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Standard of answers in a clinical case
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«IHD. Stable stenocardia III FC»
| № | Critereas of the steps assesment | |
| Collecting complaints and anamnesis | It is carried out sequentially and it is systematized | |
| Specification of symptoms of an illness | Asked questions for specification of character of pains, duration and irradiations of pains, effect from reception of Isoketum. | |
| Definition of the risk factors of development of an atherosclerosis of coronary vessels | Age, male, heredity, smoking, excess weight | |
| Physical examination | The increased body weight is revealed, conducted the examination on detection of peripheral edemas | |
| 5. | Examination of the cardiovascular system | Measurement of the CARDIAC CONTRACTIONS RATE, pulse and BP with keeping of rules. Defined the borders of the relative dullness of heart, made auscultation of heart sequentially and correctly |
| Justification and formulation of the preliminary diagnosis | Considering character of pain: gripping pains behind a breast with an irradiation in the left hand, less than 5 min., arising when walking on distance up to 150 m and passing after the prima of Isoketum, considering risk factor and given the anamnesis - attacks have constant character, there are 1, 5 years, pains did not become frequent and amplified lately: Ischemic heart disease. Anginas of exertion of the III FC. | |
| 7. | Purpose of the plan of instrumental examination | ECG, EchoCG, Daily monitoring of an ECG by Holter, physical stress test |
| 8. | Purpose of the plan of laboratory examination | 1. General blood analysis; general urine analysis. 2. Biochemical blood analysis: urea, creatinine, blood glucose Lipide profile, uric acid |
| 9. | Interpretation of the ECG | On the ECG registered at the time of an attack, noted the shift of the RS-T segment below an isoline, reflecting development of an acute ischemia and damage in subendocardial parts of a myocardium |
| 10. | Interpretation of results of daily monitoring of an ECG | Revealed: - violation of coronary blood supply: a ST segment depression to 0.2 mV in the left chest assignments |
| 11. | Interpretation of EchoCG | Aorta is sclerozed. The sizes of the right and left ventricles are not increased. Hypertrophy of a left ventricle. Hypo -akinesia of the posterior-lateral LV. Contractive ability of a myocardium is a little reduced |
| Interpretation of general blood analysis and urine | Indexes within norm | |
| Interpretation of biochemical analysis | Dislipidemy (increase of level of a cholesterin, triglycerides, low density lipoprotein, decrease in high density lipoprotein) | |
| Justification and formulation of the clinical diagnosis | Diagnosis of an ischemic heart disease, stable stenocardy of exertion of the III functional class. A postmyocardial infarction cardiosclerosis of 2013 ChHF I.FK 2 | |
| Definition treatment planning | · • Not medicamentous therapy (mode II, diet 10) Anti-anginal therapy (beta adrenoblockers nitropreparations). · • Antithrombocitic preparations (Acidum acetylsalicylicum (ASK), · • Hypolipidemic therapy (statina). |
Made by: assistant of department Usipbekova M.I.
Reviewer: Aymakhanova G. T Candidates of Medical Science., the associate professor of internship and residency on therapy No. 1
The scenario is discussed and approved at faculty meeting of ID No. 1. The protocol No. 2, from 16.09.2015.
The scenario is discussed and approved at a meeting the COP of ID. The protocol No. 1, from 29.09.2015.