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SAINT PETERSBURG STATE MEDICAL

ACADEMY NAMED AFTER


I. I. MECHINKOV
DEPARTMENT OF INTERNAL DISEASES

HEAD OF DEPARTMENT: DR.BOLIDEVA S.A


TEACHER: DR.BELYEVA E.L

CASE HISTORY

Patient Name : Valentina Emelyanovna


Natheesheena
Age :77 years
Diagnosis :
PRIMARY ARTERIAL HYPERTENSION
SEVERE DEGREE 3RD STAGE - RISK 4

Student:
Mathew Joseph
Group :
478

2010

PASSPORT PART

Surname and Name : Valentina Emelyanovna


Natheesheena

Age : 77 yrs

Sex : Female

Place of residence :Sofikelevskaya Street, SPB

Profession : Pensioner

Date of hospitalization : 22 April 2010

Type of hospitalization : Emergency


STATUS PRAESENS SUBJECTIVUS

COMPLAINTS

At the time of examination the patient was sitting on the bed


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

At the time of hospitalization the patient had high blood


pressure, headache, dyspnoea. Her hospitalization was
emergency type.

SUBJECTIVE STATE OF ORGANS AND SYSTEMS

A. Cardiovascular system

Pain in the chest region of pressing and tearing


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

B. Respiratory system

Breathing difficulty during physical exertion and during


increased BP. No other complaints of breathing difficulties,
wheezing, cough or hemoptysis. Absence of cyanosis.
Patient has clear voice.

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

D. Urinary system

Normal micturition of a clear colour. No complaints of


burning sensation or pain during micturition. Absence of
pain in the loin area.

E. Nervous system

Bad and interrupted sleep. Absence of strokes, epilepsy or


other neurological symptoms. Patient is well oriented to
time, space and person.

F. Skeletal and Muscular system

Normal musculature. Pain in large joints and pain in


vertebra due to osteochondrosis.
HISTORY OF PRESENT DISEASE
(ANAEMNESIS MORBI)

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

The first symptoms and progression of the disease:

The first signs of the disease was a rise of blood pressure


above 170/100mmHg. It was associated with weakness and
headache. After that from 2005 onwards the patient is
experiencing headache, pain in the heart area after an
increase in BP. Pain occurs sudden and dyspnoea occurs
during even small physical works. Edema was also present
during night time. Patient was undergoing therapeutically
treatment for the same. One year ago the patient had an
ischemic attack of the brain. Her mother died due to
hypertension. 30 years back 2/3 of her stomach was
recessected.

On 22nd April 2010 the patient had a sudden rise of BP


along with weakness, headache and dyspnoea and was
admitted to Hospital No. 122 at an emergency where she
underwent blood, biochemical and urine analysis as well as
ECG and , echocardiography.
At the time of examination, on 29th April:
Blood Pressure : 150/100 mmHg
Pulse : 78 beats per minute
Temperature : 36.6oC

ANAEMNESIS VITAE

1. General biographical information

Place of birth: St. Petersburg


The age at which patient began to walk and talk: Does not
remember but early
Physical and mental development in childhood: Same as for
a normal variant
Condition of life in childhood: Quite hard
The age at which patient entered school: 5 years
Education level: Secondary education

2. Occupational history

Profession: Gymnastics Trainer


Condition of work: Satisfactory but sometimes had stress
Professional hazards: Stress, over physical activities

3. Material and social conditions

Condition of life: Patient usually sleeps for 8 hours. She is


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

4. Past illnesses

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

5. Hereditary

Patient’s mother was diagnosed with arterial hypertension


and died due to that.
Patient’s father had hernia.

6. Habits

Smoking : occasional smoker


Alcohol : Doen’t use alcohol
Narcotics : Doesn’t use narcotics.

7. Allergic history

No known allergic history to drugs, foods or chemicals.

8. Epidemic history

No tuberculosis, hepatitis, jaundice, venereal disease,


malaria, diphtheria and HIV.
Has never received blood transfusion. Has not been to
another country for the last 10 years. Did not visit the
dentist for the last 6 months.
She had a decreased immunity according to records.
9. Insurance

She has medical insurance and is on the invalidity list.

STATUS PRAESENS OBJECTIVUS

General examination

-General condition : Satisfactory.


-Posture : Active (alert and
orientated).
-Consciousness : Clear.
-Constitutional type : Hypersthenic .
-Color of skin : Pale skin.
-Temperature : 36.6oC.
-Blood pressure : 150/100 mmH.g
-Pulse : 78 beats per
minute.
-Sweating : Normal.
-Gums and teeth : White teeth without
gingival recession.
-Tongue : Moist and pink.
-Eyes : No pathological
findings but wears
spectacles.
-Edema : Slight edema on
face and on
extremities.
-Skin : Elastic, Moist,
slightly decreased
turgor of skin,
brown pigmentations
present on the skin
-Nail : Shiny and pink in
color
-Hair : Soft and non-brittle
-Lymph nodes : Non palpable
-Mucosa : Pink
-Peripheral vessels : No pathological
findings
-Muscles : Muscular
development is
satisfactory,
no local atrophy of
muscles and no
weakness of
muscles
-Bones and joints : No deformations of
bones, joints

are of normal shape,


colour but
painful during
movements.

-Thyroid gland : Palpable, soft and


painless
STATUS OF OTHER ORGAN SYSTEMS

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

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

Percussion

Relative cardiac dullness:

Right border -1.0 cm laterally from the


th
sternal edge in the 4 right
Intercostal space.
rd
-3 right intercostal space next to the right
edge of
sternum.
Upper border -On the 2nd rib between the left parasternal
and sternal
line.
Left border -2.0 cm medially to the left anterior axillary
line in the 5th intercostal space.
-2.0 cm medially to the left anterior axillary
line in the 4th intercostal space.
-On the left midclavicular line in the 3rd
intercostal space.
Absolute cardiac dullness:

Right border -1 cm right to the edge of the sternum in the


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

Vascular bundle:

Along the edges of sternum left and right respectively with


transverse diameter 5 cm.

Conclusion:

Hypertrophy of the left ventricle.

Auscultation

At 1st point of auscultation: S1 louder than S2


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

-Accent of 2nd sound over aorta, no murmurs (systolic or


diastolic).
-Both sounds are decreased.
Respiratory system

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

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

Percussion

Topographic percussion:

Lower lung borders:


RIGHT LEFT
Parasternal line 6th rib Not
defined
Midclavicular line 6th rib Not
defined
th
Anterior axillary line 7 rib 7th rib
Middle axillary line 8th rib 9th rib
9th rib 9th rib
Scapular line 10th rib 10th rib
Paraspinal line Spinous process of the 11th
thoracic vertebra

Upper lung borders:


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

Conclusion:

Inspiratory dyspnoea when high BP.

Comparative Percussion:

No pathological findings.

Auscultation

-Patient has vesicular breathing without rales, crepitations


and pleural rub.

Digestive system

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

Palpation

-Left iliac, right iliac, left flank, right flank, left


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

Percussion

-Liver size according to Kurlov was 9 x 8 x 7 cm


-Spleen normal – 9th rib along midclavicular line.

Urinary system

-Kidneys are not palpable, pain free loin area.

Nervous system

-Complaints of sleep disturbances.


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

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

Her anaemnesis morbi shows a history of fluctuating


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

According to the patient’s complaints, anaemnesis morbi,


anaemnesis vitae and physical examination the preliminary
diagnosis is:

Primary Arterial Hypertension – Severe degree 3rd State with


Risk 4.

PLAN OF INVESTIGATION

1. Blood analysis – to check any disorders of blood which


could explain the increased blood pressure.
2. Biochemical analysis – to check the level of lipids,
proteins, enzymes of the liver, electrolytes and urea.
3. Urine analysis – to check the function of the kidney.
4. ECG – to check signs of hypertrophy, disorders of
rhythm and conduction.
5. Echocardiography with Doppler – to check the position
and motion of the heart walls, internal structures of the
heart. Doppler is done to check the flow blood to and
from heart.

LABORATORY RESULTS AND INTERPRETATIONS

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

Biochemical Test:

Bilirubin 12 µmol/L Normal.


ALAT 34unite/L (3-35) Normal.
ASAT 30unite/L (3-35) Normal.
Protein 76g/L (60-80) Normal.
Sugar 4.3mmol/l Normal.
Cholesterol 5.3mmol/L Normal.
Alpha Amylase 25mmol/L
Bil1urubin Direct 9mmol/l
Potassium 3.45(3.5-5) mmol/L
Calcium 2.35(2.12-2.65) mmol/L
Urea 6.5mmol/L
Creatine 90mmol/L.

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

Microalbuminuria 4.7 mg/l(N upto 20)

Echocardiography
Left heart border changing ,left ventricle hypertrophy .
Aorta is not enlarged.
General contractile ability of heart is normal.
right chambers without changes
general contractile activity normal

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

FINAL DIAGNOSIS

At the time of examination the patient had a slight


headache, weakness, dyspnoea when BP increases, edema
in face. Edema in lower extremities during night time. Had
disturbed sleep.

Her anamnesis morbi shows a history of fluctuating


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

The laboratory investigation of blood reveals


no signs of infection or inflammation. Glucose is normal and
as result no diabetes mellitus. Normal AST and ALT, so no
signs of heart failure. Urine analysis reveals that kidney
function is normal. Echocardiogram shows signs of left
ventricular hypertrophy. ECG results also reveals left
ventricular hypertrophy.
According to the patient’s complaints, anaemnesis morbi,
anaemnesis vitae, physical examination and laboratory
investigation the final diagnosis is:

PRIMARY ARTERIAL HYPERTENSION – SEVERE


DEGREE 3RD STAGE - RISK 4

DIFFERENTIAL DIAGNOSIS

The main reasons of the arterial hypertension should be


differentiated according to our patient’s signs and symptoms
with the signs and symptoms of the following diseases:

1.Thyrotoxicosis:

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

Distinguishing Features:
1. Exophthalmus
2. Some neurological symptoms
3. Increase body temperature
4. Weight loss

Though few clinical symptoms are similar most of


the signs and symptoms of thyrotoxicosis and those of our
patient differ and therefore a diagnosis of thyrotoxicosis for
our patient is not possible.
2. Cushing’s Syndrome:

A. The patient with Cushing’s syndrome will complain of


increased weight over the flanks, increased appetite,
weakness and feeling of thirst. Our patient did not have any
of the above complaints. He was asymptomatic.

B. Arterial hypertension develops in Cushing’s syndrome due


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

C.Inspection of the patient with Cushing’s syndrome shows


sign of moon face, truncal obesity, bruises on the skin and
purple abdominal striae. Our patient did not have such signs
during his examination.

D.Biochemical analysis of the patient with Cushing’s


syndrome will show a high level of cortisol in the blood. Our
patient was not tested for the level of cortisol in his blood.

The signs and symptoms of Cushing’s syndrome and


those of our patient differ widely and therefore a diagnosis of
Cushing’s syndrome for our patient is not possible.
TREATMENT
1. Diet

2. Bed Rest

3. Oxygen therapy

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

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

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

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

-Lifestyle modification – dietary management with less


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

Secondary Prophylaxis

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

April 29, 2010

-The patient did not have any active complaints.


-The patient’s condition was satisfactory overall.

• Cardiovascular system – edemas in lower extrimities,


no palpitation, no intermissions and slight dyspnea.
• Respiratory system – no cough, no pain during
breathing, no expectoration of sputum. Auscultation
revealed vesicular breathing.
• Digestive system – appetite is satisfactory, no vomiting,
no nausea, no heartburn, and no eructation. No pain in
abdomen, no flatulence. Character of stool is normal,
no constipation, no diarrhea. Palpation of the abdomen
revealed no pain, no tenderness, absence of large
formations, no rigidity and soft consistency.
• Urinary system – no edemas, no pain in lumbar region,
no disorders of urination. Urine color is normal.
• Nervous system – Subjective condition is good, no
epilepsy or other symptoms. Sleep was with
disturbances.

Blood pressure – 170/100 mmHg


Pulse rate – 78 bpm

3rd May, 2010

-The patient did not have any active complaints.


-The patient’s condition was satisfactory overall.
• Cardiovascular system – no edemas, no palpitation, no
intermissions and no dyspnea
• Respiratory system – no cough, no pain during
breathing, no expectoration of sputum. Auscultation
revealed vesicular breathing.
• Digestive system – appetite is good, no vomiting, no
nausea, no heartburn, and no eructation. No pain in
abdomen, no flatulence. Character of stool is normal,
no constipation, no diarrhea. Palpation of the abdomen
revealed no pain, no tenderness, absence of large
formations, no rigidity and soft consistency.
• Urinary system – no edemas, no pain in lumbar region,
no disorders of urination. Urine color is normal.
• Nervous system – Subjective condition is good, no
epilepsy or other symptoms. Sleep was without
disturbances.

Blood pressure – 170/100 mmHg


Pulse rate – 75 bpm

4th May, 2010

-The patient did not have any active complaints.


-The patient’s condition was satisfactory overall.

• Cardiovascular system – no edemas, no palpitation, no


intermissions and no dyspnea
• Respiratory system – no cough, no pain during
breathing, no expectoration of sputum. Auscultation
revealed vesicular breathing.
• Digestive system – appetite is good, no vomiting, no
nausea, no heartburn, and no eructation. No pain in
abdomen, no flatulence. Character of stool is normal,
no constipation, no diarrhea. Palpation of the abdomen
revealed no pain, no tenderness, absence of large
formations, no rigidity and soft consistency.
• Urinary system – no edemas, no pain in lumbar region,
no disorders of urination. Urine color is normal.
• Nervous system – Subjective condition is good, no
epilepsy or other symptoms. Sleep was without
disturbances.

Blood pressure – 160/90 mmHg


Pulse rate – 75 bpm

BP has decreased slightly.

Epicrysis:

Patient: Valentina Emelyanovna Natheesheena


Age : 77 yrs
Date of hospitalisation: 22nd April 2010.
Type of hospitalisation: Emergency

Main complaints:

i) at the time of hospitalisation:


She felt severe headache, weakness and dyspnoea
at a sudden increase of blood pressure.

ii) at the time of examination :


Weakness, headache and odema in lower
extremities .

At the time of examination the patient had a slight


headache, weakness, dyspnoea when BP increases, edema
in face. Edema in lower extremities during night time. Had
disturbed sleep.

Her anamnesis morbi shows a history of fluctuating


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

On percussion of his heart, the left border of the absolute


cardiac dullness was increased concluding left ventricular
hypertrophy.

The laboratory investigation of blood reveals no signs of


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

According to the patient’s complaints, anaemnesis morbi,


anaemnesis vitae, physical examination and laboratory
investigation the final diagnosis is:

PRIMARY ARTERIAL HYPERTENSION – SEVERE


DEGREE 3RD STAGE - RISK 4
.