643021042 unstable angina page 1

[cut-off text] OF HEALTH OF SARATOV REGION

[cut-off text] CARDIAC SURGERY CENTER

[cut-off text] Surgical Department No.2

[cut-off text] Krymskaya st, 15, tel./fax (845-2) 303220;

[cut-off text] mail: sarOKXC@mail.ru

[cut-off text] FROM THE MEDICAL RECORD NO. 4764

Full name: [redacted]

Age [redacted]

Address [Redacted]

Hospitalization period: from 16-Jan-2015 to 23-Jan-2015.

Main: coronary heart disease. Unstable angina of class IIb. Stabilized in the form of angina of functional class 2. Old myocardial infarction.

02-Jun-2014. Hypertensive heart disease, stage 3. Risk 4.

20-Jan-2015. Surgery. Transluminal balloon angioplasty and stenting of the coronary artery (left anterior descending artery stenting) with a stent Challenger 3 5x24, (BMS)

Background: obesity of class 1 (body mass index 33.6 kg/m2).

Complication: Chronic heart failure of class 2. functional class 3.

Related: Chronic gastritis, without exacerbation. Duodenal ulcer without exacerbation. chronic obstructive pulmonary disease, severe course, without exacerbation. Chronic cerebral ischemia of class 2 of mixed origin. Consequences of cerebral infarction in the territory of the left middle cerebral artery (2012) in the form of right-sided pyramidal insufficiency. Carotid atherosclerosis. Arteriosclerosis of vessels of the lower extremities.

Results of the examination on 16-Jan-2015: Platelet aggregation: Estimation of platelet aggregation: 6 sec.

16-Jan-2015 Standard biochemistry test procedure. C-reactive protein in blood serum: negative. Total protein: glucose: 6.10, albumin: 47.00, urea: 5.20, creatinine 86.00, cholesterol 4.80, total bilirubin 21.20, direct bilirubin: 5.30, aspartate transaminase (AST): 33.00, alanine transferase (ALT): 69.00, alkaline phosphatase: 165.00, triglycerides: 2.43, lactate dehydrogenase 432.00, high density lipoproteins: 0.90, low-density lipoproteins: 2.60, glomerular filtration rate: 86.00, very low density lipoproteins: 2.21; atherogenic factor: 4.20, creatine phosphokinase 111.00, creatine phosphokinase MB: 16.80; troponin: negative

16-Jan-2015 Blood type / Rh factor / Examination no.: 126.00; Rh factor: (+) positive. Blood group: 0 (I); phenotype: CCDeeCw(-)K(+)k(+)

16-Jan-2015 Coagulation: Prothrombin time: 13.70 Prothrombin index: 107.00; international normalized ratio: 0.91; activated partial thromboplastin time: 23.30; fibrinogen: 2.60; thrombin time: 17.30

16-Jan-2015 incomplete antibodies, incomplete Rh antibodies: not found; examination no.: 126.00

16-Jan-2015 Clinical blood analysis. Hemoglobin: 166.00; erythrocytes: 5.09; leukocytes 13.60; erythrocyte sedimentation rate 2.00; platelets 82.00; stab: segmented 6.00; lymphocytes: 27.00; monocytes: 6.00; basophils: eosinophils: 2.00; hypochromia: anisocytosis: poikilocytosis: hematocrit: 47.40

16-Jan-2015 Clinical urine analysis: color: light yellow; transparency: transparent; specific gravity: 1025; protein: glucose: acetone: bilirubin: urobilinogen: leukocytes 0-1; normal erythrocytes: abnormal erythrocytes: casts: epithelium: small quantity: mucus: bacteria: salts: fungi: pH 6.00

16-Jan-2015. Microprecipitation test: negative; examination number: 128.00

19-Jan-2015 Clinical blood analysis: hemoglobin: 158.00; erythrocytes: 4.81; leukocytes: 8.80; ESR: 5.00; platelets: 264.00; stab: 3.00 segmented: 59.00; lymphocytes: 31.00; monocytes: 6.00; basophils: eosinophils: 1.00; hypochromia: anisocytosis: poikilocytosis: hematocrit 45.10

16-Jan-2015 Activated partial thromboplastin time (APTT): 12-10: 22.00

16-Jan-2015. Activated partial thromboplastin time (APTT): 14-02: 49.00

17-Jan-2015. Activated partial thromboplastin time (APTT): 30.00

18-Jan-2015 Activated partial thromboplastin time (APTT): 26.00 19-Jan-2015 Activated partial thromboplastin time (APTT): 23.00

20-Jan-2015 Activated partial thromboplastin time (APTT): 20.00

21-Jan-2015 nitrogen metabolism: urea: 7.90; creatinine: 107.00

21-Jan-2015 Activated partial thromboplastin time (APTT): 26.00

22-Jan-2015 Activated partial thromboplastin time (APTT): 25.00

X-ray examination on 06-Dec-2014: Pulmonary fields in the upper segments are of increased transparency. Pulmonary pattern was not changed. Roots of the lungs are structured, of normal size. Diaphragm is in the normal position. Pleural sinuses are unobstructed. Cardiac shadow is extended to the left due to the arc of the left ventricle.

Electrocardiography on 16-Jan-2015: Sinus rhythm with a heart rate of 85 beats per minute. Electric cardiac axis is deflected to the. Anterior left bundle-branch block. Focal changes in the posterior wall of the left ventricle.

Echocardiography on 16-Jan-2015 During the examination, sinus rhythm was recorded. Left ventricle: end-diastolic dimension 56 mm (Teich), EDV 136 ml, end-systolic volume 63 mL (Simpson). Left atrium: end-systolic dimension 41 mm; end-systolic volume 68 mL. Right atrium: end-systolic dimension 36 mm. end-systolic volume 52 mL. Right ventricle: end-diastolic dimension 23 mm. Anterior wall of the right ventricle: 4 mm. Ascending aorta 38 mm. Moderate nonspecific degenerative changes in the walls of the aorta, aortic valve, fibrous structures of the heart: No significant dysfunction of the aortic valve was found. Mitral regurgitation, class 1. Tricuspid valve without abnormalities. Tricuspid regurgitation: physiological. The pulmonary artery is not expanded. Diastolic function of the left ventricle: disrupted with a relaxation type of disruption. This type of transmitral blood flow indicates a decline in the compliance of left ventricular myocardium with normal end-diastolic pressure in it. Left ventricular hypertrophy: small. Diastolic thickness of walls of the left ventricle: 1.3-1.0 mm. Left ventricular mass 230 g. Left ventricular mass index 106 g per m2 (according to two-dimensional method) Local contractility of the left ventricle is characterized by: akinesia with thinning of the bottom posterior segment, hypokinesia of the medium posterior segment. Global left ventricular contractility is slightly decreased. Left ventricular ejection fraction: 54 %. No pericardial effusions were found. Pulmonary hypertension: none. Pressure in the right ventricle (= mean pulmonary arterial pressure):  of 21 mm Hg. Inferior vena cava: of normal size, normally responds to respiratory phases.

CONCLUSION: Moderate nonspecific degenerative changes in the walls of the aorta, aortic valve, cusps and fibrous ring of the mitral valve. Small relative mitral regurgitation of class 1. Minor expansion of the left atrium cavity. Small hypertrophy of the left ventricle. Local left ventricular contractility is characterized with akinesia with thinning of the basal posterior segment, hypokinesia of the medium posterior segment. Global left ventricular contractility is slightly decreased. Ejection fraction: 54 %

Neurological diagnosis: Chronic cerebral ischemia of class 2 of mixed origin. Consequences of cerebral infarction in the territory of the left middle cerebral artery (2012) in the form of right-sided pyramidal insufficiency. Carotid atherosclerosis.