Complete History

 

       Name:Si Ruihua                                         Department:Lumber electric power bureau

       Sex: female                                                Present address: electric power bureau

       Age:80 years                                              Date of admission:2003-5-17

       Nationality: China xinjiang                         Date of record:2003-5-17

       Marital status: be married                          Reliability:reliable

       Occupation: family numbers                       History of allergy:deny

Chief complaints:  Palpitation and breathlessnss for 1 hour

Present illness:  The patient complained of palpitation with no precipitating factors an hour ago , at the same time she still feel breahlessness and precardial pain which didn’t radiated to other parts of body. This discomfort can’t be relieved by take a rest.As couldn’t suffer from that she had to came to hospital for help. In the course of the illness, he had no syncope, no cough, no headache, no diarrhea and vomiting. Her appetite, sleep, voiding and stool were normal.

Past history:  The patient deny the hypertension ,diabetes mellitus,obesity and valvular heart disease history.deny the allegies to pollen,dust medications or food.Deny the surgical procedures and injuries.

Review of systems:

Respiratory system:  no pharyngalgia; no chromic cough or hemoptysis; no dyspnea and thoracalgia;no afternoon fever or night sweats.

Circulatory system:  no palpitation and breathlessness on exertion: no precordial pain, dizziness and persistent headache; no syncope and hypertension.

Digestive system:  no sour regurgitation and dysphagia: no chronic abdominal ache, diarrhea and vomiting: no jaundice, hematemesis and melena.

Urinary system:  no past history of edema and proteinuria; no pollakiuria; no urgency and painful micturition; no visible hematuria and hypertension.

Endocrine and metabolic system:  no irritability, hidrosis or profound fatigue and headache; no impaired vision, exceeding thirsty and polyuria; no excessive hairiness or hair loss; no pigmentation and sexuality change.

Hematopoietic system:  no pale shin, no dizziness, blurred vision and tinnitus; no impairment of memory; no petechia and jaundic over the skin and mucosa; no lymph node, liver and spleen enlargement; no abnormal bony pain.

Muscle, bone and joint system:  no unusual pain, redness and swelling of the joints; no deformity of joints; no limbs and trunk limitation on motion; no myoasthenia and myoatrophy.

Nervous system:  no persistent headache and syncope; no memorial impairment or speaking obstacle; no insomnia and consciousness obstacle; no paresthesia of skin; no paralysis and convulsion. Mental status: no hallucination, delirium and orientation obstacle; no abnormal emotion

Personal history:  The patien’s economic status is good.He has no chance to  contact with poison.He consumed cigrettes 20 stickes per day,and a little of drinking.

Bearing history:  The patient was be married when he was 27 years old.He bearing 3 boys and 2grils.His husband died of  traffic accident.

Family history:  He deny the family history of such disease.

Physical  Examination

T:36.0℃   P:75bpm    R:18bpm    BP:104/53mmHg   W:45kg

General condition: normally developed, moderately nourished; active position, alert and

cooperative.

Skin and mucosa: normal temperature; no jaundice, eruptions or bleeding spots; no pigmentation,mile to moderate edema.

Lymph gland: no superficial lymph nodes enlargement.

Head organ: normal shape of head; hair black and shining with average distriution; no scars.

     Eyes: no edema of eyelids; no bleeding spots of conjunctiva; no sclera jaundice; cornea

clear, pupils round, symmetrical in size and acutely reactive to light.

     Ears: normal hearing; no purulent secretion of the external canals; on tenderness over

mastoids.

Mouth: lips red without cyanosis; teeth in alignment, no carious teeth or gingival

hemorrhage; pharynx injected; no enlarged tonsils seen; smooth and glossy tongue

in midline.

Neck: supple without rigidity, symmetrical; no cervical venous distention; no abnormal carotid

impulse; trachea in midline; no enlargement of thyroid gland.

Chest: symmetrical; thoracic breathing predominately; rhythm normal.

Lung: Inspection: equal breathing movements on two sides.

          Palpation: no difference of vocal fremitus over two sides; no friction rub felt,

          Percussion: resonant on percussion over both lungs. The lower border of lungs lies on right mid-clavicular line at fifth inertcostal space and subscapular line at ninth intercostal space and left scapular line at tenth intercostal space. Shifting degree 4cm.

          Auscultation: normal breath sound, no dry or moist rales audible.

Heart: Inspection: no pericardial protuberance. Apex beat seen 1cm within left mid-clavicular line at fifth intercostal space. Diameter of impulse is 1.5cm.

          Palpation: no thrill or friction felt; no lifting impulse: apex beat observed on the same location as on inspection.

          Percussion: normal dullness of heart borders. Relative dullness of heart borders measured as follow:                                       

Right(cm)   Intercostal space  left(cm)

2.            II           3   2.            III          4   3             IV         7                   V         8.5

Auscultation:

      heart rate: 75/ min;                                        

      rhythm regular; no                                        

      gallop thythm; no                                         

      murmur or pericardial                                      

                       friction sound audible.

Peripheral vascular sign: full pulse, rhythm regular; no paradoxical pulse and deficient pulse; no water-hammer pulse and gunshot sound; no capillary pulsation.

Abdomen: Inspection: symmetrical; no abdominal distension or dilated veins; no skin rash or scar; no abnormal intestinal and peristaltic waves seen.

         Palpation: abdominal wall flat and soft without tenderness or rebounding tenderness. no succession spleen and kidneys not palpable

         Percussion: no shifting dullness; mild tympany. Dullness of liver borders within normal limit. The upper border of liver lies in right mid-clavicular line at fifth intercostal space. No percussion tenderness over the kidney region.

         Auscultation: normal bowel sounds. No vascular murmur heard.

Anus and rectum: no anal fissure or proctoptosis; no fistulous tract or hemorrhoid.

External genitalia: normal distribution if the pubic hair; normal development of external genitalia; no scars or ulcers.

Spine: normal spinal curvature without deformities; normal movements; no tenderness.

Extremities: moderate pitting edema found over both legs. No clubbed fingers(toes); no

myoatrophy, varicose veins or fracture; no redness and swelling of joints; no

tenderness or deformities of joints. motor function normal. no limitation of joint

movement.

Neurological reflex: dermatographism. normal abdominal and bicipital muscular reflex; patellar and heel-tap reflex nomal; Babinski sign(-); Oppenhein sign(-); Gordon sign(-); Chaddock sign(-); Hoffmann sign(-); Kerning sign(-); Brudzinski sign(-).

Laboratory  Data

ECG: supraventricular tachycardia

Summary  Of  Case  History

Si Ruihua ,female, 80 years. Palpitation and breathlessnss for 1 hour is the chief complain. The patient complained of palpitation with no precipitating factors an hour ago , at the same time she still feel breahlessness and precardial pain . ECG: supraventricular tachycardia.

 

                                                                 Primary diagnosis:  supraventricular tachycardia

 The Plan of diagnosis and therapy:

1.       Antiarrhythmic agents such as calcium channel antagonists may be tried to stop the supraventricular tachycardia.

2.       The ablation therapy may be selected according to the patient’s age, phyisical condition and her attitude toward this disease.

 

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