MUNICIPAL HEALTH CARE INSTITUTION

“PRIMORYE REGIONAL CLINICAL HOSPITAL NO.1”

CARDIO-SURGICAL DEPARTMENT

Case record of a patient No. 15431

Full name:                                                     

Date of birth: 06.03.1952

Social security number:

Insurance policy: Vostochniy-Strakhovoy Alliance. No.             Dated

Disability and a degree of an incapacity for work:

Category’s code of a payment reduction:

Social status: Middle class worker

Passport data:                               assigned by Department of Internal Affairs of Vladivostok city

Home address:                            Kalinina St., Vladivostok, Primorskiy Krai.

Home phone number: 8-4232-

Taxpayer Identification Number:

Patient was having an examination and taking treatment at cardio-surgical department from 20.11.2012 to 27.11.2012.

Complaints: burning pains on the front surface of the chest, which appear while simply walking on the level ground. The pains go away after taking nitrates. Also patient rare coughs with blood spots, experiences dizziness, common weakness.

Life history: Fracture of six ribs on the left side simultaneously as a result of a fall in 2006. Patient has been sick with psoriasis for the last 40 years. Osteochondrosis of the lumbar spine, taken from the patient’s word, compression of a sciatic nerve on the left side, palsy of the left foot. Tuberculosis, viral hepatitis, diabetes mellitus, ulcerous illnesses, STD’s are denied. Allergy anamnesis is not gravid. Doesn’t smoke. Insurance anamnesis – working.

Case history: ABP increase over the past 5 years (maximum ABP 240 and 100 millimeters of Mercury). The first sharp pain has appeared in 2008, lasted for 20 minutes and went away on its own. After that, the patient has noticed occasionally breast-pang pains while straining, the patient was not examined. Did not take hypertensive medicine properly. Patient has been receiving treatment in Primorye Clinical Regional Hospital No.1 from 17.03.2011 to 31.03.2011 in cardio-surgical department with a diagnosis of hypertensive disease third stage, risk stage four. Small ischemic (lacunar) insult in the posterior cerebral artery pool on the left side dated 14.03.2011. Atherosclerosis of the brachiocephalic arteries. Dyscirculatory encephalopathy 1-2 stage, subcompensation. Coronary heart disease: stable exertion angina. Aortal (ulterior) stenosis of the aorta. CHF 2AST. Cardioangiography was recommended. Patient did not follow the instructions. Deterioration during 2012, patient started to notice frequent severe pains inside the chest, started to cough with expectoration and blood spots, received therapist consultation, directed to cardiangiography. 15.11.2012 coronary arteriography result: Left Coronary Artery trunk – stenosis 85%; anterior interventricular branch – diffuse lesion with stricture formation 80%; circumflex branch – stenosis 70%, bifurcational stenosis with obtuse marginal artery – 90%; RCA – stenosis 99%. Surgical treatment is recommended – coronary artery bypass surgery.

Examination results:

Common state of the patient: satisfying. Clear state of mind, communicates with ease, active positioning, correct body form.

Musculoskeletal system without defections. Normal nutrition.

Subcutaneous fat – 2 cm, near belly, evident.

Color of the skin integument and perceptible mucous tissues: normal. Psoriatic plaques on elbows, butt cheeks. Paresis of the left foot.

Humidity of the skin integument and mucous tissues: normal. Peripheral lymph nodes cannot be felt. Chest form is correct. Each half takes part in breathing action.

Vesicular resonance: norm. Lungs’ breath is vesicular when auscultation appears. Respiration rate: 14 times per minute.

Borders of a heart are within the norm. Cardiac sound is rhythmic. Heart rate: 90 per minute, pulse: 90 beats/min, pulse deficit: beats/min.

Arterial pressure: 130/80 millimeters of Mercury. Tongue is moist. Belly is of the right shape, not increased due to the presence of a subcutaneous fat. When touched, it’s soft.

Liver is not increased. Usual constitution, examination by touch is painless. Lien cannot be examined by touch.

CVA Tenderness is negative on both sides.

Urinating problems are not noticed. Bowel and bladder habits are adequate.

Examinations

22.11.2012. General blood analysis (with formula)

ESR=23 mm/hr; leucocytes=7.2∙10⁹/liter (4-9); erythrocytes=5∙10¹²/liter (3.8-5); Hb=167 g/l (120-160); Ht=51 pg (25-40); platelets=237∙10⁹/liter (180-320); eosinophil=3 % (0.5-5); stab cells=3 % (1-6); microxyphil=53 % (47-72); lymphocytes=34 % (19-37); monocytes=7 % (3-11);

22.11.2012. Coagulation profile (expanded)

Ethanol gelation test=negative; Prothrombin ratio (PTI)=98% (85-105); Prothrombin time (PTT)=16.1 sec. (13-17); antithrombine (fibrinogen)=4.8 g/l (2-4); thrombin time=16.6 sec. (13-17); APTT, APPT=45.1 sec (28-40); SFC=4 mg/100 ml (0-4);

21.11.2012. Blood type analysis + Rh

Blood type=0 (I) [norm]; Rh blood group=Rh- [norm];

22.11.2012. Biochemical blood analysis (automatic)

Glucose=7.11 mmol/l (3.3-6); AST=23.9 u/l (0-38); ALT=31.8 u/l (0-41); bilirubin common=36.9 mcmol/l (0-25.7); bilirubin grouped=7.1 mol/l (0-5.2); cholesterol common=6.83 mmol/l (0-6.2); triglycerides=3.69 mmol/l (0.45-1.12); creatinine=100 mcmol/l (62-115); BUN=6.01 mmol/l (1.7-8.3); crude protein=77 g/l (65-85); alkaline phosphatase (ALP)=207 u/l (0-275); LDH=313 u/l (226-450); GGT=80.7 u/l (0-66); lithic acid=260 mcmol/l (200-415); Creatinphosphokinase=131 u/l (0-190).

21.11.2012. General urinal analysis

Specific weight=1015; Reaction=acidulous [norm]; protein=0.03 g/l; squamose epithelium=3-4; leucocytes=1-2;

Echocardiogram on site

Conclusion: Sinusoid rhythm (67 per minute). Left ventricular hypertrophy with dystrophic changes of myocardia.

Ultrasound sonography of the abdominal cavity organs

Date: 21.11.2012

Result: Liver: contours are even, sharp. Parenchyma is of an increased echogenicity, homogenious structure. Vascular pattern remains unchanged.

Sizes: Right lobe – 154 mm; left lobe – 95 mm;

Postcava – 18 mm; janatrix – 10 mm;

Gall bladder: sizes: 75x32 mm. Regular shape.

Paries – 2.8 mm; dense, not thickened. Homogeneous contents.

Concretion is not defined.

Choledoch duct – 5 mm. Bile ducts are not widened.

Pancreatic gland: contours are even, sharp.

Echogenicity: increased. Structure: homogeneous.

Sizes: head – 27 mm; body – 20 mm; tail – 23 mm.

Wirsung duct is not widened.

Lien: contours are even, sharp. Parenchyma is of usual echogenicity, homogeneous structure.

Sizes: 113x48 mm; S – 38 sq.cm. Splenic vein – 5 mm.

Conclusion decision: liver increase in size. Diffusive changes in liver and pancreatic gland.

Kidney ultrasound sonography

Date: 21.11.2012

Result: Kidneys: contours are even, sharp. Position: typical.

Mobility is retained.

Right kidney: 117x56 mm; parenchyma thickness 17 mm.

Left kidney: 120x55 mm; parenchyma thickness 17 mm.

Calices-pelvis system is not widened, has a usual echogenicity. Concretions are not found. Renal ducts are not widened.

21.11.2012. X-Ray study of the thoracic organs in 1 dimension:

Conclusion: any echograms or examinations as of 2010-2011 years are absent, but patient apparently have suffered a pleuropneumonia on the left side, combined with COPD. On the performed x-ray study of thoracic organs, while standing, pleuropneumonia on the left side is defined, with outcome into pleuro/pneumosclerosis; an “enclosed” sinus can be seen and pleuro/diaphragms clots on the left side. Lung fields are without evident nidal infiltration blackouts, with single sites of damage from pneumosclerosis, with moderate refinement and deformation of the lung image; middle lobe’s size on the right side is decreased (i.e. middle lobe syndrome on the right). Roots are not widened, slightly structured, dense, especially right root is deformed. Heart shadow is up to 16 cm; aortal arch sclerosis is evident. Cupulas of the diaphragm are located on the 6^th rib, with a straightening of a left hemidiaphragm and pleuro/diaphragm clots on the left side. If a labored breathing and cough are present, pulmonologist consultation is recommended and if needed – fiber-optic bronchoscopy and CT of thoracic organs – to exclude pathology of the bronchi middle lobe on the right side.

23.11.2012. CT of thoracic organs – to exclude the pathology of a bronchus’ middle lobe on the right side.

Result: examination of the thoracic organs is executed by a typical method of SPR 1,25x1,25 mm and in a HR mode. Pathological mass is forming on the right side as can be seen on the projection of a segmented bronchus B6, with general size up to 32 mm, with lumpy, asteriated contours. Lumen of the bronchus is conically narrowed with a full loss of differentiation, with a virtual fiber-optic bronchoscopy with signs of process expansion on the low lobar bronchus.  In segment S6, obstructive pulmonitis’ signs are seen on the right side. Site of damage structure on a broad foundation is visualized on a S3 segment, right side, with diameter up to 13 mm. Section of planar pneumosclerosis is at subpleural division on the left side of a S8 segment. Single bifurcational and bronchopulmonary groups are visualized on the right side up to 5-8 mm as interpleural space’s knots. Interpleural space organs – location, configuration, and sizes are within the age norm. Evident atherosclerosis of aorta and coronary arteries is present. There are no sweating in the pleural cavities. Bone elements are without signs of a pathological deformation.

Conclusion decision: malignant neoplasms. There is a Bl of the segmented bronchus B6 on the right side, with signs of process centralization. Pulmonitis is in S6 segment. Nidal structure is at S3 segment on the right.

23.11.2012. Pulmonologist consultation.

Examination: X-ray study (CT of the thoracic organs - malignant neoplasms. Bl of the segmented bronchus B6 on the right side with signs of process centralization. Histological verification is not possible, because fiber-optic bronchoscopy is contraindicated due to the systemic vascular resistance disease.

Diagnosis:

Recommendations: decision of a patient’s treatment with attending oncologist.

Doctor Buyakova E.D.

22.11.2012. Electrolytes

Electrolytes potassium (manually)=4.65 mmol/l (3-5); electrolytes sodium (manually)=140.8 mmol/l (130-150); electrolytes chlorine (manually)=108.7 % (95-110); Hbs Ag, HCV – negative from 16.11.2012

ENT specialist (22.11.12). ENT pathologies are not diagnosed.

Dentist (22.11.12). Treatment is required.

Urologist (22.11.12). Urology pathologies are not diagnosed.

Neurologist (23.11.12). CVD. Mixed encephalopathy (minor ischemic (lacunar) insult in posterior cerebral artery pool on the left dated 14.03.2012, discirculatory type, atherosclerotic). Atherosclerosis of brachiocephalic vessels.

Oncologist (26.11.12). Malignant neoplasms B6 on the right with occurrences of hypoventilation of S6 segment.

Surgical treatment is recommended with simultaneous surgical treatment of the systemic vascular resistance pathology.

Ultrasound sonography of the brachiocephalic vessels.

Full name: Lev Dmitrievitch Agapov   Age: 60 years

Cardio-surgical department

On the right side:

On the left side:

Description: Brachiocephalic trunk: diameter – 11 mm.

Normal arterial blood flow Vs – 85 cm/sec.