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UDC: 616-01
THE IMPORTANCE OF THE INDIVIDUAL APPROACH TO THE PATIENT ON THE EXAMPLE OF CLINICAL CASE
Kaydalova A. O.1, Abdel Wahhab O. Dzh.1, Asaje S. D.2, Belal S. A. S.3, Lysenko N. V.1
1 V. N. Karazin Kharkiv National University, Kharkiv, Ukraine
2 Kharkiv City Perinatal Center, Kharkiv, Ukraine
3 Medplus Nordrhein, Dusseldorf, Germany
Any disease is the result of the interaction of pathologic process and the patient's personality, so the basis of optimal treatment strategy is physician and patient partnership in the fight for recovery and/or the most beneficial progress of chronic diseases with the highest possible quality and life expectancy. The implementation of this postulate is only possible with correct diagnosis, which presents some difficulties in this case. Due to individual approach we were able to find the optimal treatment and not to harm the patient. We recommend for all who works in practical medicine to put into the basis of the treatment, first of all, the patient's personality.
KEY WORDS: individual approach to the patient, formation of right atrium, optimal treatment
ВАЖЛИВ1СТЬ ЩДИВВДУАЛЬНОГО ЩДХОДУ ДО ПАЩеНТА НА ПРИКЛАД1
КЛШ1ЧНОГО ВИПАДКУ
Кайдалова А. О.1, Абдел Ваххаб О. Дж.1, Асадже С. Д.2, Белал С. А. С.3, Лисенко Н. В.1
1 Харювський нацюнальний ушверситет iMeHi В. Н. Каразша, м. Харюв, Украша
2 Харювський мюький перинатальний центр, м. Харюв, Украша
3 Медплюс Нордрейн, Дюссельдорф, Шмеччина
Будь-яка хвороба е результат взаемодп патолопчного процесу i шдив^альносп пащента, тому основу оптимально! тактики л^вання становить партнерство пащента i лжаря в боротьбi за одужання ^або максимально сприятливий хрошчний перебк1 хвороби з максимально можливими яюстю i тривалiстю життя. Реалiзацiя даного постулату можлива тшьки при постановцi правильного дiагнозу, що представляло певнi труднощi в нашому випадку. Завдяки iндивiдуальному пiдходу нам вдалося пдабрати оптимальне лiкування i не нашкодити пацiенту. Рекомендуемо вшм працюючим в практичнiй медицинi ставити в основу лжування, перш за все, шдивщуальнють пацiента.
КЛЮЧОВ1 СЛОВА: шдив^альний пiдхiд до пацiента, утворення правого передсердя, оптимальне л^вання
ВАЖНОСТЬ ИНДИВИДУАЛЬНОГО ПОДХОДА К ПАЦИЕНТУ НА ПРИМЕРЕ
КЛИНИЧЕСКОГО СЛУЧАЯ
Кайдалова А. А.1, Абдел Ваххаб О. Дж.1, Асадже С. Д.2, Белал С. А. С.3, Лысенко Н. В.1
1 Харьковский национальный университет имени В. Н. Каразина, г. Харьков, Украина
2 Харьковский городской перинатальный центр, г. Харьков, Украина
3 Медплюс Нордрейн, Дюссельдорф, Германия
Любая болезнь есть результат взаимодействия патологического процесса и индивидуальности пациента, поэтому основу оптимальной тактики лечения составляет партнерство пациента и врача в борьбе за выздоровление и/или максимально благоприятное хроническое течение болезни с максимально возможными качеством и продолжительностью жизни. Реализация данного постулата возможна только при постановке правильного диагноза, что представляло некоторые трудности в нашем случае. Благодаря индивидуальному подходу нам удалось подобрать оптимальное лечение и не навредить пациенту. Рекомендуем всем работающим в практической медицине ставить в основу лечения, прежде всего, индивидуальность пациента.
© Kaydalova A. O., Abdel Wahhab O. Dzh., Asaje S. D., Belal S. A. S., Lysenko N. V., 2017
КЛЮЧЕВЫЕ СЛОВА: индивидуальный подход к пациенту, образование правого предсердия, оптимальное лечение
INTRODUCTION
A patient (Latin «patiens» - suffering, enduring) is a person who receives medical care and uses medical services regardless of the presence or absence of a disease [1].
The goal of any medical procedure is to achieve the best clinical result with the greatest possible improvement in the quality and life span of the patient while minimizing the cost of therapy [2]. The basis of the approach is the cooperation of the doctor and patient in all spheres of life of the latter. We vividly elaborated the importance of an individual approach to the patient on the example of this clinical case.
OUR PATIENT
Passport data: a man, 52 years old, a resident of the city, a pensioner.
At the time of admission, he complained of piercing pain in the middle third of the rib cage on the left that occurs when weather changes. Pain lasts for several hours, does not irradiate, disappears spontaneously or after taking isosorbide dinitrate, there is no connection between chest pain and physical exertion; rhythmic heartbeat, appears mainly with excessive physical exertion, lasting up to 10 minutes, disappearing spontaneously; rare episodes of single extrasystole without any clinical manifestations lasting up to several minutes; dyspnea when performing excessive physical exertion, disappears at rest within 3-5 minutes.
ANAMENESIS OF THE DISEASE
Till May 2014 there were no complaints from the cardiovascular system: blood pressure was not monitored properly, during medical examination at work, the indicators were recorded within the limits of normotension or hypotension; suffered acute Q-positive anterior myocardial infarction from 09.05.14; he was treated repeatedly as an outpatient and inpatient at the place of residence; last month, he took aspirin, atorvastatin, isosorbide dinitrate when the need arises. His current visit to the hospital was planned for the purpose of medical examination and if necessary, correction of therapy.
ANAMNESIS OF LIFE
In 2009 during esophagogastroduodenoscopy erosive gastritis was detected without accompanying clinical manifestations, there was no treatment prescribed, no medical documentation was provided; smoked for 20 years about 20 cigarettes a day, quitted smoking from 09.05.14. Diabetes mellitus, Botkin's disease, had no history of tuberculosis. There was no allergy.
OBJECTIVE STATUS
The general condition is satisfactory, the consciousness is clear, the patient is active. BMI = 21 kg/m2. Skin and visible mucous membranes without features. Peripheral lymph nodes are not enlarged. The thyroid gland is not clearly defined. Musculoskeletal system without features. On percussion of lungs, a pulmonary sound, on auscultation breathing is vesicular. Sinus rhythm, muffled tones, pulse = heart rate = 65 beats/min, BP on both hands 120/80 mm Hg. The abdomen is of normal size, soft, painless. The liver is at the edge of the costal arch, painless. No abnormalities in physiological functions (according to the patient). Negative Pasternatsky's symptom on both sides. Absent shin Edema.
PLAN OF SURVEY
Clinical blood test, a clinical urine analysis, a biochemical blood test (total cholesterol, bilirubin, AlAT, AsAT, fasting blood serum glucose, creatinine, urea, potassium, sodium), chest X-ray, ECG, ultrasound of the heart, daily monitoring of ECG and blood pressure.
SURVEY RESULTS
Clinical blood test: the parameters are within the normal range.
Clinical analysis of urine: parameters are within the normal limits.
Biochemical blood test: hypercholes-terolemia.
Chest X-ray: Absence of Focal and infiltrative changes in the lungs. The root structures are not expanded. Sinuses are clear. The diaphragm is clearly delineated. The heart is of normal shape and size. The aorta is not changed.
ECG: Sinus rhythm, regular, heart rate 54 beats/min (bradycardia). Scarring of the myocardium in the apical anterior-septal region. Q wave is positioned in the III standard lead. The disturbance of repolarization processes is diffuse.
Daily monitoring of ECG and blood pressure: During the whole period of observation against the background of a sinus rhythm the patient had an average heart rate of 67 beats/min, single supraventricular and ventricular extrasystoles were recorded. Ischemic ECG changes are not recorded. The systolic and diastolic blood pressure are characteristic for normotension throughout the observation period.
Echocardiogram (one month before admission, provided by the patient): Sclerotic changes in the walls of the aorta, valves of the aortic and mitral valves. Dilation of the left atrium. Dilation of the ascending aorta. Hypertrophy of myocardium of the left ventricle. Hypokinesia of the myocardium of the interventricular septum, apex and antero-lateral wall of the LV. Aneurysm of the upper left ventricle and apical segment of the interventricular septum. Pathological formation in the cavity of the right atrium (thrombus? myxoma?) with the size 26,6^8,8 mm. EF 38 %.
Echocardiography (in current hospitali-zation): Sclerotic changes in the walls of the aorta, valves of the aortic and mitral valves. Dilation of the left atrium. Dilation of the ascending aorta. Hypertrophy of myocardium of the left ventricle. Hypokinesia of the myocardium of the interventricular septum, apex and antero-lateral wall of the LV. Aneurysm of the upper left ventricle and apical segment of the interventricular septum. EF 43 %. No relevant information in cavity of the right atrium was obtained.
Echocardiography (again in the present hospitalization): Sclerotic changes in the walls of the aorta, valves of the aortic and mitral valves. Dilation of the left atrium. Dilation of the ascending aorta. Hypertrophy of myocardium of the left ventricle. Hypokinesia of the myocardium of the interventricular septum, apex and antero-lateral wall of the LV. Aneurysm of the upper left ventricle and apical segment of the Interventricular septum. Vascular network Chiari in the cavity of the right auricle. EF 41 %.
Exercise stress test: the presence of myxoma/right atrial thrombus is a relative contraindication to the conduct of this test, so the procedure was not performed.
CLINICAL DIAGNOSIS
CHD: Atherosclerosis of the aorta. Postinfarction (09.05.14 Q-positive antero-posterior-apical) cardiosclerosis. Aneurysm of the tip of the left ventricle. Aneurysm of the apex segment of the interventricular septum. Formation of the right atrium (?). HF stage I 1st functional class with reduced systolic function of the left ventricle.
RECOMMENDED TREATMENT
Modification of lifestyle: dieting, regular physical activity.
Drug therapy: clopidogrel 75 mg in the afternoon until May 2015, aspirin 75 mg in the evening, atorvastatin 20 mg at night, nebivolol 2.5 mg in the morning, ramipril 2.5 mg in the morning.
RECOMMENDED SURVEYS
Lipid profile and exercise stress test after final diagnosis
Any disease is the result of the interaction of the pathological process and the individuality of the patient [3], therefore the basis of the optimal treatment tactic is the partnership of the patient and the doctor in the struggle for recovery and / or the most favorable chronic course of the disease with the highest possible quality and life expectancy [2]. Implementation of this postulate is only possible with the formulation of the correct diagnosis, which presented some difficulties in our case in view of the ambiguous results of echocardiography.
In favor of expectant management regarding the formation of the right atrium, the absence of clinical signs of any of the presumed structures of the right auricle, a significant harm to the patient's health when choosing empirical treatment of the assumed formations.
OUR TACTICS OF TREATMENT: RESULTS
We regularly made telephone visits, negative dynamics of the patient's health was not observed.
In January 2015, spiral computed tomography of the heart with contrast was performed, no formations of the right atrial cavity and Chiari vasculature were detected.
We hurried slowly and respected the basic everyone to rely on an individual approach to law of medicine - do no harm. We recommend the patient in real clinical practice.
REFERENCES
1. Oxford dictionaries [electronic source] // Access mode: http://www.oxforddictionaries.com/
2. Ashcroft R. The Goals of Medicine: The Forgotten Issue in Health Care Reform / R. Ashcroft // J Med Ethics. - 2000. - № 26. - p. 293-294.
3. Boorse C. Concepts of health and disease / C. Boorse // Philosophy of Medicine. - NY: Springer, 2011. -p. 13-64.
