KURSK STATE MEDICAL UNIVERSITY

DEPARTMENT OF THERAPY

Head of Department : Professor V.P. Mihin

Teacher in charged : Dr. Malcheva Lina Sergeevna

Case History

Patients Name : Kovalev Anatoli Anasavich

Age: 75 Years Old
Date Of Hospitalization: 02 February 2017

Clinical Diagnosis :

Diagnosis: Arterial Hypertension Degree 3, Stage III, Group Risk 4

Associated Disease: Diabetus Mellitus Type 2, Chronic Gastritis

Complication: Congestive Heart Failure, Stage IIA, Functional Class II

Student: Dhurgashree Kangga Raathigaa

Group: 16
Faculty: Medicine
Course: 4th year 2nd semester

- Kursk 2017-
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Identification

1. Name : Kovalev Anatoli Anasavich

2. Age : 75 years old
3. Sex : Male
4. Occupation : Pensioner
5. Address : Kursk region, Krasnaya Liniya, Dom 1, Apt 231
6. Date of admission : 02 February 2017
7. Date of interview with patient : 06 February 2017
8. Nationality: Russian

A) Subjective Examination
I. Complaints (with detailing)

1. Chief Complaints:

Patient complaint of headache that occurs early in the morning and subsides during
evening, heaviness in the head.
Dizziness and drowsiness.
Nausea and felt burning pain in the stomach when he eats.
General weakness.
Dyspnea during moderate physical activity.
Pain in epigastric region, not radiating pain, pain only when he eats.

2. Additional Complaints:

Felt syncope (fainting) during walking.

II. SYSTEM REVIEW

RESPIRATORY SYSTEM
1. Breathing through nose: Easy
2. Running nose: Absent
3. Larynx: Dryness and rasping feeling in the throat absent
4. Voice: Normal
5. Cough: Absent
6. Sputum: Absent
7. Blood-spiting (hemophtysis): Absent
8. Pain in the chest: Absent.
9. Shortness of breath: Absent
10. Dyspnea: Only during moderate physical exertion

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CARDIOVASCULAR SYSTEM

1. Shortness of breath: Only during moderate physical exertion

2. Irregular heartbeats: Absent
3. Pain or discomfort: Only during moderate physical exertion
4. Edema: Absent
5. Neck pulsation: Absent

DIGESTIVE SYSTEM

1. Appetite - its upset: Good appetite

2. Distinguish the taste of food: Present
3. Feeling of dryness, burning in the mouth and salivation: Absent
4. Thirst: Absent
5. Chewing of food: Good
6. Swallowing: Quiet diffucult
7. Passage of food: Quiet diffucult
8. Belching (eructation): Absent
9. Heartburn: Present
10. Nausea (sickness): Present
11. Vomiting (emesis): Absent
12. Stomach bleeding: Absent
13. Pain: No cardiac pain
14. Flatulence: Absent
15. Collywobbles: Absent
16. Stool: Normal
17. In cases of constipation: Absent
18. In cases of diarrhea: Absent

LIVER
Absent of pain, no yellowish skin or eyes, no changes in the colour of urine and feces.

SPLEEN
Normal, no pain.

URINARY SYSTEM

There was no pain in the location of lumbar and pubic region. There was no edema on the face,
legs or body. According to the patient the rate and number of urination was normal. Urination
was easy and normal flow. There was urination at night and he does not wake at night to urinate.
The urine has normal color.

GENITAL SYSTEM

The function of the genital organs was normal and there were no abnormalities.
SKIN

Itching: Absent
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Rashes, ulcer: Absent
Sweat, intensity, time and causes of appearance: Normal

LYMPH NODES
Normal

OSTEOMUSCULAR SYSTEM

Pain in bones: Absent

Pain in joints: Absent
Muscle pains (myalgia, muscular ache): Absent

NERVOUS SYSTEM (NEUROLOGY SYSTEM)

Feeling Sleepy: Sometimes

Headache: Occurs early in the morning and subsides during evening
Dizziness (Vertigo): Absent
Memory: Good

ORGANS OF SENSE

Eyesight, hearing, sense of smell, taste, touch: Normal

OTHER DATA ABOUT STATE OF PATIENT

Weakness, no loss of weight, no high temperature, body temperature was 36.6.

II. Present Illness

First symptoms of the disease, onset of the diseases:

According to patient, it appears in 1997. Headache that occurs early in the morning and
subsides during evening, heaviness in the head. Feeling of syncope (fainting) when he walks.
Experienced general weakness and malaise. Highest blood pressure was 200/110 mmHg. Blood
pressure during curation was 140/90 mmHg.

Development of disease:

The medicines was not efficient. It helps patient sometimes but not all the time and has
brought the patient to the hospital.

Life History (Personal History)

1. Childhood and Youth.
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 Place of birth: Kursk
Health of family conditions are good
2.Occupation: Pensioner
Hazards: Absent
3. Financial Status: Normal
4. Living Conditions: Satisfactory
6. Meals (Food): Regular
7. Body Hygiene: Satisfactory
8. Marital Status: Married
9. Family History: None
10. Past illnesses: He had arterial hypertension since January 1997 and was treated
with Indopamide. Patient was also diagnosed with Diabetus Mellitus type 2
11. Habits: No smoking and drink alcohol during celebration
12. Allergy: Absent
13. Blood Transfusion: Absent
14. Hormone: No disturbances

OBJECTIVE EXAMINATION
GENERAL INSPECTION
1. General condition - Satisfactory condition
2. Show- Confirm the age
3. Consciousness and stages- Conscious and active
4. Posture- Active
5. Look of the face- Normal
6. Weight- 75kg
Height-160cm
Constitution- Normosthenic
Nutritional state- Well nourished
7. Skin: Color of the skin- Normal
Mucous membrane (mucous coat)- Normal
Skin eruptation (rash) - Absent
Subcutaneous hemorrhages, ulcerations, desquamation, pigmentation,
Depigmentation, Skin scars- Absent
Nails- Normal
Hair- Normal.

8. Subcutaneous fat- Normal

Edema - Absent.
Subcutaneous emphysema- Absent

9. Musculation.
Degree of development Good, symmetrical
Muscular tension- Normal
Painfulness- Absent
Convulsions, Tremor- Absent
Muscular strength- Normal
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10. Lymphatic System: Lymph node is impalpable, absent of pain during palpation

11. Bones.
No pathological changes. No deformation, no shortening, no tenderness, no periostitis, no
clubbing of fingers.

12. Joints:
Normal form & size. No changes of skin, temperature normal, no painfulness in
palpation, no fluctuation, no crackles, movement active, tenderness in movement
absent, no changes of mobility joints, no changes in articular circumference.

13. Head: Normal size and form of the skull, no scars, no tremor
Nose: Normal shape, no septum deviation
Eyes: Normal color of the scleratic coat. Normal brightness. Cornea
state normal.
a) Lids- No edema, no ptosis, normal width of palpebral fissures
b) Sclera- No jaundice, no hemorrahage
c) Conjunctiva- Normal
d) Cornea- No scans, no ulceration
e) Pupils- Normal size, shape, equality, reaction to light and
accommodation
f) Vision- Normal
g) Ophthalmoscopic- Normal optic disks, no exudates, no
hemorrhage
Lips: Normal coloration, no scars, no fissures

14. Neck: Normal thyroid, Normal consistency, Normal surface

15. Body temperature: 36.6o C

RESPIRATORY SYSTEM

General inspection:
Normal form of chest,
Symmetrical chest, deformation absent,
Normal equality of expansion.
Normal state of intercostals region
Type of respiration: Thoracic respiration
Respiration per minute: 17, Rhythm normal
Shortness of breath: During moderate physical exertion.
Palpation of the chest.
Surface palpation of chest, ribs, breast-bone, and intercostals region
shows no pain
Vocal fremitus- Normal and equal on both sides
Percussion.
Comparative percussion- Normal resonance sound on both sides
Topographic percussion:
Height (altitude) of apex pulmonaris:
3 cm above clavicle
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 3 cm laterally to spinous process of the 7th cervical vertebra

Percussion point Right lung Left lung

Parasternal line 5th intercostals space -
Midclavicular line 6th rib -
Anterior axillary line 7th rib 7th rib
Midaxillary line 8th rib 8th rib
Posterior axillary line 9th rib 9th rib
Scapular line 10th rib 10th rib
Paraspinal line Spinous process of 11th Spinous process of 11th
thoracic vertebra thoracic vertebra

Mobility of lungs is as follows:

Right lung Left lung

Inhalation exhalation Total Inhalation Exhalation Total
Mid clavicular line 3 3 6 - - -
Mid axillary line 4 4 8 4 4 8
Scapular line 3 3 6 2 3 5

Auscultation- comparative.
Breath sounds is vesicular respiration. There is no adventitious sound such as rales and
crepitation. Auscultation sound is symmetrical on both sides of the lungs

CARDIOVASCULAR SYSTEM

Inspection:
Region of heart- Cardiac humpback absent. Point of maximal impulse (apex beat) not visible.
Cardiac beat not visible. Abnormal pulsations: aorta pulsation not visible, pulmonary trunk
pulsation not visible, ventricular aneurysm absent.
Region of neck- Aortic arch pulsation not visible. Carotid arteries pulsation not visible.
Engorgement of jugular veins not visible. Undulation of neck veins absent. Ingular venous pulse-
negative
Trachea- Position on the midline, tracheal tug absent
Peripheral arteries pulsation not visible. Capillary pulse absent, nail pulse absent, Quince's pulse
absent. Wiggliness of arteries ("worm sign") absent.
Epigastric pulsation. Hepatic pulsation not visible. Pulsation of right ventricle of the heart not
visible. Abdominal aorta pulsation absent.
Hypodermic (subcutaneous) chest, abdomen phlebectasia absent. Varicose phlebectasia of lower
extremities absent and changes of vascular walls absent.

Palpation.
Apex beat (maximal impulse). Location- 5th Inter costal space medially from mid clavicular line,
size 2 cm, Amplitude- Gentle
Duration- Unsustained
Aorta arch palpation- Right side 2nd intercostal space
Pulmonary artery pulsation to the left 2nd intecostal space
Epigastric palpation: Epigastric region normal
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Peripheral arteries pulsation:
Radial artery pulse 68/min, rhythm normal

Percussion.
Relative dullness Absolute dullness
Right lower 5th ICS 1cm from right sternal 5th ICS 1cm from left sternal
border edge edge
Left lower border 2 cm from apex beat 2 cm from relative dullness
Left upper border 3rd ICS 4th rib
Configuration of heart: Aortic configuration
Transverse diameter of vascular bundle: 5cm

Auscultation.
First heart sound: S1 is louder than S2 heard after long pause, low pitch, long duration,
synchrous with apex beat and carotid pulsation, no murmur.
Second heart sound: S2 is louder than S1 heard after short pause, high pitch, short duration,
asynchrous with apex beat and carotid pulsation, no murmur.
Auscultation points: Timbre tone normal
Systole rate: Normal. Rhythm- Normal
Murmur: Absent
Character of murmur: Absent
Auscultation of vessels: Durozier's double murmur absent. Trouble double tone. Nun's murmur
(venous hum in the neck) absent.
Arterial pressure: 140/ 80mmHg

GASTROINTESTINAL SYSTEM

Inspection of oral cavity (mouth): Normal smell

Teeth: Normal. Dental deposits absent. Artificial teeth absent.
Gums (gingiva): Color- Normal. Bleeding- Absent
Mucous membrane of the oral cavity: Color- Normal, Pigmentation- Absent. Ulceration-
Absent, Cicatrices- Absent
Tongue: Size- Normal, Color- Normal, clean
Throat: Mucous membrane- Normal. Colour- Normal
Tonsils: Size- Normal, Color- Normal.
Abdomen. Insteetion in upright and lying position.
Size- Normal. Configuration- Normal
Adiposis (obesity): Symmetrical. Participation in breathing- Normal.
Visible gastric and intestinal peristalsis is Absent. Strian- Absent. Pigmentation- Absent. Scars-
Absent.
Surface abdominal palpation: Absent
Liver and gallbladder: Normal size of liver (Gallbladder- Not palpable)
Spleen: Not palpable

URINARY SYSTEM

There was no pain in the location of lumbar and pubic region. There was no edema on the
face, legs or body. According to the patient the rate and number of urination was normal.
Urination was easy and normal flow. There was urination at night and he do not wake at night to
urinate. The urine has normal colour.
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 Main Clinical Syndromes :

1. Arterial Hypertension
High blood pressure is a common condition in which the long-term force of the blood
against your artery walls is high enough that it may eventually cause health problems,
such as heart disease.

Blood Pressure Systolic (mm Hg) Diastolic (mm Hg)

Category
Normal Less than 120 And Less than 80
Prehypertension 120-139 Or 80-89
High Blood Pressure 140-159 Or 90-99
(Hypertension) Stage 1
High Blood Pressure 160 or higher Or 100 or higher
(Hypertension) Stage 2
High Blood Pressure Higher than 180 Or Higher than 110
(Hypertension) Stage 3

Risk Stratification :
Risk group 1 no risk factors, no target organ damage/ clinical cardiovascular
disease.
Risk group 3 at least 1 risk factor, not including diabetus mellitus, no target organ
damage/ clinical cardiovascular disease.
Risk group 4 target organ damage/ clinical cardiovascular disease, diabetus with or
without other risk factors.

In this case patients highest blood pressure was 200/100mmHg. And patient having
diabetus mellitus. That tells us its Arterial Hypertension Degree 3, Stage III, Group Risk
4.

2. Left Ventricular Hypertrophy Syndrome

Left ventricular hypertrophy is a condition in which muscular wall of the left ventricle
becomes thickened.
In this case the thickness is about more than 1.1cm
The left relative cardiac dullness is located in the 5 th intercostal space, 0.5cm medially
from left border of relative cardiac dullness.

3. Congestive Heart Failure, Stage IIA, Functional Class II.

Heart failure arises asa the heart function fails to meet the oxygen demand. Stage IIA
indicates prolonged circulatory insufficiency and dysfunction of organ at rest.
Functional Class II signifies marked limitation of physical activity. Comfortable at rest,
causes fatigue, and shortness of breath (dyspnea).

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 Preliminary Diagnosis

Arterial Hypertension Degree 3, Stage III, Group Risk 4

because

1. Complaints:
Headache that occurs early in the morning and subsides during evening, heaviness in the
head. Dyspnea during moderate physical activity. General weakness

2. Anamnesis Morbi:
Patient having hypertension since 1997

3. Anamnesis Vitae:
Male
Diabetus mellitus type 2

4. Objective examination:
Arterial pressure during curation was 140/90 mmHg

a) Arterial Hypertension Degree 3 because blood pressure was 200/100 mmHg. Systolic pressure
is higher than 180 mmHg and diastolic pressure is higher than 100 mmHg.
b) Stage 3 because blood pressure 200/100 mmHg. Systolic pressure is higher than 180 mmHg
and diastolic pressure is higher than 100 mmHg.
c) Group Risk 4 because patient is having target organs damage which is heart (Congestive Heart
Failure) and patient is having Diabetus Mellitus.

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 E. FINAL DIAGNOSIS

Arterial Hypertension Degree 3, Stage III, Group Risk 4

Diabetus Mellitus Type 2, Chronic Gastritis
Congestive Heart Failure, Stage IIA, Functional Class II

Evidence based on patients examination:

1. Compailts:
Headache that occurs early in the morning and subsides during evening, heaviness in the
head.
Dyspnea during moderate physical activity. General weakness.
Dizziness and drowsiness.

2. Anamnesis Morbi:
Patient having hypertension since 1997.

3. Anamnesis Vitae:
Male
Diabetus mellitus type 2
General weakness, dizziness.

4. Objective examination:
Arterial pressure during curation was 140/90 mmHg
Left border of relative cardiac dullness: 5th intercostal space, midclavicular line of the left
laterally more than 0.5cm. Border of cardiac dullness shifted to left.
Stage III because blood pressure is more than 180mmHg/ more than 110mmHg. Risk
group C because of diabetus mellitus and target organ damage.
Heart failure stage IIA (Vasilenko-Strazesko) because present hemodynamic disorder,
work capacity of patient is decreased, congestion of lesser circulation
Heart failure class II (NYHA) because slight limitation of physical activity, shortness of
breath, and comfortable at rest.

a) Arterial Hypertension Degree 3 because blood pressure was 200/100 mmHg. Systolic pressure
is higher than 180 mmHg and diastolic pressure is higher than 100 mmHg.
b) Stage 3 because blood pressure 200/100 mmHg. Systolic pressure is higher than 180 mmHg
and diastolic pressure is higher than 100 mmHg.
c) Group Risk 4 because patient is having target organs damage which is heart (Congestive Heart
Failure) and patient is having Diabetus Mellitus.
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 D) Plan of investigations

Examination Suggested results

1. Complete Blood Analysis Increase ESR
2. Urine Analysis Increase in protein
3. Biochemical Blood Analysis Liprotein increase
ALT, AST increase
Cholestrol increase
4. X ray Left ventricular hypertrophy, Aortic
configuration
5. ECG Regular rhythm
Sinus P
Rate 60 90bpm
Position of axis deviation to left side
increase ST
6. Echocardiogram Inspection of left ventricular hypertrophy

Result of investigation

Blood analysis:
i) erythrocyte 4.6 x 1012
ii) Hemoglobin 153
iii) Color index 1.0
iv) Leukocyte 5.3 x 109
v) Eosinophils 2%
vi) Band nuclear cell 4%
vii) Segmented nuclear cell 64%
viii) Lymphocyte 28%
ix) Monocyte 2%
x) ESR 5

Blood chemistry analysis:

i) ALT 15
ii) AST 17.0
iii) Total protein 59g/l
iv) Albumin 45.5
v) Creatinine 109

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 vi) Urea 8.2
vii) Cholesterol 4.79
viii) Triglyceride 1.23
ix) Total bilirubin 24.3

Blood glucose level 4.6mmol/l

Urine analysis :
i) Amount 180/l
ii) Specific gravity 1.005
iii) Color Yellow clear
iv) Protein 0.03
v) Glucose 2%
vi) Leucocyte 0
vii) Erythrocyte 0
viii) Epithelial cell 0

X-ray chest and heart

Normal lung film but enlargement of left ventricle.

ECG
Regular sinus rhythm, ST-segment elevation in V1-V4.

Echocardiography
Normal contractility of the heart. LV hypertrophy.

F. Plan of Treatment
1. Regimen
control of diet
control cholestrol level

2. Diet
Diet No 10
The diet should spare the cardiovascular system and promote correction of abnormal
circulation, facilitates withdrawal of rest nitrogen and under oxidised metabolites.
The intake of fat is decreased. All dishes is salt free, and give to patient in 4-5g. Food is
given 5-6 times in equal portion.
The liquid intake per day is 1 liter, calorie intake is 2500-2800 kcal/day.

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 Pharmacotherapy

a. Calcium channel blockers

Amlodipine 5.0mg, 1 time per day

b. Beta blockers
Propanolol 10mg, 1 time per day in the morning

c. Angiotensin Converting Enzyme inhibitors (ACE)

Captopril 50mg, 3 to 4 times per day

d. Non Selective Cyclooxygenase (COX) inhibitors. Anti aggregants

Aspirin 75mg, 1 time per day after meal

e. Statins, HMG-CoA reductase inhibitors

Simvastin 40mg, 1 time per day in the evening

Algorithm for Treatment of Hypertension

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