FIRST MOSCOW STATE MEDICAL UNIVERSITYMedical FacultyDivision for Foreign Students with Instruction Conducted in EnglishDepartment of TherapyStudents: Tong Kah YeeGroup: 85 Date: 26/02/2015Patient: Mamysheva Age : 59Occupation: Retired (Turner before) Sex: Female Weight: 83 Height: 163 BMI: 31.2(obese) Chief Complain:Patient was admitted to the ward due to1. Chest Pain 2. Shortness of breath3. Fatigue & weakness4. Swelling on feet5. Pain in knees

History of present illness:(When did the disease start provoking factors, its exacerbation and cause, treatment)Patient suffered from Diabetes Mellitus since 1988 and hypertension (150/90) .The following drugs are used for the course of the diseases : Insulin on 2001 with 3 times per day, Indapamide (Diuretics). On the date of admission, patient experience chest pain which : Onset : from year of 2005 Duration : 1-5minutes Nature : Crushing Site & Radiation : Retrosternal and radiate to the back Aggravating Factors : Moderate Exertion Relieving Factors : Nitroglycerin Associated symptoms : dyspneaBesides, she also has shortness of breath during fast walk or walking on stairs. She has frequent fatigue and weakness. Moreover patient has blurred vision and glaucoma for years. She has no history of acute Myocardial Infarction (AMI), Stroke and dysrhythmia.

Past medical history:1. Appendicitis in 1983 and performed Appendectomy.Family Medical history:1. Mother had Diabetes Mellitus and arterial hypertension before, died on the age of 59, Cause of death: Myocardial Infarction2. Father had heart problem also (insufficiency of information)3. Only child in the family, husband and a son and a daughter (no other disease)

Allergies:1. Allergic to Animal Insulins

Gynecological history:1. Postmenopausal for 13 years

Social history:1. Non-drinkers or smokers2. Average intake 2 cups of sugar free coffee per day3. Hypoglycemic diet 4. 1-2 times of swimming per week

Physical exam: Results (only abnormal findings)Cardiovascular systemComplaint: Retrosternal pain , ankles swellingGeneral Inspection of precordial areas and vessels Size/ Any deformities: None Apex best: Not visible Pulsation of pulmonary trunk: Not visible Pulsation of aorta: Not visible Pulsation of subclavian arteries (sub- and suprascapular areas): Not visible Carotid pulse: Not visible Jugular pulse: Not visible Epigastric pulsation: Not visible Other pulsation on extremities and lower trunk : Not visible

Palpation on heart and vessels Apex beat: Palpable Capillary pulsation: Not palpable Pulsation of pulmonary trunk and aorta: Not palpable Pulsation of cardiac beat: Not palpable Pulsation of epigastric: Not palpable

Palpation on radial arteries on both hands1. Synchronous pulsation on both hands2. Same amplitude of pulsation on both hands

Auscultation of apex beat and counting radial pulse at the same timeBoth Apex beat and radial pulse are the same (no pulsus deficit)

Palpation of radial pulse Regularity : Regular Rate: 83 beats/min Amplitude: Normal Tension: Normal Velocity and shape: Normal

Percussion of heartRelative DullnessAbsolute Dullness

Right border1 cm laterally of the right edge of the sternum(left edge of sternum)

Left border1.0 cm medially of left midclavicular line(1-2cm medially of border of relative dullness)

Upper border3rd intercoastal space(level of 4th rib)

Width of vessel bundle5-6cm

Shape of heartNormal

Auscultation of heart 1st heart sound: Normal loudness and frequency 2nd heart sound: Normal loudness and frequency 3rd and 4th heart sound: Absent Adventitious sounds: Absent

Area of auscultationTone

Apex beatNormal, rhythmical tone of both S1 and S2

AortaNormal

Pulmonary arteryNormal

Tricuspid valveNormal

Botkins Erb pointNormal

Pericardial friction : Absent Heart rhythm : Rhythmic Heart rate : 80/min Pulse : 130/80 mmHg(s/d) on left hand : 130/80 mmHg(s/d) on right hand

Pulmonary SystemComplaint: Shortness of breath during exertionInspectionSymmetrical chest formSynchronous breathing on both sides

Form of chest Normosthenic Shape : Conical Supraclavicular fossa : prominent Louis angle : present Epigastric angle : 90 degree Ribs direction laterally: oblique Scapula : closely fit to the chest

Respiratory movements Breathing rate : 18/min Type of breathing : thoracic breathing Depth of breathing : superficial Rhythm of breathing : Rhythmic Accessory muscle usage : None

Ability of chest to dilate : yesAbility of chest to expel air : yes

Chest circumference Normal : 100cm During forced inspiration : 104cm During forced expiration : 98cm Expansion :6cm

Palpation of chest Area of painfulness : None Elasticity : Normal Tactile fremitus : Normal

PercussionComparative percussion : same intensity of clear lung sound/resonance was heard over symmetrical areas of the chestPart of the chestAreaSound intensity of left and right lungs

AnteriorSupraclavicular fossaClavicleSubclavicular1st intercostal space up to liver dullnessSymmetrical

Lateral Along midclavicular lineSymmetrical

PosteriorSuprascapular areaInterscapular areaSubscapular areaSymmetrical

Topographic percussiona) Upper border of lungs

ApexRight LungLeft Lung

Anterior (cm above clavicle)43.8

Posterior (cm from lateral process of 7th vertebra)33

Kroenigs area (width,cm)5.55.5

b) Lower border of lungs

Percussion pointRight LungLeft Lung

Parasternal line5th intercostal space-

Midclavicular line6th rib-

Anterior axillary line7th rib7th rib

Midaxillary line8th rib8th rib

Posterior axillary line9th rib9th rib

Scapular line10th rib10th rib

Parasternal lineSpinous process of 11th thoracic vertebraSpinous process of 11th thoracic vertebra

Respiratory mobility of the lower lung borders (cm)Topographic lineRight lungLeft Lung

InspirationExpirationTotalInspirationExpiration Total

Midclavicular line112---

Middle axillary line213212

Scapular line11.52.511.52.5

Nervous SystemComplaints : Weakness ,Sleep disturbancesSensory system : Pin prick test shows hypersensivity on distal part of both sided hands and legs.

Endocrine SystemNo feel thirsty nor polyuria

Musculoskeletal SystemComplaints : Joints: pain, swollenSpontaneous of provoked pain at locomotionsAbsent

General degree of muscular system developmentModerate

Painfulness at palpationyes

TensionNormal

ConsolidationNo

Local hypertrophies, atrophiesAbsent

Preliminary diagnosis:From physical examination of cardiovascular system, there are absence of right & left ventricular hypertrophy, absence of murmur sounds , so suggested exclusion of aortic/mitral stenosis/regurgitation and cardiomyopathy. Patient has no reveal any xanthelasma or xanthomas.Based on patientsComplaints Chest Pain and shortness of breath on walking or climbing stairs rapidly Blurred vision Swelling and pain of legsRisk factors obesity family history of premature myocardial infarction (her mother had diabetes mellitus and died of ACS on the age of 59) Diabetes Mellitus

Suggest patient has Diabetes Mellitus type 2, coronary heart disease (stable angina stage II), retinopathy, hypertension stage 2 and chronic heart failure stage I (reversible). Edema of lower extremities also may be due to kidney disease therefore further lab and instrumental investigation are needed to confirm the preliminary diagnosis.

Plan of investigation:FBCBiochemical test (include troponin test to rule out myocardial necrosis)Urine testGlycosylated haemoglobin (HbA1C) &fasting glucoseLipid Profile ECGChest XrayXray of lower extremities

Plan of treatment:Non-pharmalogical: diet modification low-sodium diet ,low-spicy diet, hypoglycemic diet.Pharmacological:Angina relief : Nitroglycerine Indapamide (2,5mg) -1 Table-morning Prestarium (10 mg) l table-morning, within 10 days ,: Insulin injectionAspirin(75mg)

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