Medicine is full of various specific terms and concepts that are clear only to the medical staff. An ordinary person simply cannot know all of them. Therefore, in this article I would like to talk about what a nursing case history is.

About the concept

First of all, you must definitely understand the terms that are dominant in this article. So what exactly is a nursing medical history? First of all, it is important medical document, which no one should forget (both the patient and the health worker himself). With regard to the main purpose, this document should fully reflect all five stages in relation to one patient.

About stages

As mentioned above, in order to correctly complete the nursing history, the health worker must go through five main stages with his patient.

1. about the patient and his state of health. The name of the patient, his age, gender will be indicated here. As well as data from examination, laboratory and instrumental studies (if any).
2. The next equally important stage is the formulation and definition of the main ones (of course, those related to health).
3. The third stage is the competent drawing up of a nursing intervention plan, which is based on the priority of the patient's problems. In doing so, the nurse should also set short-term and long-term goals.
4. The fourth stage: implementation of the plan both as prescribed by the doctor and independently (preparation for research, thermometry, etc.).
5. The most important stage: analysis of the patient's body reactions to nursing interventions. In this case, the criteria are both objective (normalization of body temperature, improvement of laboratory tests) and subjective indicators (normalization of sleep, reduction of pain).

Registration

It is worth saying that nursing (as well as another section of medicine, such as surgery or pediatrics) must be filled out according to all the rules. So, a nurse must comply with special requirements for the design of this document:

1. All lines should be filled in in a neat, even, readable handwriting.
2. It is imperative to strictly follow the form in which the nursing history is filled out.
3. The wording should be short and precise, the conclusions should be logical.
4. The information displayed in the nursing history should be as rich and complete as possible.
5. The document must be clean.

After the nursing history has been completed, this document is supported by a folder with other papers relating to a particular patient.

Example

In this article, I would also like to roughly consider what a nursing medical history may look like. So, it is worth saying that it is filled in according to the established form, often all the questions are printed, and the nurse only has to write down the answers to them. At the same time, the nurse must also draw up a plan for her own work, that is, special medical activities in relation to the individual patient. So, it can be a table of approximately the following format:

In each box, the nurse must fill in the details of what needs to be done and what has been done about the patient. The ultimate goal of this document is to compare the pre-set goals and the resulting nursing outcomes. It is worth saying that on the basis of these data, the patient's treatment by his doctor can even be adjusted.

The name of the medical institution: - GBUZ NSO BSMP No. 2

Receipt date: 12.04.13

Branch : cardiological

Full name (patient): G.N.M. Floor: Man

Age: 65 years

Permanent place residence: Novosibirsk city

Place of work, profession, position: retiree

Emergency telephone number: there is

Directed by: polyclinic at the place of residence

Clinical diagnosis: Essential hypertension 3 stage 2 degrees, ischemic heart disease, Hypertensive retinopathy, obesity 2 degrees, proteinuria.

The development of a real disease (when he fell ill, what it associates with, how often it aggravates, how it is treated, what it associates with an exacerbation at the present time):

Considers himself sick for 10 years, notes episodic headaches, heaviness in the back of the head, temples, especially in the morning, dizziness; constricting pains in the chest and in the region of the heart, which are stopped at rest or after taking 1-2 tablets of nitroglycerin. Almost all the time, during the last two years, flashes of flies before the eyes. Repeatedly he entered the emergency department with hypertensive crises, from where, after improving his condition, he left on his own, without finishing treatment. He took Papazol, No-shpu, Nitroglycerin, was treated with herbs, dietary supplements. A year ago, my feeling worsened, crises became more frequent. In this regard, the patient consulted a therapist and was hospitalized.

Intolerance to drugs, food, etc .: denies

Past diseases: Botkin's disease, tuberculosis, venereal diseases, diabetes, injuries, operations, others:

Among the transferred diseases, he notes frequent acute respiratory diseases.

Patient complaints at the time of examination:

Intense headache, heaviness in the occiput, constricting pains in the chest and in the heart, feeling short of breath, dizziness, flickering of flies before the eyes, weakness.

NURSING DIAGNOSIS

• 1. The patient's real problems :
• 1.1. Priority
• 1. Intense headache in the occipital and temporal regions;
• 2. Dyspnea of ​​inspiratory nature
• 3. High blood pressure
• 4. Compressive pain behind the breastbone
• 5. Dizziness
• 1.2. Secondary problems
• 1. Nausea;
• 2. Interrupted sleep;
• 3. Decreased appetite;
• 4. Lack of rational nutrition skills;
• 5. Increased sweating;
• 6. Fear for your health, worry about the future;
• 2. Potential problems :
• 1. High risk of stroke;
• 2. Hypertensive crisis;
• 3. Myocardial infarction;
• 4. Diseases of the respiratory system due to smoking;
• 5. Diseases of the cardiovascular system due to obesity.

PRIORITY NURSING INTERVENTION PLAN

Problem: Intense headache in the occipital and temporal regions

Purpose of nursing intervention:

Short-term goal: The patient will notice a decrease in the intensity of the headache within a few hours of the hospital stay;

Long term goal: The patient will not complain about headache by the time of discharge from the hospital.

Dependent nursing interventions:

• 1. Reserpine. Inside 0.10 mg. 1 r / day.
• 2. Vincaton. Inside 0.01 g. 2 rubles / day.

Interdependent interventions:

• 1. General analysis blood;
• 2. General urine analysis;
• 3. MRI of the brain.

Independent nursing interventions:

The nurse will provide:

• 1. medical and protective regime;
• 2. access to fresh air;
• 3. bed comfort with a raised head end of the bed;
• 4. apply distractions: a cold compress on the forehead, mustard plasters on the calf muscles;
• 5. timely fulfillment of all doctor's prescriptions;
• 6. give an anesthetic as directed by a doctor;
• 7. Leisure of the patient after recovery from an acute condition;
• 8. preparation for additional survey methods;
• 9. The nurse will talk with relatives and roommates about the need to avoid tiresome conversations;
• 10. The nurse will explain to the patient the essence of his illness, talk about modern methods diagnosis, treatment and prevention.

The goal is achieved:

• - The patient noted a decrease in the intensity of headache by the end of 1 day of hospital stay;
• - The patient had no complaints of headache at the time of discharge from the hospital;

DYNAMICS OF DEVELOPMENT OF PATIENT'S PROBLEMS

Female students Ulyanenko Natalia

Speciality Nursing

Well 2Group 03051384

Name of LPU- MBUZ "City clinical Hospital No. 1 "

Branch- therapeutic chamber - 4

Mode of transportation: can go

1. Surname, name, patronymic of the patient: Ivlev Dmitry Konstantinovich

2. Gender: male 3. Age 50 years (04.10.1964)

4. Permanent residence: Belgorod Region, Belgorod, Koneva Street, 12, Apt. 4.

5. Place of work, position: FE "Blagovest", accountant

6. Who sent the patient: MSCh

7. Medical diagnosis: Atherosclerosis of the thoracic aorta

2.3. The first stage of the nursing process - SURVEY

SUBJECTIVE SURVEY

1. The patient's current complaints about pressing and burning pains in the chest, as well as wheezing in the throat.

2. Since when does he consider himself sick: He considers himself ill for 3 years.

3.What is it associated with the disease: Associates with stress and poor diet.

4. Last deterioration: last 5 days.

5. Postponed diseases, operations: absent.

6. Risk factors:

allergic anamnesis: not weighed down

heredity: not weighed down

smoking: YES, NO;

alcohol: YES (in moderation, redundant), NO;

drugs: YES, NO;

hypodynamia: YES,NO;

obesity: YES,NO;

frequent stressful situations: in the family and at work;

occupational hazards: absent.

7. Meals:

appetite: increased;

adherence to the diet: YES, NO;

the diet is dominated by food: spicy, fatty, fried, meat;

daily fluid intake: 1.5 l

8. Is able to independently:

eat;

use the toilet;

wash your face;

move;

dress;

communicate.

9. Life Support Resources:

underestimates the severity of the condition;

attitude to religion: YES, NO;

family support: YES, NO;

support of the patient outside the family: YES, NO.

OBJECTIVE SURVEY

1. Consciousness:clear, upset, absent.

2. Position in bed:active, passive, forced.

3. The state of severity of the patient: satisfactory, moderate,

heavy, extreme severity.

4. Condition of the skin and mucous membranes:humidity, dryness

color: pallor;

defects: none

swelling: absent.

5. Musculoskeletal system

joint function: saved.

6. Body temperature:36,8 .

7. Height:168 .

8. Weight: 89 .

9. Chest circumference: on inhalation ______, on exhalation ______,

chest excursion _______.

10. Respiratory system:

NPV: 18 per minute;

breathing type: abdominal;

breathing depth: superficial;

breathing rhythm: rhythmic;

the nature of shortness of breath: mixed.

11. The cardiovascular system:

pulse: frequency 68 bpm;

rhythm: rhythmic;

voltage: moderate;

filling: full;

magnitude: big;

HELL: 135/105 mm Hg. st.

12. Gastrointestinal tract:

condition of teeth: caries;

removable dentures: YES, NO;

tongue coated: YES, NO;

smell from the mouth: YES, NO;

the nature of the vomit: absent;

the presence and nature of the chair: constipation;

­ bloating: YES, NO;

involuntary discharge of feces: YES, NO.

13. Urinary system:

urination: painless;

urine color: normal;

transparency: transparent;

daily amount of urine: norm.

14. Endocrine system:

visible enlargement of the thyroid gland: YES, NO.

15. Nervous system:

dream: restless;

gait disturbance: YES, NO.

THE PATIENT HAS IMPAIRED SATISFACTION OF NEEDS

Avoid danger, be healthy, sleep, work.

2.4. The second stage of the nursing process - PATIENT'S PROBLEMS,

Patient: Elena Petrovna Cherneta

Clinical diagnosis

The main one: ischemic heart disease, heart rhythm disturbance - atrial fibrillation, tachysystolic form, stage II A heart failure.

Associated: absent.

Complications: none.

Curator Art. IV-course, medical

f-that, 16-dec.

Mikhaltsov E.G.

Start of supervision: 03/16/98.

End of supervision: 03/19/98.

Dnepropetrovsk.

Creation date 03.23.98 18:21

PASSPORT DATA.

1. FULL NAME----

Elena Petrovna Cherneta.

1. Age

• Place of work

--- Amur-bargaining, freight forwarder

• receipt date

--- 03/11/98

COMPLAINTS OF THE PATIENT.

The patient presents with the following complaints: compressive pain in the region of the heart, shortness of breath during exercise and at rest, a feeling of heaviness in the precordial region, palpitations.

HISTORY OF THE DISEASE.

He considers himself ill since 1997, when for the first time after suffering the flu, there were compressive pains in the heart, shortness of breath during exertion, palpitations.

I went to the hospital at the place of residence, did not accept the prescribed treatment. 03/10/98 - after physical exertion, I felt a sharp compressive pain in the heart area. - turned to the local therapist and was sent for inpatient treatment in the 9th mountains. hospital.

LIFE STORY.

She was born in Dnepropetrovsk, developed according to her age. She is married with 21 years old, has two children; miscarriages, abortions were not. She suffered typhoid fever, frequent colds, an operation to remove the appendix. I did not suffer from tuberculosis, Botkin's disease, syphilis.

Works as a freight forwarder in Amur - bargaining. Over the last period of time, the working conditions are satisfactory. The patient for the most part leads a sedentary lifestyle, there were no worries and stressful situations. The living conditions correspond to the hygienic standards. The quality and nature of the food is satisfactory. Has no bad habits.

The daughter suffers from a heart defect.

PATIENT STATUS.

The general state of health of the patient is not satisfactory, the consciousness is clear. The position in bed is active. The constitution is normosthenic, height - 160 cm, weight - 70 kg. According to Chernorutsky, the constitutional type is normostenic. Body temperature -36.7 * C, no chills.

The skin is clean, pale, moderate sweating, no visible pigmentation and scars. Visible mucous membranes are pale and moist. Subcutaneous fat is moderately developed, there is no edema. The lymph nodes not palpable, negative pharyngeal symptom. Muscles are poorly developed, joints are normal, painless on palpation. Active and passive movements in the joints are preserved in full.

THE CARDIOVASCULAR SYSTEM.

The patient complains of severe paroxysmal pain behind the sternum, of a compressive nature, radiating to the left shoulder, left arm, interscapular space, arising after emotional and physical stress. Compressive pains, they decrease when the load is removed. They can be stopped by taking 1-2 tablets. The duration of the pain is 5-10 minutes. The patient also complains of shortness of breath, with predominantly difficulty breathing, aggravated by physical exertion; the patient complains of palpitations.

On examination, the chest in the region of the heart is not deformed. The apical impulse is not visually detected.

On palpation, the apical impulse is determined in the V intercostal space, by 1 cm. outward from l.medioclavicularis sinistra. The shock is spilled, high, strong, resistant. Retraction of the chest at the site of the apical impulse, systolic and diastolic tremors, the symptom of "cat's purr" at the apex of the heart, absent above the aorta. The heart beat is not detected.

The boundaries of the relative dullness of the heart:

Right --- IV intercostal space by 1 cm. outward from the right edge of the sternum.

Left --- V intercostal space by 1 cm. outward from l.medioclavicularis sinistra.

Upper --- lower edge of the III rib along l. parasternalis sinistra.

The diameter of the relative dullness of the heart is 14.5 cm, the length is 16 cm.

The diameter of the vascular bundle in the II intercostal space is 6 cm.

The boundaries of the absolute dullness of the heart:

Right --- IV intercostal space along the left edge of the sternum.

Left --- V intercostal space by 0.5 cm. inward from l. medioclavicularis sinistra.

Upper --- IV intercostal space along l. sternalis sinistra.

On auscultation, deaf heart sounds, atrial fibrillation, tachysystolic form.

Heart rate --- 120 beats per minute.

There are no visible pulsations of the carotid, subclavian and other arteries. Jugular vein pulsation is not detected. There is no epigastric pulsation. On palpation, the arteries and veins are elastic, elastic, painless. The value of the pulse on both hands is the same, the pulse of weak tension, arrhythmic, frequent.

Conclusion:

based on the patient's complaints and objective research, it can be assumed that the patient has IHD, heart rhythm disturbance such as atrial fibrillation, tachysystolic form.

Respiratory system.

Breathing is carried out through the nose, in a calm state without tension, with physical exertion - difficult, shortness of breath appears, disappearing at rest. There is no discharge from the nose. The sense of smell is not impaired.

The rib cage is cylindrical, symmetrical, without visible deformities.

Chest circumference:

• at rest --- 94cm.
• with a deep breath --- 98cm.
• with a deep exhalation --- 90cm.

The supraclavicular and subclavian fossa are moderately expressed. The ribs are directed obliquely, from top to bottom. Epigastric angle approximately 90 degrees. Both halves of the chest are evenly involved in the act of breathing. Rhythmic breathing, mainly chest type, of medium depth. The number of respiratory movements in 1 min. --- 20, inhalation is 2 times shorter than exhalation. During shortness of breath --- 28 min. On palpation, the chest is painless, transverse and longitudinal loading painful sensations not accompanied.

Topographic percussion data.

The upper border of the lungs.

1. front:

a) on the right - 4.5 cm above the clavicle.

b) left --- 4cm. above the collarbone.

• behind --- level spinous process of the VII cervical vertebra.

Kroenig fields width:

• left --- 6cm.
• right --- 5cm.

The lower boundaries of the lungs.

Right lung Left lung

L.sternalis V mr

L.parasternalis V rib

L.medioclavicularis VI rib

L. axillaris anter. VII p. VII p.

L. axillaris med. VIII p. VIII p.

L.axillaris poster. IX p. IX p.

L.scapularis X p. X p.

L.paravertebralis spinous process XI

With comparative percussion over both lungs, a clear pulmonary sound.

The mobility of the pulmonary edge l. Axillaris mediana

Left lung:

• on inhalation --- 3cm.
• on exhalation --- 3cm.
• total --- 6cm.

Right lung:

• on inhalation --- 3cm.
• on exhalation --- 3cm.
• total --- 6cm.

At auscultation over the lung tissue, weakened vesicular breathing is determined. Bronchophonia and vocal tremors in symmetrical parts of the chest are carried out with the same force.

Digestive system.

Good appetite, thirst, dry mouth do not bother. Chewing, swallowing, and the passage of food through the esophagus is free. Heartburn, belching, nausea and vomiting are not noted. Sometimes constipation is a concern. The stool is regular, the act of defecation is painless, the discharge of gases is free.

The lips are pale pink. The mucous membrane of the oral cavity is pale pink in color, clean, without ulceration and hemorrhages, the papillae of the tongue are moderately expressed.

Dental formula:

The abdomen is of the correct rounded shape, symmetrical, the anterior abdominal wall evenly participates in the act of breathing. Divergence of the rectus abdominis muscles is not observed, there are no visible peristalsis of the stomach and intestines. On superficial palpation, the abdomen is soft, painless; there is no tension. Symptoms of Shchetkin-Blumberg, Mendel, Rovzing are negative.

With deep methodical palpation according to the Obraztsov-Strazhesko method, in the left iliac region, sigmoid colon in the form of a smooth dense strand about 20 cm long. and a diameter of 1.5 cm., very sluggish and rarely peristaltic; in the right ileal region, the cecum is palpated in the form of a moderately tense cylinder slightly expanding downward with a rounded bottom, 3 cm in diameter.

The greater curvature of the stomach is palpable in the epigastric region in the form of a roller lying on the spine and on the sides of it.

Other organs abdominal cavity(liver, spleen, small intestine) are not determined by palpation.

The border of the absolute dullness of the liver.

• along l.parasternalis dexra - the upper edge of the VI rib.
• l.medioclavicularis dextra - VI rib.
• by l.axillaris ant. dextra - VII rib.
• on l .scapularis dextra - IX rib.
• by l.paravertebralis dextra - X

• along l.parasternalis sinistra - the edge of the costal arch.
• l.medialis anterior - at the border of the 13th distance from the xiphoid process to the navel.
• l.parasternalis dextra - 2cm. below the costal arch.
• on l.medioclavicularis dextra - costal arch.
• along l.axillaris anterior dextra - X rib.

Height of hepatic dullness:

l.axillaris anterior dextra --- 10cm.

l.medioclavicularis dextra --- 9cm.

l.parasternalis dextra --- 8cm.

At the point of the gallbladder, soreness is not defined.

Symptoms of Ortner, Kara, Georgievsky are negative.

Spleen borders:

Upper --- along the l.axillaris anterior sinistra - the upper edge of the IX rib.

Lower --- along l.axillaris anterior sinistra - the lower edge of the XI rib.

Front --- 1.5cm. to the left of l.axillaris anterior sinistra X mr.

The width of the splenic dullness is 6cm.

Genitourinary system.

Daily urine output - 1.5 liters. free, painless urination, mainly in the daytime. Lumbar region without features. Palpation of the kidneys are not determined, there is no pain on palpation. Pasternatsky's symptom is negative. The renal (costo-muscular and costo-vertebral) and ureteral (upper and lower) points are painless.

Neuropsychic state and sense organs.

Consciousness is clear, mood is good, sleep is calm. Tendon and skin reflexes are easy, lively, and without any peculiarities. No pathological reflexes were found. Symptoms of Kernig, Babinsky are negative. Skin sensitivity is fully preserved.

He hears whispering speech at a distance of 6m. Vision is reduced. Pupillary reaction friendly, direct, lively.

To clarify the diagnosis and the possibility of differential diagnosis it is necessary to conduct complementary methods research.

Additional research methods.

General blood analysis:

Hemoglobin --- 120 hl

Erythrocytes --- 3.6 T

Leukocytes --- 6.2 GL

Eosiniphils --- 2%

Basophils --- 0%

Sticks .--- 2%

Segments .--- 76%

Lymphocytes --- 15%

Monocytes --- 5%

ESR --- 3mmh

Conclusion:

a blood test without features.

Analysis of urine.

Color - light yellow

Transparency - transparent

Specific gravity - 1022

Reaction Pn = 5.0

Protein - not detected

Microscopy.

Erythrocytes - 12 in pz.

Leukocytes - 3-4 in PP.

Epithelium - not found

Oxolates - no

Conclusion:

urine analysis within normal limits.

Conclusion:

paroxysmal atrial fibrillation, tachysystolic form, left ventricular hypertrophy, dystrophic changes in the myocardium.

Analysis of feces for eggs of worms.

Conclusion: no worm eggs were found.

Symptom complex of pathological data.

Supervised patient Cherneta Elena Petrovna, 71 years old,

complains of severe paroxysmal pain

behind the sternum, of a compressive nature that occurs during exercise (usually walking), shortness of breath, a feeling of heaviness in the precordial region, palpitations. Has been sick for 1 year; the disease is associated with the transferred in 1997. flu.

Objectively: with percussion, the displacement of the borders of the heart to the left is determined, which is also visible on the chest X-ray. With auscultation, a violation of the heart rhythm is determined (atrial fibrillation, tachysystolic form).

ECG: signs characteristic of left ventricular hypertrophy, dystrophic changes in the myocardium, atrial fibrillation.

All of the above is a symptom complex pathological signs... Based on this, the following syndromes can be distinguished:

1. Pain syndrome.
2. Respiratory Failure Syndrome.
3. Syndrome of morphological changes in the myocardium.

Because These syndromes can occur in a number of diseases, a differential diagnosis should be made with cardialgia arising from the following diseases:

• Myocardial infarction.
• Pericardial effusion.
• Prinzmetal's spontaneous angina.

Differential diagnosis.

• Differential diagnosis of a symptom complex of pathological signs of a supervised patient with exudative pericarditis.

Pericardial effusion is an inflammatory disease of the pericardium and the outer lining of the heart, accompanied by the accumulation of effusion in the pericardial cavity.

Common symptoms are:

• Chest pain
• Shortness of breath on exertion
• Displacement of the boundaries of cardiac dullness
• Muffled heart tones

But exudative pericarditis is characterized by:

• Dull, pressing pains, often localized to the left of the sternum.
• A feeling of heaviness in the region of the heart, aggravated by a deep breath and with a change in body position.
• Nitroglycerin has no analgesic effect.

Decreased appetite, dry cough, vomiting, low-fibril body temperature, leukocytosis, accelerated ESR, speak in favor of the presence of an inflammatory process, which is not detected in this patient.

Objective changes: expansion of the borders of cardiac dullness in all directions (in the supervised patient, the border of the heart is expanded to the left); the apical impulse is not defined; heart sounds are muffled and combined with a pericardial friction murmur, which is heard for a long time; characterized by the presence of a paradoxical pulse, swelling of the cervical veins, which is absent in the supervised patient.

Additional methods data:

• On the roentgenogram: expansion of the shadow of the heart, approaching trapezoidal in shape, combined with clear pulmonary fields.
• ECG: ST segment elevation, T wave inversion, low voltage Z.R.

Considering that these symptoms are not expressed in the supervised patient, exudative pericarditis can be excluded.

• Differential diagnosis of a symptom complex of pathological signs of a supervised patient with myocardial infarction.

Myocardial infarction - acute illness due to the occurrence of foci of ischemic necrosis in the heart muscle due to insufficient blood flow to it.

Common symptoms are:

• Compressive chest pain radiating to the left shoulder blade, shortness of breath that occurs during physical exertion and psychoemotional overstrain.
• The presence of risk factors: the onset of the disease in persons over 40 years of age, frequent stress.
• Expansion of the boundaries of the heart to the left.
• Deafness of tones.
• ECG: displacement of the ST segment below the isoline, negative Z.T in V5-V6, aVL.

But myocardial infarction is characterized by the presence of three syndromes:

1. Painful: with a typical (angular) form at the onset of myocardial infarction, there is intense acute long-term pain behind the sternum (in the supervised patient, pain behind the sternum of a pressing character), lasting more than an hour (up to several days), with irradiation to the left shoulder, arm, scapula.

Pain is not relieved by nitroglycerin (unlike this patient), accompanied by cold sweat, fear of death.

1. Cardiovascular syndrome: focal damage and myocardial necrosis leads to a decrease in shock ejection, fluctuations in blood pressure, which is accompanied by characteristic symptoms cardiogenic shock: pallor of the skin, nausea, vomiting, fainting and loss of consciousness are possible. Signs of central circulatory insufficiency may develop: systolic murmur (due to relatively defective closure mitral valve as a result of expansion of the heart), tachycardia, acrocyanosis, shortness of breath, congestion in the lungs, a rapid increase in venous pressure, an attack of cardiac asthma. Myocardial infarction can lead to a disorder of excitability and contractility: extrasystole, bradycardia, tachycardia, atrial fibrillation, partial or complete blockade... Sometimes a pericardial friction noise is heard, a gallop rhythm (for 2-3 days).
2. Resorptive-necrotic syndrome appears as a result of the absorption of the decay products of the ischemic area of ​​the muscle, which is manifested by:

• Fever (chz 12-36 hours after the onset of pain syndrome);
• Leukocytosis above 10-15 thousand;
• Acceleration of ESR;

ECG changes:

1. Reduction of Z.R below 5mm. Or his disappearance altogether; the appearance of a pathological Z.Q (expansion more than 0.33 s, depth more than 13 Z. R in this lead).
2. Depression of the ST segment (decrease with intramural infarction, rise higher with subendocardial).

With a heart attack, an increase in the activity of LDH 1, AST (aspartate aminotransferase), and CPK (creatine phosphate kinase) is found.

By comparing the patient's complaints, history, physical examination and additional research data with the classic form of myocardial infarction, we can exclude myocardial infarction.

3.Differential diagnosis of a symptom complex of pathological signs of a supervised patient with variant angina pectoris.

Common symptoms are:

• Retrosternal pains of a compressive-pressing character radiating to the left shoulder, arm, interscapular region.
• Dyspnea.
• Muffled heart sounds.

But for variant angina pectoris, an attack occurs at rest, which, as a rule, is not associated with an increase in the metabolic demands of the heart muscle.

• Cyclic pain: the onset of an attack at night or during the day.
• Usually high exercise tolerance.
• ECG change: segment evolution (with depression in a supervised patient).
• Pain relief with nitrate preparations exceeds 10 minutes. And the effect is negligible.

Since these symptoms are not expressed in our patient, variant angina should be excluded.

Clinical diagnosis.

Based on the symptom complex of pathological signs of the supervised patient and the differential diagnosis we can make the following clinical diagnosis:

1. Main disease: ischemic heart disease, violation heart rate- atrial fibrillation, tachysystolic form.
2. Concomitant disease: absent.
3. Complications: none.

Etiology and pathogenesis of the underlying disease.

The main reason for the development of coronary artery disease is atherosclerosis of the coronary arteries of the heart.

Risk factors for ischemic heart disease:

• hypercholesterolemia
• lack of exercise
• arterial hypertension
• obesity
• smoking
• diabetes
• neuropsychiatric stress
• genetic predisposition of the type of metabolism

In the pathogenesis of ischemic heart disease, the following links are distinguished:

1. Morphological (atherosclerotic) lesion of the coronary arteries.
2. Functional tropism to coronary spasm.
3. Changes in the blood - an increase in the activity of the blood coagulation system.
4. The ability of the heart to contract with a pronounced systolic and diastolic effect.
5. A state of venous return to the heart.

Currently, the main causes of all arrhythmias are considered impulse formation disturbances in the heart, impulse conduction disturbances, as well as a combination of these disturbances. Strengthening the automatism of specialized myocardial cells located outside the sinus node (ectopic foci of automatism) leads to the formation different types extrasystoles, paroxysmal tachycardia (the first main mechanism of their formation). The second mechanism of their formation is re-entry and circular movement of the impulse. In addition, oscillations (small fluctuations in the transmembral resting potential, trace potentials, local potential differences) can lead to the development of paroxysmal tachycardia.

Various causes (ischemia, dystrophy, inflammation) lead to a violation of the permeability of the cell membrane and, consequently, to a violation of the ionic composition of myocardial cells, which leads to electrophysiological mechanisms of cardiac arrhythmias.

Most frequent illnesses accompanied by these violations:

• Organic (ischemic heart disease, heart defects, hypertension, myocarditis);
• Toxic (intoxication with cardiac glycosides, sympathomimetics, caffeine, etc.);
• Hormonal (with thyrotoxicosis, myxedema, pheochromocytoma);
• Functional (neurogenic, sports);
• With surgical interventions;
• With anomalies in the development of the heart (WPW syndrome, etc.);

Treatment and prevention.

Therapy should be aimed at:

1. Elimination of risk factors - arterial hypertension, violation of lipid metabolism, obesity, physical inactivity, bad habits.
2. Normalization of work and rest of the patient.

From drug therapy, the following groups of drugs are used:

• Increasing the supply of oxygen to the heart:

1. Means that improve blood circulation and myocardial metabolism:

• Nitroglycerine
• Prolonged forms of nitroglycerin (nitrong, sustac)

2. Myotropic coronary artery disease:

A) classic antispasmodics

• Papaverine.
• Dibazol.

B) Dimethylxanthines:

• Euphilin.
• Tenisal.

• Means that reduce myocardial oxygen demand:

a) Betta-adrenergic blockers:

• anaprilin

b) Ca 2+ antagonists:

• verapamil
• nifedipine

• Means that improve microcirculation

• A nicotinic acid
• Trental

The patient's diet is also important.

• Rp: Tab.Nitroglycerini 0.0005 N 40

Da. Signa. 1 tab. for an appointment under the tongue.

• Rp: Tab. Nitrosorbidi 0.0005 N 50

D.S. 1 tab. 2 times a day.

• Rp: Tab. Anaprilini 0.02 N 20

D.S. 1 tab. 3 rday.

• Rp: Sol. Papaverini hydrochloridi 2% - 2ml

D.t.d. N 10 in ampullis

S. 2ml per day per day.

• Rp: Tab. Celanidi 0.00025 N 30

D.S. 1 tab. 1-2 p. in a day.

• Rp: Sol. Glucosae 5% 400.0

D.t.d. N 2 in flaconis

S. for intravenous infusion.

Diaries.

Temperature sheet.

For life:

favorable.

For recovery

: favorable in compliance with the regimen and prescribed therapy.

For work capacity

: adverse - avoid excessive physical activity.

Patient Cherneta Elena Petrovna, 71 years old, was admitted to cardiology department city ​​hospital N9 03/11/98 with complaints of severe paroxysmal pain behind the sternum of a compressive nature that occurs during exercise, constant shortness of breath, a feeling of heaviness behind the sternum, palpitations.

The pain is relieved by nitroglycerin within 5-10 minutes.

From the anamnesis it is known that the patient has been suffering from ischemic heart disease since 1997, the disease is associated with the flu. Until now, she has not been treated, she turned to the admission department in the direction of the local doctor, was urgently hospitalized in the cardiology department.

Objectively: the condition on admission is unsatisfactory, the skin is pale, the apical impulse is determined in the V intercostal space on the left according to L. Medioclavicularis sinistra. The borders of the heart are shifted to the left. Auscultatory: muffled heart sounds, systolic murmur, tachyarrhythmia is heard. Heart rate 120 beats per minute.

ON ECG: paroxysmal atrial fibrillation, tachysystolic form, left ventricular hypertrophy, dystrophic changes in the myocardium.

Based on the anamnesis data, as well as objective and additional research methods, the patient was diagnosed with coronary artery disease. Atrial fibrillation, tachysystolic form.

In the clinic, the patient was prescribed the following treatment:

• Anaprilin - 0.01 g, 2 tab. 3p. in a day.
• Cordaron - 0.2 g, 1 tab. 2-3 p. in a day.
• Nitrosorbide -0.01, 1 tab. under the tongue with an attack of angina pectoris.
• Celanide - 0.25 mg. 1 tab. 1-2 p. in a day.
• Nitroglycerin -0.0005g. 1 tab. under the tongue.
• Glucose - 400 ml intravenously
• Table N 15.
• Half-bed mode

During his stay in the hospital, the patient's condition improved. Attacks of angina pectoris do not bother, dyspnea and weakness have decreased, there is a decrease in heart rate.

• Nitroglycerin 1 tab. under the tongue to relieve angina attacks.
• Celanide 1 tab. 2 p. in a day.
• Compliance with the regime of work and rest.
• Observation of the local therapist.

LITERATURE.

• F.I. Komarov, V.G. Kukes, A.S. Smetnev "INTERNAL DISEASES" Moscow "Medicine" 1990.
• V.V. Murashko "ELECTROCARDIOGRAPHY" Moscow "Medicine" 1987.
• M.D. Mashkovsky "DRUGS" Moscow "Medicine" 1994.

Moscow Medical Academy. I. M. Sechenova

Department of Internal Medicine № 4

Medical history for therapy

Performer: 4th year student of l / f

Britsko D. B.

Teacher: Yurazh V. Ya.

Moscow 2001

Passport part:

Surname, name, patronymic of the patient: Soloviev Mikhail Nikolaevich

Age: 74

Profession: pensioner, disabled group II (previously worked as a loader)

Residence: Moscow, st. Bnekhskaya 5 - 179

Curation date: 29.11 01.

Patient complaints at the time of admission: Shortness of breath, which occurs with a slight load, lying with a low pillow, mainly at night. Cough with mucous expectoration. Increasing swelling of the legs, an increase in the abdomen due to the accumulation of fluid. Recurrent pain in the region of the heart, of a constrictive nature, of moderate intensity, without irradiation, arising without connection with physical activity that do not go away after taking nitroglycerin. Frequent rises in blood pressure up to 200/100 mm. rt. Art.

History of the present disease: A patient at the age of 17 in 1947 suffered from rheumatism for which he was in the hospital. After 3 years, mitral valve defect was diagnosed. After that, the patient was not bothered by complaints, he led a normal life, worked as a loader. From the age of 55, the patient's condition began to deteriorate: rises in blood pressure appeared (hypertension was exposed), recurrent pain in the area of ​​the heart, shortness of breath, edema, atrial fibrillation. The patient began to be observed in the district clinic, to undergo treatment 2 times a year in a hospital. The last hospitalization was in February 2001 at City Clinical Hospital No. 63. The above complaints during hospitalization developed within 3 weeks.

Anamnesisvitae: Born in the countryside, in a village in the Kursk region. He lived in a private house. The living conditions were poor, he received irregular food (he was in the occupied territory during the war). From education I finished only 4 classes in comprehensive school... Since 1946 he has been living in Moscow. At the moment, the living conditions are good, he lives in a separate apartment, in a family.

Past diseases: In childhood, suffered from measles, rubella, parotitis (without complications). He often suffered from colds, sore throats. At the age of 41, he was in a hospital in urological department diagnosed with: urolithiasis disease, right-sided renal colic, as a result of treatment, the calculus came out on its own, in the future there were no complaints of urolithiasis. At the age of 56, an operation was performed - hernia repair for a hernia of the white line of the abdomen.

Hereditary and family history: Denies the presence of inherited diseases. The father died at the age of 50 from esophageal cancer. Mother died tragically.

Allergic manifestations: on medications, food, plants and animals are missing.

Bad habits: Smokes since 12 years old, currently smokes one pack of cigarettes a day.

Industrial hazards: He worked as a loader at a brick factory, was engaged in loading coal.

Statuspraesens:

State: medium.

Position: active at the time of supervision, forced orthopedic on admission.

Facial expression: normal.

Body type: normosthenic.

Temperature: 36.7 0 C

Skin integument: clean, normal humidity, acrocyanosis, cyanotic color of visible mucous membranes. Subcutaneous fat of moderate development, evenly distributed. Expressed pasty legs, on admission, pronounced peripheral edema on the legs, feet. Skin on lower limbs pale, smooth, tense.

From the side joints, skeletal and muscular system no pathology.

The lymph nodes: normal, not visible on examination.

Respiratory system: Complaints are stated above. On examination, breathing through the nose is free. NPV 22, the rhythm of breathing is correct. The thorax is normosthenic. The right and left halves are symmetrical, they move synchronously when breathing, painless when palpated. On palpation, chest rigidity is noted. Vocal tremor is weakened in the lower sections on both sides. The boundaries of the lungs are expanded. Limitation of excursion of the lower pulmonary margin. With percussion, dullness of the pulmonary sound in the lower sections. Breathing is hard on auscultation. In the lower parts of the lungs, moist small-caliber unsonic rales are heard. At the time of admission, moist voiced fine bubbling rales were heard in the upper parts of the lungs on the right (which was also confirmed by X-ray). Bronchophonia: Vocal tremor is locally weakened on both sides in the lower lungs.

Circulatory organs: Complaints are stated above. On examination of the neck region, pulsation of the carotid arteries is noted. When examining the area of ​​the heart: the chest in the area of ​​the heart is not changed, there is no heart hump, there is no cardiac impulse. There is no local ectopic pulsation in the precordial region. The apical impulse is determined in the 6th intercostal space 1.5 cm outward from the midclavicular line, according to the characteristics: spilled, high, reinforced. There is no pulsation in the epigastric and liver regions.

Percussion boundaries of relative cardiac dullness:

right: 1 cm outward from the right edge of the sternum

left: 1.5 cm outward from the midclavicular line.

upper: 1 cm to the left of the left sternal line at the level of the II rib.

Heart sounds:

I and II tones are weakened at all points of auscultation. III and IV tones are not heard. At the apex, a pansystolic murmur is heard, blowing, soft, timbre, high frequency, conducted into the axillary region. Also at the top, a protodiastolic, fading noise of a blowing timbre is heard. During auscultation at the Botkin-Erb point, a protodiastolic, decreasing noise of a soft, blowing timbre is heard. The heart rhythm is wrong, heart rate is 64 per minute. Pulse rate - 62 per minute, pulse deficit 2. Expressed rhythm disturbances in the form of atrial fibrillation. Blood pressure on right hand 160/90 mm. Hg., on the left hand 155/90 mm. rt. Art., with a working blood pressure of 140/80 mm. rt. Art. The pulse on the radial arteries is the same, the vascular wall is smooth. Pulse characteristic: arrhythmic, high and fast, satisfactory filling and tension. Examination of veins: saphenous veins of the head, neck, chest, abdomen, thighs are not dilated, not twisted.

Digestive system: Complaints about hernial protrusion, recurrent cramping pain in the right groin area.

When viewed at the present time, the symmetrical belly participates in breathing evenly. In a standing position at the medial part of the inguinal fold, hernial protrusion is oval in shape, measuring 10 x 8 cm. Painful when palpated into the scrotum does not descend, with percussion dullness of the percussion sound. V horizontal position the hernia is repositioned, upon examination, the superficial ring of the inguinal canal is expanded, a positive symptom of a cough impulse.

On palpation, the abdomen is soft, painless, with percussion tympanitis. On auscultation, normal peristaltic murmurs are heard. Stool tendency to constipation.

At the time of admission, the abdomen was enlarged due to the accumulated fluid, the shape of the abdomen was convex. When percussed, a dull sound in the lower sections.

Liver examination: Complaints about the recurrent feeling of heaviness in the right hypochondrium. There is no connection with the food intake.

When examining the area of ​​the liver, there is no swelling of the pulsation in the area of ​​the liver. Cutaneous venous collaterals are absent. Currently, the liver protrudes from under the edge of the costal arch by 2 cm, at the time of admission it protruded by 6 cm. On palpation, the liver is enlarged, smooth, soft, with a rounded edge, painless.

On palpation, the spleen is not palpable, painless.

Gall bladder: No complaints, not detected on palpation, painless.

urinary system: no complaints, free urination. The kidneys are not palpable. Pasternatsky's symptom is negative on both sides.

Endocrine system: no pathology, thyroid not changed.

Neuropsychic sphere:

The patient is correctly oriented in space, time and self. Contact, willingly communicates. Perception is not impaired. Attention is not weakened. The memory is reduced. Intelligence is average. Thinking is not impaired. The mood is even, the behavior is adequate. Nervous system: movement disorders no, the sensitivity is preserved. There are no meningeal and focal signs.

Preliminary diagnosis: Rheumatism, inactive phase. Combined mitral-aortic heart disease: mitral regurgitation, atrial fibrillation. Aortic insufficiency. GB II. NK IIb. Chronic bronchitis in remission, pulmonary emphysema. Right-sided upper lobe focal pneumonia. Right-sided reducible straight inguinal hernia.

Justification of the preliminary diagnosis: After suffering rheumatism (to which frequent tonsillitis and starvation were predisposed), the patient has data for mitral heart disease. For mitral valve insufficiency: expansion of the borders of the heart to the left and upward (hypertrophy and dilation of the left ventricle and atrium), weakening of the I tone, systolic murmur at the apex, soft, conducted into the axillary region. Atrial fibrillation. For mitral valve stenosis: protodiastolic murmur at the apex, expansion of the right border of the heart, decompensation in the systemic circulation. There is also evidence for aortic valve insufficiency: pulsation of the carotid arteries, high and rapid pulse, protodiastolic, decreasing murmur at the V point of auscultation, although there are conflicting data: there is no decrease in diastolic pressure. For stage IIb circulatory failure, pronounced hemodynamic disturbances in the systemic circulation (peripheral edema, ascites, enlarged liver) and in the pulmonary circulation ( stagnation in the lungs). For chronic bronchitis in remission: smoking from 12 years old, hard breathing, absence of dry wheezing, purulent sputum discharge. For emphysema of the lungs, expansion of the boundaries of the lungs, weakened breathing, decreased excursion of the lower pulmonary margin. For right-sided upper lobe focal pneumonia: congestive changes in the lungs suggesting a factor, moist voiced fine bubbling rales in the upper parts of the lungs on the right. For right-sided, reducible, straight inguinal hernia abdominal examination data.