2. Passport Data
Name: Premarchuk Yevdo Ivanivna
Age: 64 years
Sex: Female
Address: Village Buadkivski
Occupation: Pensioner
Date of admission: 12/01/2015
Diagnosis: Angina pectoris, unstable,
destabilization from 11/01/2015
3. Complains
• Chest pain behind sternum, irradiating to left
arm, intensive
• Pain starts after emotional stress or physical
activity
• Duration of pain is around 10 minutes and
subsides after taking nitroglycerine
• Dyspnea, Headache, Fatigue
4. Anamnesis of Disease
• She started to feel this pain in her chest since
two days, after some emotional stress, and
decided to take professional help.
• She was having dyspnea since last two weeks.
• She has been suffering from arterial
hypertension since last 10 years.
• She also have diabetes mellitus type 2 since
last 7 years.
5. Anamnesis of disease (Contd.)
• Never had any severe ischemic heart disease
like myocardial infarction or stroke earlier.
• Under medication for hypertension –
enalapril, and captopres sublingually in case of
sudden rise of blood preassure.
• Also under anti diabetic medicine.
6. Anamnesis of Life
• She has only 4 members in her family. Her son
and his family stays with her. In recent times
she is not in good terms with her son, and that
is the reason of her emotional stress, hence
leading to her condition.
7. General Status
• General condition: Normal
• Skin: Pale, decrease of skin turgor
• Auscultation of heart: Regular, without
pathology, accentuation of second heart
sound near aorta.
• Heart rate: 84 bpm
• Pulse: 84 bpm
• Blood pressure: 160/100 mmHg
22. Final Diagnosis
• Ischemic heart disease – Angina Pectoris,
unstable, destabilization from 11/01/2015.
• Diffused Cardiosclerosis
• Heart Failure IIA, functional class III
• Arterial Hypertension, stage II, degree II
• Diabetes Mellitus type 2
23. Treatment
• CLEXAN 0.4 2t/d for first 3 days, followed by 0.2 2t/d for
next 2 days (LMW Heparin)
• LOSPIRIN 75 mg po 1t/d in evening (NSAID)
• MONONITROSIDE po 10 mg 3t/d (Nitrate)
• ETSET 20mg 1t/d in evening (Statin)
• METOPROLOL 25 mg po 2t/d (Beta blocker)
• EOSINOPRIL 5 mg po 2t/d (ACE blocker)
• TICAGRELOR 90 mg po 1t/d (Cardiomagnil)
• TRIFAS 5 mg po ½ tablet in the morning (Diuretic)
• METFORMIN 50 mg po 1t/d in the morning (Anti diabetic)
• HYDAZEPAM 2 mg po 2t/d (Sedative)
• ARMADIN 2.0 injection iv 1t/d
• Neuropathological consultation