Entrance examination Case 1

Basic Information
Family History
Social History
Pharmacological Anamnesis
Allergic Anamnesis
Personal History
Current Disease

   Patient K u z m  n e k Milan, PIN 370812/099, address: Praha 5, Fantova 8, post code 15000, home telephone number 24678913, health insurance company 111.
   admitted to Clinic of Internal Medicine of Teaching Hospital in Prague-Motol on January 1, 1999, at 11.50 p.m.
   for retrosternal pain persisting for 3 hours.
 
The second hospitalisation, the previous one was in June 1996.
Relatives: wife Ludmila, identical address.
 
FH: Father died at the age of 63 of recurrent myocardial infarction (the first infarction at 55), treated for hypertension, Type 2 DM, on diet.
Mother died at 72 of generalised breast carcinoma.
Two sisters 65 and 68 years, both still alive, one of them has suffered of Type 2 DM since the age of 60, treated with a diet.
Two children 35 and 38 years, both healthy.
 
SH: Old-age pensioner, lives with his wife in a flat on the 3 floor with a lift.
Previously worked as an electrician, this was a rather stressful job.
 
FA: NitroMack 1-1-0 capsule (coronary vasodilator)
Anopyrin 100mg 1-0-0 tablet (antiaggregation therapy following MI)
Vasocardin 1/2-0-1/2 tablet (cardioselective betablocker)
Enap 5mg 1-0-1 tablet (ACE inhibitor vasodilator for treatment of hypertension and heart failure)
Lipostat 20mg 0-0-1 tablet (statin for treatment of hypercholesterolaemia)
 
AA: hypersensitivity to penicillin (exanthema)
 
PH: In childhood frequent tonsillitis, no other serious illnesses.
Surgeries: appendectomy in 1960, cholecystectomy in 1988 due to gall stones.
Injuries: car accident in 1989 with a fracture of the left femur and osteosynthesis, no coma, without permanent disability.
Habits: ex-smoker 20 cigarettes a day, smoked from the age of 20 to 59 years, when he suffered myocardial infarction, has not smoked since. Coffee: 1 cup a day, alcohol only occasionally.
 
Ischaemic heart disease from 1996, when he suffered myocardial infarction of the lower wall (hospitalised here), in the interim after the infarction he felt well. In case of a greater physical activity he suffers from dyspnoea. Type 2 DM diagnosed in 1996, compensated only with a diet.
Neither digestive nor urinary disorders. Since 1996 he has been treated for hypercholesterolaemia, the body weight has become stable (86 kg), good appetite, stools regular without pathological components.
 
CD: On the day of admission, later in the evening (10.00 p.m.), an intensive retrosternal compressive pain occurred when at rest due to agitation, which prevented him from sleeping, irradiated to the neck and left arm, and was accompanied by general nausea - Cold sweat, and dyspnoea. Gradual application of 2 tablets of nitroglycerin under the tongue did not bring any relief. Based on recommendation by the ambulance he was admitted to the Coronary Unit at 11.30 p.m. The intensive pain persisted till the time of admission.

 

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