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Сервис дистанционной консультации врачей по Вашим снимкам

CENTRAL CLINICAL HOSPITAL OF CIVIL AVIATION. THE CARDIOLOGY DEPARTMENT.

Medical discharge report XXXXX
The name of the patient XXXXX
Date of birth XXXXX
Age XXXXX
Home address XXXXX
Date of admission — XXXXX
Date of discharge — XXXXX

Diagnosis:

Hypertensive disease III degree. The risk of developing cardiovascular complications 4. «Hypertensive heart». Paroxysmal form of atrial fibrillation. Ventricular premature beats. Circulatory failure 2A. Chronic heart failure 2nd functional class. Peptic ulcer of the duodenum.
Exogenous alimentary obesity 2nd degree. Dyslipidemia. Gout. Varicose veins of the extremities. Adenoma of the prostate. Adenocarcinoma, resection of sigmoid colon and rectum in 2012. Postoperative ventral hernia, surgical treatment in 2013.
Complaints:

interruptions in heart rhythm, shortness of breath when walking, increased blood pressure, recurrent pain in the left side of the chest.
Medical history: patient notes the increase of blood pressure for a long time. Maximum blood pressure was 260/100 mmHg. In 2010 patient was examined in the central clinical hospital of the President Administration of the Russian Federation and diagnosed hypertrophic cardiomyopathy. Diagnose based on ECG changes (formerly ECG changes were regarded as myocardial infarction).
In 201З year for the first time revealed the paroxysm of atrial fibrillation, a rhythm was restored after counter-shock therapy. The patient constantly took pradaxa 110g 2 times per day, lozap 50 mg twice a day, cordarone 200 mg 1 per day, amlodipine 2.5 mg, 20 mg Liprimar, akatinol 20 mg morning and evening.
The patient noted feeling unwell during 10 days, when the renewed rise of blood pressure up to 150/100 mmHg. Then the patient independently increased the dose of cordarone to 400 mg, once took propanorm 150 mg. After frequent interruptions in the heart rhythm 06.04.2016 the patient applied to the emergency department of CENTRAL CLINICAL HOSPITAL OF CIVIL AVIATION and was hospitalized in the intensive care unit. The therapy was carried out until the return of sinus rhythm on the EKG. After the patient was transferred to the cardiology unit for further evaluation and treatment.

Condition:

satisfactory condition of patient. The skin — normal color and clean. Pasty legs. Auscultation of the lungs: breathing is hard, without wheezing. The number of respiratory movements 16 times per minute. Heart tones are muted, with regular rhythm. Heart tones are muted, with regular rhythm. Heart murmurs are not auscultated. Heart rate is 60 per minute. Blood pressure is 150/100 mmHg. The abdomen is usual form and involved in the act of respiration. Auscultated peristalsis. On the midline of the abdomen is postoperative scar. During palpation abdomen is soft, painless. A liver on edge of a rib arch. Pasternatskiy-sign is negative.

Findings:

ECG: sinus Rhythm with heart rate of 54 beats/min (sinus bradycardia). Electric axis of the heart rejected the left. Slowing of atrioventricular conduction. Disturbance of intraventricular conduction. Changes of left ventricular myocardium in the apical-lateral, anterior-basal region of the left ventricle.
The echo-KG: the Aorta (N — 4-cm): 4.0 cm, thickened, sclerotic (fibrous).
The ascending aorta is 4.5 cm.
The divergence of the folds (N > 14 mm): 20mm, edge hardening.
Maximum pressure gradient on aortic valve (N up to 10 mm Hg): N. Regurgitation is not detected.
The left atrium (N-4.0 cm): 4.7 x 6.2 cm the Volume of the left atrium (N to 65 ml): 95 ml
Mitral valve: the seal of the fibrous annulus. Small calcification is in the grounds of the valves. Regurgitation: 1 degree.
Left ventricle: end-diastolic dimension (N to 5.7 cm) — 5.6 cm, end-systolic dimension (N to 4,0sm) — 3,5 cm, Ejection Fraction — 67%, myocardial contractile function is satisfactory.
Diastolic function: broken 1 type.
Ventricular septum (N to 1,2sm) — 1,7cm.
Left Ventricular Mass — 272 gr. The structure of the myocardium with increased echogenicity.

The right ventricle (N to 3.6 cm): 3.2 cm wall (N 0.5 cm) 0.3 Pulmonary artery (N up to 2.8 cm): N. Regurgitation: 0-1 degree. The pressure in the LA (N up to 30-36 mm Hg. calendar): N.
The right atrium (N 3.8×4.6 cm): 4.3 x 5.8 cm Tricuspid valve:
seal of the annulus. Regurgitation: 1 degree. Inferior Vena cava (N 2.5-2.7 cm): N

Conclusion:

Atherosclerosis of the aorta. Expansion of the ascending aorta. Dilatation of the left atrium and the right atrium. Myocardium hypertrophy of the left ventricle. Violation of diastolic function of the left ventricular myocardium — 1 type.

Daily monitoring of ECG:

Sinus rhythm with among heart rate 57 beats/min (minimum heart rate of 40 beats/min during sleep; maximum heart rate 107 beats/min). Recorded ventricular (3024 e/s/day, 1-436 e/s/h, including 12/323 e/s type bi/trigeminy) arrythmia (33 er/s/day,0-5 e/s/h), unstable inverted teeth T in l, aVL, V4-6.
Pathological displacement of ST segment is not registered.

Daily monitoring of blood pressure:
During the day was 42 check blood pressure. During wakefulness fluctuations blood pressure ranged from 129/62 mmHg to 176/88 mmHg. The maximum blood pressure amounted to 193/90 mmHg. Average blood pressure war 147/74 mmHg, heart rate war 58 beats/min. Hypertensive load of systolic blood pressure — 60%.
Night decrease of arterial pressure at 13-8%. The average blood pressure of 128/68 mmHg, Heart rate 54 beats/min. Hypertensive load 68-55%. Conclusion: Daily blood pressure profile corresponds to a soft arterial systolic hypertension.

Clinical [common] blood analysis

The white blood cells. The red blood cells. Hemoglobin. Hematocrit. Platelets.
8,2 4,14 129 36,9 187

Biochemical blood test:

glucose — 4.9mmol/l, creatinine.- 123umol/l, urea. 4.7mmol/l, uric acid 4,7mmol/l, alanine aminotransferase-26.1 iu/l, aspartate aminotransferase — 28.3 iu/l, lactate dehydrogenase 255u/l, Сreatine phosphokinase-57 iu/l and Сreatine phosphokinase МВ 13, triglycerides.- mmol/l, cholesterol.-3,83 mmol/l, potassium 4.12mmol/l
Urinalysis: specific gravity-1020, protein — not identified sugar-not identified, leukocytes — 1-23 in the field of view, erythrocytes were not identified
Сoagulogram — Activated partial thromboplastin time 48,5s, INR — 1,8% Quick-46,5% fibrinogen — 3,878 g/l.
HBsAg, aHCV — negative
Syphilis — negative
HIV — negative

Treatment:

pradaxa — 110 mg twice per day, losartan 50 mg twice per day, amlodipin 5 mg in the middle day, simvastatin 20 mg in the evening, bisoprolol 2,5 mg in the morgen.
Examination and treatment carried out in accordance with the standard of care for patients with hypertensive disease with heart failure code ICD 11.0 i, code of standard 69.080

Epicrisis:

The reason for hospitalization was increased blood pressure, increased shortness of breath and arrhythmias. On the background correction regimens achieved an optimal reduction of blood pressure during daily ECG monitoring was 3024 ventricular extrasystoles, but paroxysms of atrial fibrillation were not. In connection with the poor tolerability of the arrhythmia was recommended to cancel cordaron, but assigned to bisoprolol 2.5 mg with subsequent change of antiarrhythmic therapy (b-blocker in combination with carbamazepine 100-200 mg/day) in 3 weeks.
The patient’s condition before discharge improved. Decreased symptoms of heart failure such as shortness of breath, swelling, and blood pressure level is 130/80 mmHg. There are no negative dynamics on EKG. There was no complications associated with therapy and the survey.

Recommendations:

  1. The supervision of a cardiologist.
    2. Diet with limit animal fats and foods containing cholesterol, reducing the use of salt and liquid.
    3. Control of blood pressure.
    4. To continue taking: pradaxa 110 mg x 2 p\q, losartan 50 mg x 2 p/d, amlodipine 5 mg in the middle of the day, simvastatin 20 mg evening, bisoprolol 2.5 mg in the morning.

Date XXXXX
Head of cardiology unit XXXXX
Doctor XXXXX

 

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