Case record No. XXX

First name, patronymic, and last name of a patient: XXX

Date of birth: XXX

Place of residence: XXX

Place of work: XXX

Date of admission: XXX

Date of discharge: XXX

Clinical Department: XXX

Predominant diagnoses:

Atherosclerotic heart disease (ICD code: I25.1).

Essential (primary) hypertension (ICD code: I10).

Discirculatory encephalopathy, 3rd stage (ICD code: 093.4).

Negative health outcomes of an acute cerebrovascular accident by ischemic type in the pool of the left medial cerebral artery in 1998, 1999, 2008.

Osteochondrosis of the spine in adults (ICD code: M42.1).

Anemia NOS (ICD code: D64.9).

Esophagitis (ICD code: K20).

Chronic gastritis (ICD code: K29.3).

Duodenal ulcer (ICD code: K26.7).

Erosive bulbitis.

Disease Peptic ulcer of the duodenal bulb, exacerbation (ICD code: K29.5).

Postcholecystectomy syndrome: biliary dependent pancreatitis (ICD code: K95.1).

Diverticulosis of the colon.

OU Presbyopia (ICD code: N52.4).

Initial cataract (ICD code: N25.0).

Retinal angiopathy ((stage 1), angiosclerosis (ICD code: 35.0 05).

Mild hyperopia (ICD code: N52.0).

Neuromuscular dysfunction of the bladder (ICD code: N31.9).

Examination by a neurologist

Diagnosis:

Discirculatory encephalopathy (stage 3) (ICD code: 093.4).

Negative health outcomes of an acute cerebrovascular accident in the pool by ischemic type of the left medial cerebral artery in 1998, 1999, 2008.

Osteochondrosis of the spine in adults (ICD code: M42.1).

Examination of the urologist

Diagnosis:

Neuromuscular dysfunction of the bladder (ICD code: N31.9).

Examination of the physician

Diagnosis:

Atherosclerotic heart disease (ICD code: I25.1).

Essential (primary) hypertension (ICD code: I10).

Gastroduodenitis NOS (ICD code: K29.3).

Anemia NOS (ICD code: D64.9).

Examination of the allergist

Diagnosis:

Herpetic infection NPH (ICD code: V00.9).

Allergy to iodine (noted in the past medical history) (ICD code: Z91.0).

Allergy to penicillin (noted in the past medical history) (ICD code: Z88.0).

Anemia NOS (ICD code: D64.9).

Examination of the gastroenterologist

Diagnosis:

Esophagitis (ICD code: K20).

Chronic gastritis (ICD code: K29.3).

Duodenal ulcer (ICD code: K26.7).

Erosive bulbitis.

Examination of the gastroenterologist

Diagnosis:

Peptic ulcer of the duodenal bulb, exacerbation (ICD code: K29.5).

Postcholecystectomy syndrome: biliary - dependent pancreatitis (ICD code: K95.1).

Diverticulosis of the colon.

Examination of the ophthalmologist

Diagnosis:

OU Presbyopia (ICD code: N52.4).

Initial cataract (ICD code: N25.0).

Retinal angiopathy (stage 1), angiosclerosis (ICD code: 35.0 05).

Mild hyperopia (ICD code: N52.0).

Clinical urinalysis

Glu: normal (mmol / L).

Uro: normal (mmol / L).

pH: 7.5.

WBC: negative (l / mkL).

Specific gravity: 1010.

Color: colorless.

Epithelium: a small amount.

Absolute WBC count: 2-4 per field of vision.

Red blood cells (unmodified): 1-2 per field of vision.

Mucus: a small amount.

Salt (amorphous phosphates): a small amount.

Biochemical blood assay

Total bilirubin: 11.4 mmol / L.

Glucose: 5.3 mmol / L.

Creatinine: 74 mmol / L.

Urea (UV): 6.7 mmol / L.

ALT: 27 U / L.

AST: 29 U / L.

ALP-AMP: 71 U / L.

g-GT-13 U / L.

immunochemiluminometric assay (Access)

TSH: 4.27 uIU / ml.

Free T4: 8.01 pmol / L.

Anti-thyroid peroxidase antibodies: 1.2 IU / ml.

Complete blood cell count

RBC: 3.36 × 10¹² / L (3.36).

Hematocrit: 32.4% (32.4).

Platelets: 297 × 109 / L.

WBC: 7.1 × 109 / L.

Hb: 110 g / L (110).

Segmentonuclear neutrophils: 54.8%.

Eosinophils: 3.3%.

Basophils: 0.7%.

Lymphocytes: 31%.

Monocytes: 10.2%.

Erythrocyte sedimentation rate: 15 mm / hour.

Urinalysis (method of Nechyporenko)

Glu: normal (mmol / L).

Uro: normal (mmol / L).

pH: 6.5.

WBC: negative (l / mkL).

Specific gravity: 1006.

Color: colorless.

Absolute WBC count: 1,250.

Absolute RBC count: 500.

HIV, hepatites and syphilis

Anti-HIV: negative.

HBs (antigen): negative.

Anti-HCV: negative.

Antibodies to Tr. pallidum: negative.

Cardiolipin antigen for reaction of microprecipitation: negative.

Biochemical blood assay

Iron (Ferrozine): 3.6 IU / ml (3.6).

Complete blood count

RBC: 3,48 × 1012 / L (3.48).

Hematocrit: 32.3% (32.3).

Platelets: 265 × 109 / L.

WBC: 7.3 × 109 / L.

Hb: 110 g / L (110).

Segmented neutrophils: 63.4%.

Eosinophils: 2.1%.

Basophils: 1%.

Lymphocytes: 25.1%.

Monocytes: 8.4%.

Erythrocyte sedimentation rate: 12 mm / hour.

Immunoassay

IgG: 816.

IgA: 121.

IgM: 97.4.

Electrocardiographic examination

Rhythmus: sinus rhythmus.

Heart rate: 60.

PQ Interval: 0.16.

QRS Interval: 0.08.

QT Interval: 0.4.

Semihorizontal position of the electrical heart axis.

Moderate changes (diffuse) in the myocard of the left ventricle.

Frequent, mostly paired, supraventricular extrasystoles.

Rheoencephalography

Pulse blood filling in the circulation system of A. carotis: upper normal limit (on both sides).

Pulse blood filling in the circulation system of A. vertebralis: significantly increased (on both sides).

Arterial tone of the distribution over a circulation system of A. carotis: left - the moderately reduced, the right - significantly reduced.

Arterial tone of the distribution over a circulation system of A. vertebralis: greatly reduced (on both sides).

Arterial tone of the resistance over a circulation system of A. carotis: normal (on both sides).

Arterial tone of the resistance over a circulation system of A. vertebralis: left - greatly reduced, the right - within normal range.

Asymmetry of the blood filling over a circulation system of A. carotis: within normal range.

Asymmetry of the blood filling over a circulation system of A. vertebralis: within normal range.

Venous outflow: It's not difficult.

Electroencephalogramm

General characteristics of the EEG at rest:

1. Alpha rhythm is irregular, at 10 - 11 Hz, amplitude up to 30 mV, recorded in separate groups of oscillations, zonal differences are flattened. Disorganization is noted by single theta-waves. Index of alpha-activity is decreased.

2. Activation reaction to afferent stimuli causes low amplitude alpha-activity, at photostimulation a clear perception was not observed.

3. Index of the beta-oscillations is increased, recorded in all the leads, amplitude up to 15 mV, the frequency is high and low.

4. During hyperventilation the amplitude characteristics of EEG and index an alpha-activity slightly increase.

CONCLUSION:

1. EEG-flat type, mild cerebral disorders of the brain activity (irritative nature) in the form of increase in the index of beta-oscillations.