Case study (case history) of a patient with arterial hypertension (high blood pressure)with complications
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Medicine
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Vitebsk State Medical University
This is a case history of a patient with arterial hypertension and he has complications. The case history includes patient’s data, complaints, anamnesis vitae, anamnesis morbi , clinical manifestations, examination of each system and diagnostic methods; laboratory, instrumental etc. , differentia...
CASE HISTORY
PATIENT-MR ANDREY PETROVICH (66 YEARS)
MAIN DAIGNOSE-ARTERIAL HYPERTENSION GRADE 3, STAGE 2, RISK 3
COMPLICATIONS-ENCEPHALOPATHY, ANGIONEUROPATHY
CONCOMITANT DISEASE HEARING LOSS
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,PASSPORT DATA
NAME - ANDRE PETROVICH
DATE OF BIRTH - 1963.04.03
AGE - 57 YEARS
GENDER - MALE
FAMILY STATUS - MARRIED
OCCUPATION - WORKS IN A FARM ASA AN AGRICULTURAL WORKER
HOME ADRESS - 26, TERESHKOVOI, VITEBSK
DATE OF ADMISSION - 02.02.2020
PRELIMINARY DIAGNOSIS - ARTERIAL HYPERTENSIONGRADE 3, RISK 3
Complaints
The main complaints: severe oppressive headache in the temporal and frontal parts
of the head, arising in the evening and during excitement. For periodic dizziness,
accompanied by visual impairment flashing “flies" in front of the eyes, tinnitus,
single vomiting.
Additional complaints: for moderate constant pain in the hip joints, aggravated by
walking, prolonged standing, subsiding at rest. For a constant violation of mobility,
a feeling of stiffness in the hip joints. On heavy legs in the evening
Anamnesis morbi
Considers himself a patient since 2004, when headaches first appeared, dull,
periodic, occurring mainly in the evenings, as well as after physical exertion, the
pains stopped on their own; dizziness accompanied by vomiting; increase in blood
pressure up to 160/100 mm Hg She went to the hospital for medical help, underwent
a course of treatment and was discharged with a diagnosis of hypertension of 2 nd
stage, 2nd degrees, risk3. The patient was put on a dispensary account with a
therapist, the following drugs were prescribed: enalapril, indapamide. She received
treatment irregularly, and when she improved, she stopped taking medication.
From 2005-2007, she noted a periodic increase in blood pressure and 150/100
mmHg. In February 20, 2008, after psycho-emotional stress, the patient worsened:
a throbbing headache appeared in the occipital and parietal region of the head, which
could not be stopped with the usual doses of drugs, nausea, vomiting appeared,
visual impairment appeared in the form of a shroud, flashing of “flies” "Before the
eyes, tinnitus, blood pressure increased to 200/110 mmHg.
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, 02.02.20 was hospitalized in the therapeutic department of No. 5. During stay in the
hospital, he noted an improvement - headaches, dizziness, no visual impairment,
tinnitus - decreased, blood pressure decreased to 140/90 mm Hg. which was not
stopped by taking the usual doses of drugs, nausea, vomiting appeared, visual
impairment appeared in the form of a veil, flashing of "flies" in front of the eyes,
tinnitus, blood pressure increased to 200/110 mmHg.
Anamnesis vitae
General biographical information: Born on April 3rd, 1963. In 1988 he moved to
Vitebsk.
Social history: born in a complete family, was the second child of three. Nutritional
conditions of the family were unsatisfactory. Grew and developed normally, in
physical and mental development is also unsatisfactory
Professional history: she started working at the age of 16, worked on a collective
farm for agricultural work, graduated from vocational school, worked as a pastry
chef. Occupational hazards: work associated with prolonged standing. Retirement
since 55 years.
Domestic history: lives in a comfortable one-room apartment, in which three people
live. Food is regular, the regime is respected.
Obstetric and gynecological history:
Beginning of sexual activity 18 years.
Insurance history: retired from 55 years
Past diseases: acute pancreatitis in 2004
Viral hepatitis, tuberculosis, sexually transmitted diseases denied. Injury, blood
transfusion denied. She underwent surgery: appendectomy - 1987, surgical treatment
of pancreatitis - 2004.
Epidemiological history: contact with infectious patients and highly febrile denies.
Allergic history: There were no allergic reactions to drugs and food products.
Chronic intoxication: does not smoke, alcohol, does not use drugs.
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