Volgodonsk Psychoneurological Dispensary

DISCHARGE SUMMARY No. 534

YUKHINA TATYANA VALERYEVNA - born 1973, Volgodonsk
100 Morskaya St., apt. 119
PUGH (Urban Economy Production), cleaner

Admitted: 21.09.99
Discharged: 10.12.99

Diagnosis: Post-traumatic stress disorder. Post-concussion syndrome. Barotrauma /E43.1/308.3, E07.2/310.2/

Examinations:
* Hepatitis, P-20-none, TB No. 48 dated 20.09.99, normal.
* RV (Syphilis test) No. 23 dated 22.09.99.
* VG (Blood group) No. 1007 dated 22.09.99.
* VS (Blood sugar) No. 1827-28 dated 23.09.99.
* Urinalysis: 1010, acidic, Protein-neg, epithelium 6-8-10, leukocytes 1-2
* Complete Blood Count: RBC 4.0x10^12, Hb-122, WBC-4.8x10^9, ESR-13

Echo-EG dated 22.09.99: Displacement of midline brain structures not registered. Midline M-echo = 15mm. Pronounced signs of intracranial hypertension.
Echo-EG dated 12.11.99: Displacement of midline brain structures not registered. Midline M-echo = 11mm. Signs of moderately pronounced intracranial hypertension.

REG (Rheoencephalography) dated 4.10.99:
* Carotid artery basin: pulse blood filling moderately reduced; arteriolar resistance slightly increased; peripheral vascular resistance on the left slightly increased.
* Vertebral artery basin: pulse blood filling slightly reduced; arteriolar resistance increased; resistance of postcapillaries and venules slightly increased; venous outflow on the left slightly obstructed; peripheral vascular resistance on the left slightly increased.

ECG dated 22.09.99: Sinus rhythm 69 bpm. Left ventricle rotated forward. Impairment of myocardial repolarization processes in the anteroseptal region.

Treatment: phenazepam, amitriptyline, aloe IM, magnesia IV, dibazol IV, piracetam IV, nicotinic acid, aminalon, FIBS IM, cinnarizine, sonapax, vit. B1 + ascorbic acid IV, vit. B6 IM, xanthinol nicotinate IM, tanakan, glycine.

The patient was discharged with improvement.
Recommended: Follow-up with a neurologist.

Acting Head of Department: Nesterova T.K.
Attending Physician: Cherepelitsa V.V.