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the Stuff has sent Zemljanov D.A.
the Mark - 4 ("chorus")
the CASE HISTORY
the Clinical diagnosis: Not hospital bilateral focal pneumonia in the inferior lobes of both mild, average flow with respiratory failure I of a degree.
the Curator: the student 3ãî a course honey. F-that, gr. 6, des. 9, Zemljanov D.A.
the Principal: ass. Kolbina I.V.
Zaporozhye 2002
I. THE PASSPORT PART.
- FIRST NAME, MIDDLE INITIAL, LAST NAME: ********** ******* **********
- Age: 19.12.1987 g.r. (15 years)
- the Sex: man's
- the Nationality: ukrainets
- Formation: the pupil compare schools
- the Marital status: it is single
- the Home address: ******************************
- the Place of study: compare school ¹3, 9 class
- Date of entering in a hospital: 11.11.2002
- Number of the days lead by a hospital: 11 (till 22.11.)
II. COMPLAINTS:
At entering in a hospital of the patient showed complaints on: tussis with a viscid difficultly abjointed sputum, delicacy, a sweating, rising t*deg; up to 39*deg; With.
At the moment of a curatio at the patient tussis with a mucous sputum, delicacy, a sweating was kept.
III. INTERROGATION ON SYSTEMS:
à). The general state: average, character of a temperature curve - aperient; the fever is not present, edemas is not noticed. The itch is not observed, icteruses too; in the past of hemorrhages, an eruption, ulcers were not; changes on the part of organs of locomotion it is not revealed.
á). A respiratory organs: respiration through a nose free. Of nasal bleedings does not complain. A state of olfactory function without pathological changes. Pains in a larynx and a nasopharynx are absent. Fauces bloodshot. Tussis with the viscid difficultly abjointed sputum, not connected in due course day. Of a pneumorrhagia does not complain. The short wind arises at a usual exercise stress. Of stethalgias does not complain.
â). Cardiovascular system: complaints to palpitation and a pain in range of heart does not show.
ã). Organs of digestion: on dryness in a mouth, the hypersalivation, abnormal taste in a mouth does not complain. Appetite is reduced. A swallowing free. Allocation of reception of nutrition within day uniform, a malaxation careful. Complaints to an eructation, a heartburn, a nausea, a vomiting, gravity and in an anticardium are not present a pain. The chair correct, constipations, diarrheas, at a defecation and tenezmov is not present pains. Colour of fecal masses usual, without pathological admixings. Othozhdenie parasites it is not observed. The itch in range of an anus is not present. Hemorrhoidal shishek, bleedings from a fundament are not present.
ä). A liver: pains in the right hypochondrium are not present.
å). Genitourinary system: on a back pain of complaints does not show. The daily urine is not broken. Sexual ability is kept. An emiction free, painless. Pains and a burning sensation in a urethra are absent. Abjections from a urethra are not present.
æ). Nervous system: mood quiet. Ability to brainwork is not broken. Memory and dream without changes. Headaches are not present.
ç). Sense bodys: vision, audition are not broken.
IV. THE ANAMNESIS OF ILLNESS:
Has felt the patient 27.10.2002. Disease began is acute, when after a frigorism has raised t*deg; up to 38*deg; S.Na the next day has appeared dry tussis. Behind a medical care of the patient it did not address, treated independently. Accepted antipyretic, expectorants, saws tea with a raspberry. On a background of the lead treatment the state of the patient has improved - t*deg; has gone down up to 36,7*deg; With, tussis has decreased.
From 07.11.2002 began deterioration: has raised t up to 39*deg; With, delicacy, a sweating have appeared tussis with a viscid difficultly abjointed sputum. The patient has caused the local doctor who has diagnosed: an acute pneumonia also has directed on hospitalization.
V. THE ANAMNESIS OF LIFE:
Was born in Zaporozhye 19.12.1987. The first child in monogynopaedium. A state of health of parents at the moment of a birth of the child satisfactory. At children's age educed normally. Studies well. The attitude to study and collective positive.
Conditions of a life good, on a regular basis eats, with clothes on a season it is provided.
In an anamnesis often acute infections, a chronic bronchitis which usually becomes aggravated in the autumn and in the winter.
Harmful habits has no. Family, constitutional diseases at parents and close relatives it is not revealed. A state of health of parents satisfactory.
Allergoanamnez it is not burdened.
VI. OBJECTIVE INSPECTION OF THE PATIENT:
the Position of the patient awake. Consciousness clear. A look quiet. A state of a palpebral fissure without seen pathological changes. Body height 170ñì. Weight 56êã.
the Body build strong. Normostenik. Fatness sufficient.
the Skin dry, acyanotic, a Crocq's disease. Eruptions, hemorrhages and cicatrixes it is not observed. Decubituses are not present. The skin is elastic. A hair and nails is in good condition. The hypodermic fat is advanced in regular intervals. Edemas it is not revealed.
submandibular, axillary, inguinal lymphonoduses, as spherical mjagkoellasticheskih formations, by the dimension about 0,8 sm, not spajannyh among themselves and environmental tissues Are palpated. At a palpation painless. A skin above lymphonoduses without changes.
the Muscular system is advanced moderately. Tone of muscles normal. Pains in muscles are not present.
Thickenings of a periosteum and bones it is not observed. Changes of size, the form of bones, pains are not present. Pathological rachiocampsises are not present. The size and the form of joints are not changed. Morbidities, a crunch, are not present fluctuation. Colour of a skin and temperature above joints without changes.
the Respiratory organs:
the Thoracal cell normosthenic, symmetric. Both half of thoracal cell participate in the act of respiration. A state above and subclavial fossas, intercostal spaces without changes. The auxiliary musculation does not participate in the act of respiration. Scapulas prizhaty to a body. CHDD - 20, phylum of respiration blended.
the Palpation of a thoracal cell:morbidity of intercostal spaces, ribs is not marked. A voice tremor in limens of norm.
the Relative percussion mild:clear pulmonary a note.
the Topographical percussion mild:
Height of standing of apexes mild in front: dextral mild - 3,5 sm, left - 4 see.
the Height of standing of apexes dextral and left mild behind corresponds to a level of an acantha of VII cervical vertebra.
the Width of fields Kreniga on the right and at the left compounds 5 see.
the Inferior border mild.
Dextral mild:
Lin. parasternalis dextra - the top edge of VI rib;
lin. medioclavicularis dextra - the inferior edge of VI rib;
lin. axillaris anterior dextra - the top edge of VIII rib;
lin. axillaris posterior dextra - the inferior edge of VIII rib;
lin. scapularis dextra - IX rib;
lin. paravertebralis dextra - an acantha of XI thoracal vertebra.
Left mild:
Lin. parasternalis sinistra - the top edge of IV rib;
lin. medioclavicularis dextra - the inferior edge of VI rib;
lin. axillaris anterior dextra - the top edge of VIII rib;
lin. axillaris posterior dextra - the inferior edge of VIII rib;
lin. scapularis dextra - IX rib;
lin. paravertebralis dextra - an acantha of XI thoracal vertebra.
Excursion mild is peer 3 see.
Auskultatsija mild:respiration rigid. Wet microvesicular rhonchuses in subscapular and axillary ranges of both mild. The crepitation is not listened. The pleural rub, a capotement on Hippocrates, hum of a dropping drop is absent.
Cardiovascular system.
At survey of range of heart and large pots: diverticulums, systolic vtjazhenija, an epigastri? pulsing, a pulsing in II intercostal space, in a bulbar fossa, a pulsing somnolent and other arterias, capillary sphygmus, a swelling of cervical veins and their pulsing, " the cat's purring " and a positive venous pulse it is not revealed.
the Apical beat is localized in V an intercostal space on 1,5 sm knutri from lin. medioclavicularis sin., resistant, the area of 2 sm, high.
the Percussion:
Relative cardiac dullness:
Dextral border: on 0,5 sm knaruzhi from lin. sternalis dex.
Left: on 1,5 sm knutri from lin. mediîclavicularis sin.
Top: the top edge of III rib on lin. parasternalis sin.
Absolute cardiac dullness:
Dextral border: by a left edge of a breast bone.
Left: on 1,5 sm knutri from lin. mediîclavicularis sin.
Top: corresponds to a cartilage of IV rib.
the Width of a vascular bundle is peer 6 see.
Auskultatsijathe Heart rhythm: a tachycardia. Tints sonorous, rhythmical, clean. Accents, scissions, dualizations and hums of heart are not auscultated.
Sphygmus rhythmical, a normal strain, the good filling, symmetric. On a radial arteria sphygmus of 82 ud./minutes.
a blood pressure on a humeral arteria 100/70.
Organs of digestion.
Survey of an oral cavity: an odour from a mouth normal. Fractures around of a mouth and are not present a pigmentation. Kajmy on edge desen it is not revealed. At the patient of 32 able-bodied dens. Tongue wet, impose - at a root a white strike. Atrophies of papillas of tongue are not present. Fauces bloodshot. Tonsils are not enlarged, without cicatrixes, without purulent a proside in kriptah, do not leave for the palatal handle.
Survey of a gaste:the form of a gaste correct, without vtjazheny and the diverticulums, the seen peristalsis is not present. A belly-button involve. Dilatings of saphenas of a forward abdominal wall, hernias it is not observed.
Ata superficial palpationmorbidities and a muscular strain of a forward abdominal wall it is not revealed. Sign SHCHetkina-Bljumberga negative. The ascites is not present.
the Deep palpation:the sigmoid intestine is palpated in the left ileal range as the smooth dense painless not rumbling cylinder, diameter 2 see. Shift of a mesentery 5 see.
the Descending department of a colon is palpated in left flanke a gaste as mobile moderately dense, painless cylinder.
the Caecum is palpated as smooth, painless, moderately resilient, weakly mobile, slightly rumbling cylinder, width 4 see. Shift of a mesentery 5 see.
the Ascending department of a colon is palpated in the right flanke a gaste as mobile moderately dense, painless cylinder.
the Inferior border of a stomach is palpated on 3 sm above a belly-button as the smooth, mild, inactive platen.
the Transversal colon is palpated in umbilical range as cross-section laying, arcually curved from top to bottom, the dense, painless cylinder. It is easily displaced upwards and downwards.
the Appendix is not palpated.
the Dimensions of a liver on Kurlovu:
on a dextral mammilar line - 9 sm;
on a lobby median - 8 sm;
on the left costal arch - 7 see.
the Inferior edge of a liver is at edge of a costal arch. He mild, acute, painless. Cholic bladder is not palpated. A Frenikus-sign and sign Kurvuazje negative.
the Lien is not palpated. It is percussion borders are determined: dlinnik - 7 sm, a diameter - 5 see.
At a conjoined manipulation of nephroses it has not been revealed ptoses, morbidities and bugristosti.
Sign Pasternatskogo negative. Morbidities on a course of ureters are not present.
It is percussion in suprapubic range the blunt note is determined, morbidity is absent.
VII. THE PRESUMABLE DIAGNOSIS.
On the establishment of complaints of the patient on tussis with a viscid difficultly abjointed sputum, delicacy, a sweating, rising t*deg; up to 39*deg; With.
On the establishment of an anamnesis of illness: has felt the patient 27.10.2002. Disease began is acute, when after a frigorism has raised t*deg; up to 38*deg; S.Na the next day has appeared dry tussis. Behind a medical care of the patient it did not address, treated independently. Accepted antipyretic, expectorants, saws tea with a raspberry. On a background of the lead treatment the state of the patient has improved - t*deg; has gone down up to 36,7*deg; With, tussis has decreased. From 07.11.2002 began deterioration: has raised t*deg; up to 39*deg; With, delicacy, a sweating have appeared tussis with a viscid difficultly abjointed sputum. The patient has caused the local doctor who has diagnosed: an acute pneumonia also has directed on hospitalization
On the establishment of an anamnesis of life: often acute infections, a chronic bronchitis which in the season autumn - winter usually becomes aggravated.
On the establishment of interrogation on systems: originating of a short wind at a usual exercise stress.
On the establishment of the objective data: respiration rigid. Wet microvesicular rhonchuses in subscapular and axillary ranges of both mild. It is possible to formulate the presumable clinical diagnosis: not hospital bilateral focal pneumonia in the inferior lobes of both mild, average flow with respiratory failure I of a degree.
VIII. THE DATA OF ADDITIONAL RESEARCHES
Analysis of a blood:
the Blood on RV: negatively.
the Blood from 12.11.2002: erythrocytes - 4,88 · 10*12/ë; Hb - 154 g/l; a color parameter - 0,9; leucocytes - 15 · 10 (in 9îé degrees)/ë; JU - 0,02 %; P - 3 %; With - 60 %; E - 3 %; L - 27 %; M - 8 %; SOE - 26 mm / ch.
the Thymol turbidity test: 1,0 units of opacification
ALT: 0,59 mmol/l
the Bilirubin the general: 2,5 mmol/l
Crude protein: 81,1 g/l
Saccharum of a blood: 5,0 mmol/l
Alkaline fosfotaza: 4565 n/mol/sek/l
Analysis of a feces:the ja/worm is not found.
Analysis of a sputum:
Colour - grayish; character - mucopurulent; a consistence - tough; E - 2 %; leucocytes - 25-35 %; epitel. alv. 0-1; VK it is not revealed; pnevmotsisty is not present.
Analysis of urine:
Amount - 110; colour: straw-coloured; a transparence: weak - cloudy; densities: 1013; reaction pH: alkalescent; protein: is absent; a glucose: is absent; an acetone: is absent; cholic pigments: are absent; flat epithelial cells: 2-5; erythrocytes - are absent; leucocytes: 7; cylinders - are absent.
AN ELECTROCARDIOGRAM:
Infringements of an excitability and conduction it is not revealed: voltazh zubtsov the rhythm sinus, correct is kept, the electrical axis of heart is not rejected.
the Photofluorogram (12.11.2002):
From both sides in the inferior lobes pulmonary the drawing is amplified, deformed for phylum petlistogo an annular fibrosis with elements of an infiltration.
Spirogramma:
UP TO - 1,02 l; FASHIONS - 19,32 l; MVL - 37,50 l;
DLvd - 1,52 sek; DLvyd - 1,65 sek; DLvd/DLvyd - 0,923;
CHD - 19 ed/mines; CHDm - 35,73 ed/mines; the HOUSE - 1,05 l; ZHELvyd - 4,88 l; ROvd - 1,38 l; ROvyd - 2,49; FZHEL - 3,23 l; ÎÔÂ1/ÔÆÅË - 0,93 l; POS - 5,83 l/sek; OFVpos - 0,54 l; ÎÔÂ1 - 3,02 l; Tpos - 0,09 with.
the Conclusion: In assays of an expiration of infringements of ventilation is not present.
IX. THE FINAL CLINICAL DIAGNOSIS
On the establishment of complaints of the patient on tussis with a viscid difficultly abjointed sputum, delicacy, a sweating, rising t*deg; up to 39*deg; With.
On the establishment of an anamnesis of illness: has felt the patient 27.10.2002. Disease began is acute, when after a frigorism has raised t*deg; up to 38*deg; S.Na the next day has appeared dry tussis. Behind a medical care of the patient it did not address, treated independently. Accepted antipyretic, expectorants, saws tea with a raspberry. On a background of the lead treatment the state of the patient has improved - t*deg; has gone down up to 36,7*deg; With, tussis has decreased. From 07.11.2002 began deterioration: has raised t*deg; up to 39*deg; With, delicacy, a sweating have appeared tussis with a viscid difficultly abjointed sputum. The patient has caused the local doctor who has diagnosed: an acute pneumonia also has directed on hospitalization.
On the establishment of an anamnesis of life: often acute infections, a chronic bronchitis which in the season autumn - winter usually becomes aggravated.
On the establishment of interrogation on systems: originating of a short wind at a usual exercise stress.
On the establishment of the objective data: respiration rigid. Wet microvesicular rhonchuses in subscapular and axillary ranges of both mild.
On the establishment of the data of additional research: On a photofluorogram from both sides in the inferior lobes pulmonary the drawing is amplified, deformed for phylum petlistogo an annular fibrosis with elements of an infiltration.
On the establishment of the general analysis of a blood: a leukocytosis (15 · 10 (in 9îé degrees)/ë, povynennoe SOE (26 mm / ch).
It is possible to formulate the final clinical diagnosis: not hospital bilateral focal pneumonia in the inferior lobes of both mild, average flow with respiratory failure I of a degree.
IX. TREATMENT
1) Polupostelnyj a regimen.
2) the Diet: a table ¹15, the abundant drink as decoctions of a dogrose, vitamin nastoev, fruit juices is in addition recommended.
3)>Medicamental treatment:
antibacterial therapy: bunch tsefalosporinov III generations.
Rp: Ceftriaxon 0,5
D.t.d. ¹ 14
S.: For v/m injections 2 times day, contents
1ãî a bottle to dissolve 5 ml 0,5 % of solution
Novocainum, during 7 days.
expectorants: a mucolytic preparation with expectorating effect.
Rp: Tab. Bromhexini 0,008 ¹ 20
D.S.: on 2 tablets 3 times day - 5 days.
dezintoksikatsionnaja therapy:
>
Rp: Neohaemodesi 200 ml
D.t.d. ¹ 3
S.: intravenously, kapelno (40-80 drops in
minute) once a day - 3 days.4) the Physiotherapy in 5-7 days after downstroke t*deg;:
· with the anti-inflammatory purpose: UVCH
· for enriching drainage function of bronchuses: inhalations with grasses (a camomile, zveroboj, a plantain)
· for enriching microcirculation and intensifying of resorptional action: LFK, electrophoresis with eufilinom
· bronholegochnaja a sanitation.
X. THE DIARY OF OBSERVATION
11.11.2002the Patient shows complaints on: tussis with a viscid difficultly abjointed sputum, delicacy, a sweating, rising t*deg; up to 39*deg; S.Dyhanie rigid. Wet microvesicular rhonchuses in the inferior lobes of both mild. CHDD - 20; sphygmus - 84; a blood pressure - 110/70.
20.11.2002the State of the patient with positive dynamics. On a background of spent therapy t*deg; it was normalized (36,7*deg; Ñ). Tussis appears less often. A mucous sputum *deg; 20 ml day. Respiration rigid, in the inferior lobe dextral mild individual microvesicular rhonchuses. CHDD - 18; sphygmus - 82; a blood pressure - 100/70.
XI. THE EPICRISIS
the Patient ********* *.*., 15 years, was on hospitalization in allergo-pulmanologicheskim abjointing 6 municipal hospitals from 11.11.2002 till with the diagnosis: not hospital bilateral focal pneumonia in the inferior lobes of both mild, average flow with respiratory failure I of a degree.
Complaints at entering: tussis with a viscid difficultly abjointed sputum, delicacy, a sweating, rising t*deg; up to 39*deg; With.
the Anamnesis: in the childhood often acute infections. A chronic bronchitis with exacerbations in the season autumn - winter. Has felt the patient 27.10.2002. Disease began is acute, when after a frigorism has raised t*deg; up to 38*deg; S.Na the next day has appeared dry tussis. Behind a medical care of the patient it did not address, treated independently. Accepted antipyretic, expectorants, saws tea with a raspberry. On a background of the lead treatment the state of the patient has improved - t*deg; has gone down up to 36,7*deg; With, tussis has decreased. From 07.11.2002 began deterioration: has raised t*deg; up to 39*deg; With, delicacy, a sweating have appeared tussis with a viscid difficultly abjointed sputum. The patient has caused the local doctor who has diagnosed: an acute pneumonia also has directed on hospitalization.
the Photofluorogram: From both sides in the inferior lobes pulmonary the drawing is amplified, deformed for phylum petlistogo an annular fibrosis with elements of an infiltration.
Analysis of a blood:
the Blood from 19.11.2002: erythrocytes - 4,88 · 1012/ë; Hb - 154 g/l; a color parameter - 0,9; leucocytes - 5,2 · 10 (in 9îé degrees)/ë; JU - 0,02 %; P - 3 %; With - 60 %; E - 3 %; L - 27 %; M - 8 %; SOE - 8 mm / ch.
Treatment: tseftriakson, Bromhexinum, neogemodez, a physiotherapy. On a background of spent therapy the state of the patient has improved. Tussis does not disturb, t*deg; - 36,7*deg; With, dream, appetite good.
the Patient to write out with enriching.
REFERENCES:
- the Dispensary observation.
- To avoid frigorisms.
- Adequate exercise stresses.
- the R-control over 1 year.
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