial wall, chronic diffuse deforming endobronchitis, exacerbation). In view of the development of nosocomial pneumonia, an analysis of washing water was taken, in which a multidrug-resistant strain of Klebsiella pneumonia, Acinetobacter baumanii was identified (06.10.2017). Against the background of the treatment, by October 10, a moderate positive effect was achieved in the form of achieving the target indicators of the work of internal organs against the background of pronounced age-related dystrophic changes. In the course of bilateral congestive pneumonia, a significant positive trend was registered. Respiratory alkalosis was predominantly of central origin (deep breathing without tachypnea).
Senile lesions of the central nervous system and signs of sarcopenia with the development of muscle weakness and age-related dementia remained dominant in the picture of the disease. The patient was transferred to the cardiology department for comprehensive care, regular external monitoring of prescribed medications, prevention of bedsores and congestion (regular frequent changes in body position in bed, percussion massage, exercise therapy).
The course of the disease was characterized by a progressive increase in encephalopathy phenomena in the form of an organic brain disease of mixed genesis with severe cognitive impairment, hypoproteinemia and hypoalbuminemia, sarco- and dynamopenia, intoxication syndrome, which manifested itself in the formation of the day-night inversion (wakefulness between 15:00 and 04:00) and signs of dementia, an increase in the severity of general weakness, congestion in the basal parts of the lungs, the appearance of subfebrile fever, a tendency of hemodynamics to hypotension, decubitus heel areas (the appearance of cyanosis of the skin on 16.10, examined by a surgeon on 17.10 - “forming bedsores” were verified). As a symptomatic therapy, transfusion of two doses of albumin was performed. Changes in urine sediment were associated with the presence of an epicystostomy, the toilet of which was carried out daily. Despite the relative stability of the patient in general therapeutic terms, there were still high risks of life-threatening nosocomial complications. The combination of a high risk of developing life-threatening thromboembolism (PADUA scale = 7 points) and an equally low risk of bleeding (H. DECOSUS scale = 12.5 points) predetermined a personalized approach to antithrombotic therapy. Severe cognitive impairment prevented from conducting endoscopic studies. Taking into account the extremely high risk of falls (HENDRIK II = 6 points), an individual medical and nursing station was created, the patient was placed in the maximum allowable place from the alarm call button, the height of the bed was lowered to the minimum allowable level, and the construction of bed rails. During the entire hospitalization, both current and final disinfection was carried out. high risks of life-threatening nosocomial complications persisted. The combination of a high risk of developing life-threatening thromboembolism (PADUA scale = 7 points) and an equally low risk of bleeding (H. DECOSUS scale = 12.5 points) predetermined a personalized approach to antithrombotic therapy. Severe cognitive impairment prevented from conducting endoscopic studies. Taking into account the extremely high risk of falls (HENDRIK II = 6 points), an individual medical and nursing station was created, the patient was placed in the maximum allowable place from the alarm call button, the height of the bed was lowered to the minimum allowable level, and the construction of bed rails. During the entire hospitalization, both current and final disinfection was carried out. high risks of life-threatening nosocomial complications persisted. The combination of a high risk of developing life-threatening thromboembolism (PADUA scale = 7 points) and an equally low risk of bleeding (H. DECOSUS scale = 12.5 points) predetermined a personalized approach to antithrombotic therapy. Severe cognitive impairment prevented from conducting endoscopic studies. Taking into account the extremely high risk of falls (HENDRIK II = 6 points), an individual medical and nursing station was created, the patient was placed in the maximum allowable place from the alarm call button, the height of the bed was lowered to the minimum allowable level, and the construction of bed rails. During the entire hospitalization, both current and final disinfection was carried out. The combination of a high risk of developing life-threatening thromboembolism (PADUA scale = 7 points) and an equally low risk of bleeding (H. DECOSUS scale = 12.5 points) predetermined a personalized approach to antithrombotic therapy. Severe cognitive impairment prevented from conducting endoscopic studies. Taking into account the extremely high risk of falls (HENDRIK II = 6 points), an individual medical and nursing station was created, the patient was placed in the maximum allowable place from the alarm call button, the height of the bed was lowered to the minimum allowable level, and the construction of bed rails. During the entire hospitalization, both current and final disinfection was carried out. The combination of a high risk of developing life-threatening thromboembolism (PADUA scale = 7 points) and an equally low risk of bleeding (H. DECOSUS scale = 12.5 points) predetermined a personalized approach to antithrombotic therapy. Severe cognitive impairment prevented from conducting endoscopic studies. Taking into account the extremely high risk of falls (HENDRIK II = 6 points), an individual medical and nursing station was created, the patient was placed in the maximum allowable place from the alarm call button, the height of the bed was lowered to the minimum allowable level, and the construction of bed rails. During the entire hospitalization, both current and final disinfection was carried out. 5 points) predetermined a personalized approach to antithrombotic therapy. Severe cognitive impairment prevented from conducting endoscopic studies. Taking into account the extremely high risk of falls (HENDRIK II = 6 points), an individual medical and nursing station was created, the patient was placed in the maximum allowable place from the alarm call button, the height of the bed was lowered to the minimum allowable level, and the construction of bed rails. During the entire hospitalization, both current and final disinfection was carried out. 5 points) predetermined a personalized approach to antithrombotic therapy. Severe cognitive impairment prevented from conducting endoscopic studies. Taking into account the extremely high risk of falls (HENDRIK II = 6 points), an individual medical and nursing station was created, the patient was placed in the maximum allowable place from the alarm call button, the height of the bed was lowered to the minimum allowable level, and the construction of bed rails. During the entire hospitalization, both current and final disinfection was carried out. lowering the height of the bed to the minimum allowable level, the construction of bed sides. During the entire hospitalization, both current and final disinfection was carried out. lowering the height of the bed to the minimum allowable level, the construction of bed sides. During the entire hospitalization, both current and final disinfection was carried out.
However, despite the entire sector of medical and nursing activities, during a planned round of the ward, attention was paid to the increasing drowsiness of the patient, does not respond to sound and tactile stimuli, and reacts to pain impulses. Due to a sharp increase in neurological deficit, a high risk of developing hypostatic, aspiration pneumonia, the need for dynamic monitoring of vital functions, as well as in order to eliminate and prevent life-threatening conditions, on October 18, the patient was again transferred to the intensive care unit.
On admission to the ICU, the patient's condition was severe. Consciousness is depressed to the level of a deep stupor, contact with the patient is difficult. The severity of the condition is determined by the increasing phenomena of multiple organ (hepatic, cardiac, respiratory, cerebral), predominantly respiratory failure in a polymorbid elderly patient against the background of nosocomial pneumonia. The skin is pale, dry, hematomas at the injection sites, multiple subcutaneous hematomas of the extremities. Visible mucous membranes are clean, pale. In the heel region on both sides at the site of contact with the mattress, bedsores with a diameter of about 5 cm are formed. Peripheral lymph nodes are not enlarged. The musculoskeletal system with signs of severe sarcopenia. hypoproteinemic edema is formed on the lower surface of the body. Pulse 60 in 1 min, low filling and tension, rhythmic. The left border of the heart along the left mid-clavicular line. BP 95/65 mmHg Art. Heart sounds are muffled, rhythmic, systolic murmur at the apex of the heart of moderate intensity. Breathing is hard, weakened in the lower sections, there is also a moderate amount of congestive rales against the background of a moderate amount of dry rales over all fields of the lungs. Respiratory rate 22 in 1 min. SaO2 98% against the background of constant insufflation with humidified oxygen. The tongue is moist, covered with a whitish coating. The abdomen is soft, painless in all departments. The liver and spleen are not enlarged. Tapping on the lumbar region is painful on both sides, more on the right due to spinal disease. Urination through epicystostomy. Breathing is hard, weakened in the lower sections, there is also a moderate amount of congestive rales against the background of a moderate amount of dry rales over all fields of the lungs. Respiratory rate 22 in 1 min. SaO2 98% against the background of constant insufflation with humidified oxygen. The tongue is moist, covered with a whitish coating. The abdomen is soft, painless in all departments. The liver and spleen are not enlarged. Tapping on the lumbar region is painful on both sides, more on the right due to spinal disease. Urination through epicystostomy. Breathing is hard, weakened in the lower sections, there is also a moderate amount of congestive rales against the background of a moderate amount of dry rales over all fields of the lungs. Respiratory rate 22 in 1 min. SaO2 98% against the background of constant insufflation with humidified oxygen. The tongue is moist, covered with a whitish coating. The abdomen is soft, painless in all departments. The liver and spleen are not enlarged. Tapping on the lumbar region is painful on both sides, more on the right due to spinal disease. Urination through epicystostomy. the spleen is not enlarged. Tapping on the lumbar region is painful on both sides, more on the right due to spinal disease. Urination through epicystostomy. the spleen is not enlarged. Tapping on the lumbar region is painful on both sides, more on the right due to spinal disease. Urination through epicystostomy.
From the moment of admission, the condition steadily worsened - the phenomena of respiratory failure, general intoxication, hypoproteinemia and hemostasis disorders increased. In the washings of the bronchi, a multi-resistant strain of Klebsiella pneumonia, as well as Acinetobacter baumanii, Enterococcus faecalis, was sown, in the urine and lungs - candida albicans. Based on the initial culture, ceftaroline (sensitivity unknown) and levofloxacin (susceptible to Acinetobacter baumanii), as well as inhaled Colistin and Dioxidine, were prescribed. As an antimycotic therapy - fluoknazol 200 mg / day + bladder lavage.
It was determined that hypoproteinemia is of a mixed nature. The main contribution is made by severe protein-synthetic dysfunction of the liver (senile and infectious dystrophy and fibrosis in combination with cardiac fibrosis). In addition, there is a high protein catabolism (including gluconeogenesis) under conditions of an active immune response against the background of an infectious process, which leads to a rapid breakdown of the administered albumin / plasma proteins and progressive saturation of the interstitial space with fluid with an increase in hypoproteinemic edema. This forms the ineffectiveness of low-dose albumin replacement therapy and increases the concentration of drugs, including antibacterial and antimycotic agents in plasma. The use of antibacterial agents in the absence of adequate drainage of the final part of the tracheobronchial tree predetermines the extremely low effectiveness of antibiotic therapy and forms the resistance of the systemic edematous syndrome and congestive manifestations in the lungs. The frequent absence of coagulation according to the result of the coagulogram, the increase in subcutaneous hemorrhagic manifestations, along with severe hypoproteinemia (low levels of globulins, proteins of the coagulation system against the background of protein synthesis insufficiency of the liver) required correction of the hemostasis system. The drug of choice in this situation was determined to be fresh frozen plasma as a medium with a wide range of plasma proteins and the most suitable option for "prosthetics" of existing disorders. Additionally, albumin infusions were performed to replenish and normalize oncotic pressure,
In view of the persistence of fever, a control R-gram of the chest was performed on 10/23/2017. on which congestion in the lungs increased. Increased amount of fluid in the pleural cavities with a tendency to encystation. Pneumonic infiltration persists in the lower sections of the lungs. On October 24, 2017, the sanation-diagnostic bronchoscopy was repeated. Due to the ineffectiveness of antibiotic therapy, based on the culture data on the sensitivity of microorganisms to antibiotics, ceftaroline was replaced with linezolid, and amikacin was prescribed by inhalation.
After 3 days, despite the change in antibiotic therapy, fever persisted, indicating an active infectious process. As a result of inoculation of washing water, a multi-resistant strain of Klebsiella pneumonia was determined (produces metallo-beta-lactamase NMD) with sensitivity to polyvalent Klebsiella bacteriophage, fosfomycin, colistin, tetracycline, tigecycline. In view of the absence of fosfomycin and bacteriophage in the supply service and the pharmacy network of the academy, a decision was made to increase the dose of Colistin administered up to 4 times a day. Given the resistance of the flora to amikacin (according to culture), its toxicity, as well as the systemic toxicity of levofloxacin, it was decided to cancel the further use of these drugs. The doses of administered Colistin were increased up to 4 times a day with its additional intrabronchial administration during fibrobronchoscopy. Fosfomycin, linezolid, and human polyvalent immunoglobulin were retained as part of complex antibacterial therapy.
In addition, the fact of sowing yeast-like fungi of the genus Candida ssp. in sputum and in large quantities in urine (urine culture was taken with the determination of sensitivity to antimycotics) indicated the formation of systemic mycosis against the background of a systemic immunosuppressive state, and the detection of Candida ssp. after frequent flushing of the urinary tract with fluconazole, along with their systemic use at a dose of 200 mg / day, it was urgent to change the antimycotic drug and conduct systemic therapy. The loading dose of voriconazole was reduced due to both its toxic effects and low levels of albumin and renal excretory function (low creatinine is not a reflection of a high glomerular filtration rate, but a consequence of severe sarcopenia), which creates the prerequisites for a higher concentration of the drug in the blood.
The change in antibiotic therapy did not affect the course of the disease - in the next three days, fever and respiratory failure persisted, and a rapid decrease in the previously introduced protein was noted. which needed to be corrected.
As a result of sowing the washings, a strain of Klebsiella pneumonia (producing metallo-beta-lactamase NMD) was sown with sensitivity to the polyvalent Klebsiella bacteriophage, fosfomycin, colistin, tetracycline, tigecycline. Due to the ineffectiveness of the ongoing complex antibacterial therapy with all antibiotics available in the Medical Academy, a decision was made for vital indications, in view of the direct threat to the life of the patient, to ask the leadership of the academy to purchase tigecycline (the use of this drug in nosocomial pneumonia caused by carbapenemase-producing Klebsiella pneumonia is determined by the National Guidelines (Nosocomial pneumonia in adults: Russian national recommendations / under the editorship of B.R. Gelfand; editors-in-chief D.N. Protsenko, B.Z. Belotserkovsky - 2nd ed., revised and additional - Moscow: Medical Information Agency, 2016. - 176 p. [c. 133]).
During the X-ray examination of the chest on October 30, 2017. in the horizontal position of the patient in the conditions of the ICU without holding the breath, a pronounced negative trend was determined with a significant increase in the amount of encapsulated fluid, especially on the right, and subtotal infiltration of the right lung of an uneven nature, which does not exclude abscessing. Pleural empyema? A CT scan of the chest was performed immediately. Data for the presence of pleural empyema and abscessing pneumonia was not received. Bilateral middle hydrothorax with compression of the lower lobes of both lungs was revealed. The patient underwent evacuation of the pleural fluid.
Against the background of initiated therapy with tigecycline, the body temperature returned to normal in a day, the severity of respiratory failure decreased. Antibacterial therapy has been adjusted - it is represented by Tigecycline (Tygacil 50 mg 2 times a day), inhaled Colistin (4 million units / day) and Dioxidine (80 mg / day).
In the obtained analysis of urine culture on November 01, an increase in Klebsiella pneumonia was detected. It was stated that there were no convincing data for ongoing candidiasis of the urinary and respiratory tract, and voriconazole therapy was discontinued. Due to the low level of potassium, its correction was initiated by a constant infusion of a 4% solution through a dispenser.
Against the background of ongoing therapy, a positive trend has been noted to date in the form of normalization of the function of external respiration, central hemodynamics, stabilization of body temperature, and improvement in cognitive phenomena.
AT DISCHARGE: An
elderly patient with symptoms of multiple organ failure. Complex therapy is being carried out aimed at achieving a stable relief of inflammation in the urinary system and respiratory tract caused by Klebsiella pneumonia, Enterobater cloacae sensitive to tigecycline (the course of antibiotic therapy is completed). Active anti-decubitus measures made it possible to prevent the occurrence of new pressure sores, and the use of iodine-based preparations significantly improved the condition of pressure sores in the heel areas.
In blood tests, signs of respiratory alkalosis are determined, which is predominantly of central origin (deep breathing without tachypnea, episodes of the Kussmaul type). Most likely. this is a reflection of severe metabolic disorders of the microcirculation and the phenomena of renal failure. During sleep, the nature of breathing changes to Grokk, most likely due to severe atherosclerosis of the cerebral vessels. Therapy was prescribed to correct the identified disorders.
Senile lesions of the central nervous system, signs of sarcopenia with the development of muscle weakness and immobility, and age-related dementia remain dominant in the picture of the disease, which largely determines the development of complications.
The patient needs comprehensive care, regular external monitoring of prescribed medications, prevention of bedsores and congestion - regular frequent changes in body position in bed, percussion massage, exercise therapy
RECOMMENDED:
1. continue treatment in conditions of the possibility of providing auxiliary medical care and care.
2. Strict adherence to anti-decubitus measures !!!
3. Continue the course of selected therapy:
- Omeprazole 40 mg - intravenously in the morning
- PK-Merz 0.1 - 2 capsules in the morning and 1 capsule at 18:00
- Spironolactone 25 mg - 1 tablet 2 times a day
- Symbicort 160/45 mcg - 1 dose 2 times a day
- Linex - 2 capsules 3 times a day
- Through a nebulizer:
• Colistin 1 million units - 2 times a day for a week
• Dioxidin 2 ml (dilute 2 times with saline sodium chloride solution) 3 times a day
• Ambroxol 2 ml (dilute 2 times with saline sodium chloride solution) 2 times a day
- Dermazin ointment - treatment of the exit area of the urinary catheter
- Brownadin - treatment of the heel area 2 times a day
4. Daily toilet of the skin around the catheter with antiseptic solutions, change of aseptic sticker; heparin "lock" at the end of each infusion.
5. Control of the level of total protein, albumin, coagulogram 1 time in 3 days. Correction if necessary
FBU "442 DISTRICT MILITARY CLINICAL HOSPITAL ZVO" MO
RF
was on examination and treatment at 15 m / o 442 OVKG in the period from 26.10. on 02.11.2010 with a diagnosis of
Hypertensive disease of the second stage (Risk of CVE is high).
Ischemic heart disease: stable exertional angina first functional class. Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis. Dyslipoproteinemia type 2. Heart failure of the first stage, the first functional class.
Diffuse pneumofibrosis without signs of respiratory failure.
Dyscirculatory encephalopathy of the first stage of the mixed (atherosclerotic, hypertensive) type.
Gastroesophageal reflux disease without exacerbation. Chronic gastritis in remission.
He was hospitalized with complaints of headache, dizziness, shortness of breath and discomfort behind the sternum during physical exertion, episodes of sleep apnea.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
Lf, %
M, %
Gran. %
27.10
146
4.84
4.8
6
31.2
4.6
64.2
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
27.10
w. mut
>1030
yellow
sour
no
no
no
0
0
0
0
0
1-2
0-0-1
Biochemical blood test:
Name
Unit. rev.
27.10
Name
Unit rev.
27.10
Creatinine
mmol/l
94.21
TG
u
4.27
ALT
U/L
27
CS
mmol/l
5.23
AST
U/L
29
LDL
g/l
9.45
Glucose
mmol/l
5.8
HDL
mmol/l
0.77
CAT
times
5.8
Safety factors [HBsAg, Anti-HCV (Core-n NS3-p NS4-n; Core-n NS4 -p NS5-n), AT-HIV 1 and 2; Microreaction with cardiolipin antigen (RW)] from 27.10.2010. – negative
Results of instrumental studies:
ECG from. 27.10.10 .: sinus rhythm with a heart rate of 60 in 1 min. EOS is deflected to the left. Left ventricular hypertrophy.
FLG of the chest organs dated 10/27/2010. lungs expanded. Fresh focal and infiltrative changes were not revealed. The roots of the lungs are structural. The pulmonary pattern is enhanced in the basal sections due to the vascular and fibrous components. The shadow of the heart is expanded in diameter due to the left ventricle. The aorta is sealed.
Echo-CG from 26.10.10: Aortic root diameter 31mm, pulmonary artery 22mm, AK dilatation 20mm, LA 40x40x53mm, IVS 12mm, AP 11mm, LV EDR 48mm, LV ECR 26mm, EF 78%, FU 40%, PP 33x44mm, PZh 26mm. Hypertrophy of the myocardium of the left ventricle, hypokinesia of the apical-lateral segment. Dilatation of the left atrium. Calcifications in the annulus of the aortic valve. Type 1 LV diastolic dysfunction. Systolic function is normal. Cavities, pericardium free.
Esophagorastroduodenoscopy No. 851 dated October 28, 2010: esophagus: normal lumen, wall elasticity is not changed, peristalsis is normal, mucous membrane without pathological changes. Cardiac sphincter closes incompletely. Stomach: the sifting is not changed, the contents are normal, the wall is elastic, peristalsis is not changed, the mucosa in the antrum with focal atrophy and hyperemia of the mucosa. The gatekeeper is centric, gaping. The duodenum: the lumen is normal, the wall is not changed, peristalsis is normal. The mucosa of the postbulbar duodenum with focal point hyperemia, peristalsis is not changed. OBD is not visually changed. Bile is light. Conclusion: insufficiency of the cardia, gastroesophageal reflux, chronic gastritis, chronic proximal duodenitis.
VEM dated October 29, 2010. Conclusion: no ischemia was detected, hypertensive reaction to exercise.
Treatment: regimen, diet, antihypertensive, metabolic, hypocholesterolemic, antiplatelet therapy.
On the background of the therapy, the patient's condition improved. Discharged in a satisfactory condition.
Recommended:
225. Outpatient supervision of a therapist.
226. Dispensary observation:
a. clinical blood test, lipidogram, AST, ALT - twice a year;
b. Echocardiography - 1 time per year;
c. ECG - 1 time in 6 months
227. Continue taking:
a. Cardiomagnyl 75 mg - 1 tablet in the morning;
b. Ko-renitek - 1 tablet in the morning;
c. Concor-cor - 1 tablet in the morning;
d. Norvasc 5 mg - 1 tablet in the evening;
e. Crestor 10mg - 1 tablet in the evening
Federal State Institution "442 DISTRICT MILITARY CLINICAL HOSPITAL" of the Ministry of Defense of the Russian Federation
Discharge (transfer) epicrisis No. 7190
Rear Admiral of the reserve was examined and treated at 19 and 15 m / o 442 OVKG in the period from 28.06. on 07/04/2011 with a diagnosis of
coronary heart disease. Stable exertional angina 2 functional class. Atherosclerosis of the aorta and coronary arteries. Atherosclerotic cardiosclerosis complicated by the development of a complete atrioventricular block from 06/30/2011. Combined aortic valve disease with a predominance of stenosis (AC-1; AN 0-1) of sclerodegenerative genesis.
Hypertension stage II (AH-3; Risk-4).
Chronic heart failure III functional class, stage IIA.
Chronic obstructive pulmonary disease, predominantly bronchitis type, mild course without exacerbation. Diffuse pneumosclerosis. Emphysema of the lungs. DN 0-1 Parasternal lipoma of the right costophrenic sinus.
TsVB. Dyscirculatory encephalopathy of mixed (atherosclerotic, hypertensive) genesis stage 2.
Secondary nephropathy of mixed (atherosclerotic, hypertensive) genesis. Diffuse nephroangiosclerosis. Chronic kidney disease stage II (GFR 64.8 ml / min / 1.73 m2), without signs of renal failure.
Alimentary-constitutional obesity of the 2nd degree, stable course.
Solitary brush of the left lobe of the thyroid gland.
Hospitalized with complaints of moderate general weakness; shortness of breath when walking to the toilet.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Xia
%
Pya%
Gran.
%
28.06.
156
4.95
6.9
4
10
22
6
58
4
01.07.11
128
4.61
8.2
7
31.3
3.6
65.1
General clinical analysis of urine:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar, mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
28.06
sl.mut
1020
yellow
sour
no
no
no
0
0
0
0
0
1-2
0-0-1
Biochemical blood test:
Name
Unit. rev.
28.06
Name
Unit. rev.
28.06
Creatinine
mmol/l
TG
u
1.21
Urea
mol/l
5.3
Glucose
mmol/l
6.33
Total protein
g/l
69
cholesterol
mmol/l
5.34
ALT
U/L
26
CAT
times
3.0
AST
U/ L
29
Na
mmol/l.
135
LDH
U/L
128
K
mmol/l
3.4
CPK
U/L
0.6
Cl
mmol/l
94
Tot. Bilirubin
µmol/l
17
Prothromb.index
%
90.9
Uric acid
Mmol/l
0.39
Fibrinogen
g/l
5.78
Results of instrumental studies:
ECG from. 07/30/11: complete atrioventricular blockade of the 3rd degree, HR ~ 38 per minute. Complete blockade of the right leg of the bundle of His.
FLG of the chest organs dated 06/29/2011. Conclusion: chest organs without fresh focal and infiltrative changes. The upper sections of the lungs are emphysematous, in the basal sections the pulmonary pattern is enhanced due to the vascular and fibrous components. On the right, in the area of the costophrenic sinus, intense shading with clear, even contours is determined, most likely a parasternal lipoma. The shadow of the heart is expanded in diameter due to the left divisions. The aorta is thickened and dilated.
Echo-CG from 06/30/11: Aortic root diameter 33mm, pulmonary artery 24mm, dilatation of AK 12mm, LA 45x43x56mm, IVS 14mm, AP 14mm, LV EDR 60mm, LV ECR 39mm, EF 44%, FU 22%, PP 37*46mm, RV 37mm. The walls of the aorta are sealed, with calcifications. Aortic crescents with calcifications limiting their opening - aortic stenosis of the 1st degree, minimal aortic regurgitation. Calcifications in the mitral annulus, MR 1 degree. Hypertrophy of the left and right ventricles. The kinetics is not broken. Dilatation of the left heart and right ventricle. Minor pulmonary hypertension. Diastolic dysfunction of the rigid type. The pericardium is not changed.
Ultrasound of the abdominal cavity and thyroid gland from 30.06.11. Liver. Right lobe 18.6, left 12.0*9.0 Structure of uniform density, echogenicity diffusely changed. The gallbladder is not enlarged, the walls are even, thin. The cavity is free. The echogenicity of the pancreas is diffusely changed. The spleen is not enlarged. The kidneys are not enlarged. The cavity system is not expanded, there are no calculi. In the projection of the adrenal glands without features. The thyroid gland is not enlarged. Echostructure with areas of fibrosis. In the left lobe, the cyst is 0.5 mm.
Treatment: regimen, diet, aminophylline, atropine, enalapril, aspicor.
Against the background of the therapy, the patient's condition is without dynamics.
According to the recommendations of the ACC/ANA/HRS 2008, the patient has a class 1 (C) indication for implantation of a pacemaker [registered and documented during the present hospitalization of complete atrioventricular block with an HR<40/min in the awake state in the absence of symptoms, refractory to ongoing antiarrhythmic therapy, aimed at correcting heart rate].
Recommended:
228. hospitalization in the arrhythmology department for further diagnosis and treatment of the Federal State Institution “442 DISTRICT MILITARY
CLINICAL
HOSPITAL LenVO” of the RF Ministry of Defense
. was on examination and treatment at 15 m / o 442 OVKG in the period from 14.05. on May 31, 2010 with a diagnosis:
Reiter's syndrome with damage to the right ankle joint and II and III metatarsophalangeal joints of the left foot of the II degree of activity. Hemorrhagic vasculitis, cutaneous form. Hypertensive disease of the first stage (Risk of CVE is moderate) without signs of heart failure. Polyp of the gallbladder. Chronic gastritis in remission.
He was hospitalized with complaints of rashes on the skin of the legs (small petechial confluent rash), subfebrile condition in the evening, pain during movement in the ankle joints, headaches and general weakness.
Laboratory results:
General clinical blood test: Hb
date
, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
E
%
B
%
Lf
%
M
%
Xia
%
Pya%
Gran.
%
14.05
117
3.5
5.3
20
4
1
13
9
59
14
25.05
124
4.05
5.1
5
25.8
2.8
71.4
Clinical urinalysis:
Date
Transparency
Relative density
Color
pH
Protein, g/l
Sugar , mmol/l
Salts
Mucus
Acetone
M/o
MEP epithelium in p.z.
Cylinders
in r.z.
Leukocytes
in p.z.
Erythrocytes in p.z.
16.05
mud
1020
yellow
acid
0.15
no
no
0
0
0
0
0
1-2
0-0-1
In daily urine from 18.05.2010 protein was not detected
Biochemical analysis of blood:
Name
Unit. rev.
14.05
Name
Unit. rev.
14.05
Creatinine
mmol/l
106
TG
units
Urea
mol/l
5.9
Glucose
mmol/l
6.42
Total protein
g/l
75
cholesterol
mmol/l
3.87
ALT
U/L
21
CAT
times
AST
U/L
13
Na
mmol/l.
145
LDH
U/L
122
K
mmol/l
4.6
CPK
U/L
0.83
Cl
mmol/l
104
Tot. Bilirubin
µmol/l
14
Prothrombindex
%
100
Uric acid
Mmol/l
Fibrinogen
g/l
4.08
Sowing from the pharynx for flora dated 17.05.2010: Staphylococcus epidermidis, Staphylococcus viridans
Nasal swab for flora dated May 17, 2010: Small amount of Staphylococcus epidermidis
Results of instrumental studies:
ECG dated. 05/12/10 .: sinus rhythm with a heart rate of 60 in 1 min. EOS is horizontal.
FLG of the chest organs dated 14.05.2010. Conclusion: chest organs without visible pathological changes.
Echo-CG from 12.04.10: Aortic root diameter 33mm, pulmonary artery 20mm, dilatation of AC 19.1mm, LA 37x46x45mm, IVS 10mm, AP 8mm, LV EDR 53mm, LV ECR 35mm, EF 63%, FU 34%, PP 33*44mm, RV 25mm. Without dynamics with ECHO-KG from 04/09/2010. (see discharge summary).
Ultrasound of the abdominal cavity and thyroid gland from 17.05.10. Sick after eating Liver. Right lobe 14.6, left 9.0*7.0 Structure of uniform density, echogenicity is not changed. Gallbladder contracted (after eating). On the front wall there is a polyp 0.6 cm. The right kidney is 10.6x5.6 cm. The parenchyma is 2.8 cm. The left kidney is 11x5.6 cm in size. The parenchyma is up to 2.5 cm. The echogenicity of both kidneys is increased, the structure is homogeneous. PCLS with fibrosis. Ultrasound signs of toxic kidneys. The spleen is not enlarged 11x4.6 cm, the structure is homogeneous, echogenicity is not changed. The splenic vein is not changed. The prostate gland is not enlarged 3.6x2.8x3.4 cm (volume 21.6 cm3), the structure is homogeneous, echogenicity is not changed, there are no nodes. The thyroid gland is not enlarged: S=6.9 cm3, D=8.1 cm3 the structure of both lobes is homogeneous, there are no nodes. Echogenicity, blood flow are not changed.
Treatment: regimen, diet, nise, clexane, sulfasalazine, prednisolone, physiotherapy, acupuncture.
On the background of the therapy, the patient's condition improved. Discharged to the unit in a satisfactory condition.
Recommended:
229. Outpatient observation of therapists, rheumatologist.
230. Dispensary observation:
a. clinical blood test, urinalysis - twice a year;
b. Echocardiography - 1 time per year;
c. ECG - 1 time in 6 months
231. Continue taking:
a. Sulfasalazine 2.0/day
was examined and treated in the intensive care unit of the hospital therapy clinic
from June 14 to 15, 2010 with a diagnosis of:
IHD: large-focal inferolateral myocardial infarction dated May 28, 2010, AHF 1 according to T. Killip, CT 3, early postinfarction angina pectoris dated June 14, 2010. Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis.
Hypertensive disease of the third stage
The patient was admitted to the clinic with complaints of pressing pains behind the sternum, the intensity of which somewhat weakens when taking nitroglycerin.
From the anamnesis it is known that in the period from June 1 to June 3 he was in the city clinical hospital No. 71 in Moscow with a diagnosis of IHD: lower myocardial infarction dated 05.28. Atherosclerosis of the aorta and coronary arteries, atherosclerotic cardiosclerosis. Epistenocardic pericarditis. Hypertensive disease of the third stage. He was discharged ahead of schedule at his own request (on the 5th day of myocardial infarction). 06/14/2010 about 5 o'clock in the morning the pains described above arose. At 18:04 on 06/14/2010 called an ambulance, which at 19:30 was delivered to the hospital therapy clinic with a diagnosis of "unstable angina pectoris IIIC".
Upon admission, the condition was regarded as moderate, due to the instability of the coronary blood flow. Therapy was prescribed according to the scheme for the treatment of acute coronary syndrome.
Research results:
General clinical blood test:
Date
Hb, units.
Er., *1012/l
Leuk., *109/l
ESR, mm/h
Thrombus
*109/l
E
%
B
%
Lf
%
M
%
Pia
%
Xia
%
14.06
139
4.37
5.4
27
142
4
1
32
10
4
49
Troponin test at admission - negative
Biochemical blood test (according to cito):
Name
Unit. rev.
Norm
01.06
AST
U/l
up to 37
23
CPK
U/ml
24-195
100
CPK-MB
U/ml
up to 37
27
glucose
mmol/l
4.2-6.4
5.4
ECG from 14.06.2010 (at admission): sinus rhythm with HR=68 in 1 min., QII, III, avF, V6 Single supraventricular extrasystole
ECG from. 06/15/2010 (8:00 am): sinus rhythm with heart rate=68 in 1 min., no dynamics per day.
Treatment: regimen, diet, analgin with diphenhydramine, polarizing mixture, nitroglycerin, heparin, enalapril, aspicor, metoprolol, seduxen.
Convincing evidence for acute myocardial injury at admission was not received, a working diagnosis was made: "CHD: unstable angina III C".
Against the background of the therapy, the pain syndrome was stopped, the patient's condition improved.
With a joint bypass of the Acting Deputy Head of the Department for Clinical Work, Colonel of M / S, Head of the Resuscitation and Intensive Care Department, Professor, Senior Resident of the Therapeutic Department of the Hospital Therapy Clinic. the patient demanded a guarantee of his further transfer to the city rehabilitation center. The patient was explained that, given that he is in a military medical institution without a medical policy, registration at the place of residence, this issue needs to be clarified and this will be reported to him in the future after consultations with the clinical department of the academy after stabilization of his condition. However, the patient categorically refused further treatment due to the impossibility of guaranteeing him future transfer to a city rehabilitation center. Arguments about the severity of his condition, the need to continue further therapy had no effect - the patient said that "he does not change his mind" and categorically demanded that he be provided with discharge documents urgently. He categorically refused to write or sign anything.
ECG issued by hand.
Discharged to the clinic at the place of residence at his own request.
Be warned of the consequences.
A certificate of temporary incapacity for work was not issued
Recommended:
11. Hospitalization in the cardiology department for further treatment! If the patient refuses, follow-up by a cardiologist at the place of residence.
12. Bed rest. Expansion of the motor regimen and correction of the therapy carried out after the examination and at the decision of the cardiologist!
13. Optimization of the mode of work, rest, nutrition.
14. Continue taking:
• Enalapril 0.01 ½ tablet 2 times a day continuously
• Metoprolol 0.05 ½ tablet 2 times a day continuously
• Thrombo ACC 0.1 1 tab. 1 r / d after breakfast
• Mildronate 0.25 ½ capsule 2 r / d (after breakfast and lunch) - 2 weeks.
• Olikard 0.04 1 capsule in the morning.
• Heparin - 5000 IU 4 times a day subcutaneously under the control of coagulogram parameters.
15. For pain in the heart - nitroglycerin under the tongue.
.
June 15, 2010.