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Keywords: a case history, an endocrinology, diabetum melitous, 1 type, the serious form, subindemnification, an angioretinopathia, an angiopathia of the bottom extremities, a distal sensory polyneuropatia
THE CASE HISTORY ON THE ENDOCRINOLOGY
The clinical diagnosis:
diabetum melitous, 1 type, the serious form, subindemnification.
the Angioretinopathia. An angiopathia of the bottom extremities. A distal sensory polyneuropatia.
Trophic infringements of calcaneal areas of both stop. Amputating stump V of a finger left stops, III finger of the left arm. A nephropathy III. A symptomatic hypertonia.
Fatty dystrophia of a liver, dyskinesia of biliferous ways. An ischemic disease, a stenocardia of a strain. Normohromnaja an anemia.
NAMEPLATE DATA
1. A surname, a name, a patronymic: ***** ********** **************
2. Age: 46 flying
3. A sex: man's
4. A nationality: Russian
5. Formation: srednetehnicheskoe
6. A place of work, a trade: does not work - the invalid of II group; by a trade - the carpenter
7. A home address: ñ. Pridonskoe
8. Date of entering in clinic: 15.07.2002
9. The diagnosis of the directed establishment: the Diabetic angiopathia of the bottom extremities
COMPLAINTS of the PATIENT AT ENTERING
On whining, arching, sometimes - raking pains in the bottom extremities, especially expressed in the field of a calcaneus, achille tendons and on border pljusnevyh bones and phalanxes of fingers. Pains, the burning sensation, a pricking in stops of the patient connects to purulent wounds on them.
Purulent wounds in area achille tendons.
Cramps in ikronozhnyh muscles which arise more often when the patient in time does not accept the put medicine. Cramps are frequently accompanied by a plentiful diaphoresis, a shiver in arms and in all a body, appreciable delicacy.
Strong pressing headaches, especially bright in occipital and on border frontal and temporal shares which amplify at change of weather, an emotional load.
At considerably expressed headaches, accompanying with a giddiness and a nausea, sick measured arterial pressure, and it appeared considerably increased - 240 and 130.
Infringements of vision: all subjects seem shrouded in a mild screen, before eyes frequently there is a hymenium which becomes more dense (" as ?«?«¬«") during an attack of strong headaches. The patient sees more precisely when has a rest and does not test any emotional discomfort.
Gravity, pressure behind a breast bone which gripping pains sometimes join.
Unpleasant sensations pass independently within 10-15 minutes, in dormancy calm down much faster (in 5-7 minutes).
a Short wind arising at insignificant exercise stresses. Without a short wind can rise on 1-st floor on crutches.
Deterioration of appetite, dryness in a mouth, a constant heartburn.
incidentally arising pains in the right the hypochondrium, sometimes bitter tastes accompanying with feeling in a mouth. An edema of a belly and the right anticnemion.
Whining back pains, which occurrence of the patient to anything does not bind.
Pains amplify, stoped independently, last from 30-40 minutes till 1,5 o'clock, unpleasant emotions do not cause. An emiction 2-4 times day. At the night of the patient does not rise.
the Stool regular, 1 once a day.
Rising of evening temperature up to 37,5°Ñ. the HISTORY of the PRESENT DISEASE
Counts itself the patient during 21 years. For the first time has addressed to the doctor 21 one year ago (in 25 flying) concerning sharp loss of weight (45-50 kg) for 2-3 years. Complained also of delicacy, a flaccidity, apathy, appreciable fatigability after a mild exercise stress, a strong diaphoresis. In a polyclinic on a residence the general analysis of a blood - a level of a glucose of 23 mmole/l has been made. The patient is hospitalized , lead a course of an insulin therapy. Felt like well, went for work, houses independently applied preparations of an insulin.
In the age of 36 and 41 years got in hospitals with the diagnosis " Gipoglikemicheskaja ¬«?a", Which came that the patient in time did not accept I peep.
The loss of consciousness last no more than 3 minutes (from words of the patient).
Constantly disturbed tooths - were blasted and were sick, approximately in 1997 year (the patient precisely does not remember) - false teeth (all).
in the Summer 1999 years of the patient has wounded to stop in the field of a heel. To the doctor has not addressed, as a pain did not test, an erythema and a tumescence in the field of a wound has not found out.
The wound did not heal within 2 weeks, attributes of an inflammation have then appeared: a pain, a tumescence, an erythema, puffiness, has become inconveniently to attack a heel. The yellowish purulent discharge has appeared. At a X-ray inspection the osteoporosis of both calcaneuses (from words of the patient) has been found out. Long treatment of a purulent wound appeared not successful, periodically there come exacerbations. In 2000 year of the patient has pinned a little finger of the left leg, the wound also did not heal, then the purulent inflammation has become to be distributed, the gangrene began. Ablation of this finger is lead.
In this (2000) year the long finger of the left arm concerning a diabetic gangrene is amputated.
About 2001 years of the patient marks attacks of very high blood pressure (240 and 130), accompanying with strong pressing headaches. In 2001 year infringements of vision (a hymenium before eyes) have appeared.
In the beginning 2002 years have appeared purulent is long not healing wounds and on other leg, with complaints to which exacerbation of the patient and have been hospitalized during the present moment.
to Words of the patient, the last 3 years he is treated in a hospital not less than 2 times in year. Therapy is carried out concerning a high blood pressure and diabetic stops. Last time was hospitalized in April 2002 years. During the present moment accepts 8.00 - humulin NPH 16 ED + aktropid 8 ED; 17.00 - humulin R 5 ED, 22.00 - humulin NPH 10 UNITS. In total for day of the patient receives 39ÅÄ.
the HISTORY of LIFE of the PATIENT
Was born in Voronezh, in family of workers. Dews also developed in conformity with the years.
At school studied well, at known diligence - it is good. Has stopped prof. Those. A school, has received a speciality of the carpenter - joiner. Worked on building objects. Periodically it was necessary to work in the street under adverse weather conditions (snow, a rain, a strong wind). From professional harmfulnesses marks an often raising of gravities, contact to diabrotic and strongly smelling substances (a drying oil, paints, dissolvents). On work tried to not enter conflicts, with colleagues and the heads without effort found common language. Now does not work, receives pension as the invalid of II group. In the days off and holiday worked on a rate, sometimes - on the building objects demanding urgent delivery in operation.
Smokes from 17-18 a flying. Now smokes a pack for 3 days, 3 years smoked on 2 packs in day back. Alcohol does not use the last 5-7 flying, up to that - abused (" drank »«Onn«??«") .
the Tuberculosis, oncologic, venereal diseases and AIDS denies. An allergy to foodstuffs and medicinal substances, allergic diseases denies.
It is married, to the son 19 flying.
At parents and close relatives of a sugar diabetes never was. the PRESENT CONDITION of the PATIENT
The general inspection: a condition of the average patient, consciousness clear, but the patient is slightly delayed: questions answers slowly, very much razdumchivo, but it is correct.
Position of the patient active. A look quiet, a little bit released.
Body build normosthenic.
Body height of 184 sm, mass of a body - 85 kg. An index of mass of a body: 85 / 1,842=25,1
the General feed normal.
Integuments acyanotic, hardly yellowish, labiums slightly cyanochroic, the person a little bit bloated; on stops, anticnemions, a back surface of brachiums and in the field of a ulnar joint plural light brown nevuses pigmentosus in diameter from 0,5 up to 1 see are observed. A skin dry, cold, on anticnemions and stops rasping, peeling, with white large (0,3-0,5 sm) flakes, the turgor of it is reduced. In the right ileal area - cicatrix after an appendectomia. On both stops in area achille tendons - purulent wounds of 1*2 and 2*3,5 sm - trophic ulcers.
Nails convex, remind hour glasses under the form. A pilosis on man's type, moderate. Hair on a belly, it is especial on a white line, long, rigid. Hair on a head and a body almost completely gray-haired.
the Expressed edema of the right anticnemion. Ascites (the level of a liquid is not determined).
Cervical, subclavial lymph nodes are not enlarged, the submandibular lymph node of 0,5-0,7 sm, slightly morbid, with a skin not commissured on the right is palpated.
the Muscle system is well advanced, the tonus and force of muscles sufficient, morbidity of muscles of an anticnemion, are occasionally observed their cramps.
Bones and joints of a regular form, are not deformed, at a palpation and a palpation painless. It is amputated V a finger left stops and III finger of the left brush.
the Body temperature subfebrile - 37,5°Ñ.
System of organs of respiration: a chest of a normal form, type of respiration belly, a frequency of respiratory movements=16, a rhythm of respiration correct, respiration deep. In dormancy of a short wind is not present. A percussion sound clear above all pulmonary fields. Border mild on a mammilar line - the bottom edge of 6 ribs, on average axillary - the bottom edge of 8 ribs. Mobility of pulmonary edge on the right - 3 sm, at the left - 4 see. At an auscultation rigid respiration in the top third mild, further - vesicular is auscultated. Individual dry whistling rhonchuses.
System of organs of a circulation: borders of heart are displaced to the left: the right border - 1-2 sm to the left from a right edge of a breast bone, top - the top edge of 4-th rib, left - is displaced to the left on 2-3 sm from a mammilar line.
At an auscultation: cardiac sounds rhythmical, a tachycardia (up to 100 impacts in one minute), a rhythm correct. On an apex cardiac sounds are amplified, 1-st is especial. On an aorta - accent and splitting of 2-nd tone. Hums are not present.
the Pulsation of vessels of a neck and a forearm is well expressed. The pulsation a. dorsalis pedis is weakened on both legs.
Pulse of rhythmical, 96 impacts in minutes, good filling and a strain.
a blood pressure at the moment of inspection - 150 and 90. Maximal - 240 and 130. In a dormant state - 140 and 90.
System of organs of digestion: the smell from a mouth is not present. Labiums slightly cyanochroic, a mucosa of an internal surface of labiums, cheeks, firm and a soft palate, a mucosa of gingivas acyanotic, wet. Tooths are not present - plug-in. Tongue of the usual size, bright - crimson, slightly wet, with flattened papillas, with the dark yellowish raid more expressed on the right.
the Belly enlarged in size, " ?nuO?a??®", participates in the act of respiration. At a superficial palpation moderate morbidity is revealed in the field of legal hypochondrium and in epigastric area. An ascites.
the Liver acts on 0,5-1 sm for edge of a rib arch. The sizes on Kurlovu: 6, 8 and 12 see. The edge of a liver in connection with an expressiveness of a hypodermic fatty tissue and an ascites is good for palpating it was not possible. The lien is not palpated.
System of a uropoiesis: an emiction free, painless, 3-4 once a day. Occasionally there is a mild morbidity in the field of a loin. Sign Pasternatskogo from both sides negative.
Endocrine system: body height of 184 sm, weight of 85 kg, an index of mass of a body 25,1: FROM 93 sm, ABOUT 102 sm, FROM / ABOUT=93/102=0,9. The isthmus of a thyroid gland by thickness 0,5-0,7ñì is palpated. The smell of an acetone from a mouth at the patient is not present. Vision has worsened for last year. Legs cold, sensations of a burning sensation and a pricking - a polyneuropatia.
Palpebral fissures of the usual form, sick a proportional body build, normal body height. Secondary sexual attributes are well expressed.
Nervous system: the consciousness is kept, speech clear, slightly time-lapse, mild block. Memory on the current events is well kept, reduced on the last events (the patient cannot remember as for a long time there was an event, forgets names of medicines). Mood equal, reduced. The patient is disturbing. Pupils in diameter of 3 mm from both sides. A straight line and sodruzhestvennaja reactions to light are expressed, symmetric.
Paresises and paralysises are not present, pain sensitivity is reduced in the field of both stop. the DATA of LABORATORY AND TOOL METHODS of INSPECTION:
the General analysis of a blood:28.0818.09
a haemoglobin 7866
erythrocytes 2,62,46*1012
a colour parameter 0,9
leucocytes 10,2*109
relating to stab neutrophile 3 %
segmentojadernye 72 %
eosinocytes of 5 %
lymphocytes of 12 %
monocytes of 8 %
a rate of gravitation of blood 59
the General analysis of urine (30.07): transparence N, relative density 1010, fiber of 2,3 mg / l, leucocytes 2-3, erythrocytes 5-6, hyaline cylinders 0-1.
the Biochemical analysis of a blood (18.09): a urea 14,0, a creatinine 209, the general fiber 63.
the Biochemical analysis of a blood (16.08): nuclear heating plant 17, ALT 30, a bilirubin the general 5,0, a urea 14,6, a creatinine 172, a cholesterin 5,3, lipoproteins 6,5, a prothrombin ratio 86, an amylase of a blood 5,0, the general fiber 69.
Assay Reberga (15.07): a daily urine 2,0, minute - 1,38, a creatinine of a blood - 172 mmole/l, a creatinine of urine - 15,4 mmole/l, a filtration - 123,5 mmole/l (65-120), reabsorbtsija 98,9 (98 - 99) mmole/l.
Glikemichesky a profile (15.07 : 8.00) - 19,1, 11.00 - 23,8, 14.00 - 11,3, 17.00 - 13,0, 21.00 - 15,2 mmole/l.
Glikemichesky a profile (13.09 : 8.00) - 9,7, 11.00 - 12,4, 14.00 - 8,4 mmole/l.
an electrocardiogram:the Sinus tachycardia, an electric axis of heart - a normal position, a heart rate=100 impacts in minute, attributes of a hypertrophy of the left auricle and a left ventricle. Ischemic changes on a forward wall and a septum of heart.
the Tank. Crop on sensitivity of a flora to antibiotics: Oxacillinum, erythromycin, Cefazolinum, tsiprofloksatsin, Vancomycinum.
the DIAGNOSIS
diabetum melitous, 1 type, the serious form, subindemnification. An angioretinopathia. An angiopathia of the bottom extremities. A distal sensory polyneuropatia. Trophic infringements of calcaneal areas of both stop. Amputating stump V of a finger left stops, III finger of the left arm. A nephropathy III. A symptomatic hypertonia.
the SUBSTANTIATION of the DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Taking into account, that disease began in pullet age (23-25 flying), proceeded zlokachestvenno (high parameters of a glucose of a blood, predilection to hypoglycemic comas, fast progressing, a forwardness of serious complications), the family anamnesis not burdened on a sugar diabetes, we assume: diabetum melitous, 1 type, the serious form. Taking into account complaints of sick vision to deterioration only in last year, absence of exercise stresses, stressful situations, traumas, we assume: an angioretinopathia, oslozhdenie diabetum melitous. For specification of a condition of the patient and the diagnosis: consultation of the oculist, viewing of an out-patient dossier. Taking into account paleness, a cold snap of a skin of anticnemions, weakening of pulse a. dorsalis pedis, characteristic complaints of the patient, the long experience of smoking, we assume: an angiopathia of the bottom extremities.
We can think and of a beginning obliterating endarteritis. For specification - consultation angiohirurga. Taking into account complaints of the patient on parestezii, cramps in ikronozhnyh muscles, changes pain chuvstvitelnsti, presence of trophic ulcers, dryness and an ecdysis of a skin, we assume: a distal sensory polyneuropatia. Trophic infringements of calcaneal areas of both stop (" diabetic ?O«»a") . For specification: consultation of the neurologist, a roentgenogram of anticnemions and stop. Taking into account presence purulent separated from a wound, an appreciable edema only one leg (right), a proof subfebrile fervescence of the patient, we assume a bacterial infection of a trophic ulcer right stops. For acknowledgement of the diagnosis: a tank. Crop, definition of sensitivity of microorganisms to antibiotics, crop of a blood on a sterility. Taking into account the expressed proteinuria (2,3 g/l), the expressed arterial hypertension, normal rate of a glomerular filtration, duration of disease about 23 flying, complaints of the patient on whining, nagging pains in the field of a loin, we assume: a nephropathy III. For specification of the diagnosis: ultrasonic of kidneys, consultation of the nephrologist. Taking into account cases of rising of a blood pressure up to 240 and 130, complaints of the patient to the strong headaches, arisen year back, some odutlovatost his persons, we assume: a symptomatic hypertonia (renal). For specification: More careful interrogation of the patient: whether there were in family sick hypertonic diseases, whether there were at him attacks of rising of a blood pressure, whether they were accompanied by unpleasant sensations. Studying of an out-patient dossier. Taking into account block of the patient, a memory impairment: we assume: initial attributes of an encephalopathy? Taking into account presence of pains at a palpation in the right hypochondrium, feeling of a bitter taste in a mouth, abusing alcohol a little bit flying back, we shall assume: a dyskinesia of biliferous ways. For specification of the diagnosis: consultation of the gastroenterologist to lead duodenalnoe intubation, to investigate chemical properties of a gall. It is possible, that the fatty dystrophia of a liver (diabetum melitous in an anamnesis, abusing alcohol) is observed. Taking into account low parameters of a haemoglobin and erythrocytes of a blood, the normal CENTRAL PROCESSING UNIT, the expressed tachycardia, paleness of integuments of the patient, we assume: normohromnaja an anemia. Considering progressing of an anemia, morbidity in a zone of an epigastrium, presence of a liquid in an abdominal cavity, and also smoking of the patient, we assume: a bleeding. Taking into account, that at patients diabetum melitous pain sensitivity can be reduced, lead: macroscopical and an analysis of a feces (to estimate colour, a consistence, presence of a blood). Consultation of the surgeon, the gastroenterologist.
To recommend antianemic preparations (Durules, Totema) .Uchityvaja complaints of the patient to pains in the field of heart, ischemic changes of a myocardium, attributes of a hypertrophy of the left departments of heart (on an electrocardiogram), constantly high blood pressure, we assume:
Ischemic disease, stenocardia. The differentiation is required: strains or dormancy: detailed inquiry of the patient about his position, a condition, mood at the moment of occurrence of cardiac pains. If necessary - an exercise tolerance test. Probably also: an ischemic disease and a myocardiosclerosis as result of a diabetic macroangiopathia (vessels of heart are amazed). Consultation of the cardiologist, at the decision of a question on necessity koronaroarteriografii - the cardiosurgeon. Taking into account block of the patient, some odutlovatost his persons, presence in an anamnesis of serious endocrine disease - to hand over a blood on TTG and Ò4. We shall deny a hypothyroidism.
Thus, the diagnosis it is possible to add to the following points: a fatty dystrophia of a liver, a dyskinesia of biliferous ways, a diabetic macroangiopathia, an ischemic disease, a stenocardia of a strain. An anemia.
THE LEAF OF PURPOSES:
- the Table ¹9.
- 8.00 - humulin NPH 16 ED + aktropid 8 ED; 17.00 - humulin R 5 ED, 22.00 - humulin NPH 10 UNITS. In total for day of the patient receives 39ÅÄ.
- Tab. Erythromycini 0,25 - on 2 tablets of 5 times in day.
- Dressings with a lavage of wounds of 3 % solution Í2Î2 (Sol. Hydrogenii peroxydi diluta - 20 ml) and hlorgeksidinom (
- Sol. Chlorhexidini 0,05 % - 500 ml). An aseptic bandage.
the DIARY of the PATIENT
18.09. The surgeon. Granulating wounds on each side achille tendons, the area about 7 sm2. On walls of a wound - the purulent - necrotic discharge, is lead a partial cut of walls and a bottom of a wound. Positive dynamics, the area ranevoj surfaces is observed decreases. To continue dressings.
the Curator. Complaints to whining pains in the field of anticnemions and stop. Not strong headache, a hymenium before eyes. Subfebrile temperature (37,1°Ñ) Morbidity at a palpation in epigastric area. The patient is acyanotic, delayed, tired.
Blood pressure 150 and 90, pulse 96, a frequency of respiratory movements 16. A tachycardia, cardiac sounds rhythmical, clear, intensifying of tones on an apex of heart, accent and splitting of 2-nd tone on an aorta.
19.09. The surgeon. A trophic ulcer with scanty serozno-hemorrhagic separated.
the Curator. The patient recently has woken up, therefore looks delayed. The head does not hurt, the hymenium before eyes is kept. Complaints to whining pains in ikronozhnyh muscles. Temperature 37,0°Ñ. a blood pressure 145 and 80, pulse 92 impacts in minute, a frequency of respiratory movements 14. The nystagmus is not present. Pain sensitivity on stops is reduced.
the EPICRISIS
***** ********** **************, 46 flying has acted 15.07 with complaints to pains, a burning sensation, a pricking in ikronozhnyh muscles, presence on both legs is long not healing purulent wounds. 5-th finger on left stop and 3-rd - on the left brush are amputated. Marks dryness in a mouth, headaches, a giddiness, a hymenium before eyes. Strong delicacy. It is sick of a sugar diabetes during 21-22 flying. The flying was ill at 23-25, is acute, has lost in weight *gt; 40 kg. At initial hospitalization the level of a glucose in a blood has made 23 mmole/l. Constantly accepts preparations of an insulin. For the last 3 years the condition has worsened: trophic ulcers have appeared, vision has worsened, headaches and rising of a blood pressure up to 240 and 130 have appeared. Objectively: presence on both stops in area achille tendons of trophic ulcers with yellowish purulent separated. The expressed tachycardia (pulse about 100-105 in one minute). The patient is acyanotic, the plentiful diaphoresis is observed. The smell of an acetone is not present. Level of a glucose of a blood at 11.00 (15.07) - 23,8 mmole/l.
the infection of wounds by a staphylococcal flora, sensitive to erythromycin, Oxacillinum, Cefazolinum Is revealed. The expressed proteinuria (2,3). On an electrocardiogram - attributes of ischemic changes of a forward wall and a septum of heart. On the basis of an anamnesis, inquiry, the inspection, the given laboratory and tool methods of treatment, the diagnosis is put:
diabetum melitous, 1 type, the serious form, subindemnification. An angioretinopathia. An angiopathia of the bottom extremities. A distal sensory polyneuropatia. Trophic infringements of calcaneal areas of both stop. Amputating stump V of a finger left stops, III finger of the left arm. A nephropathy III. A symptomatic hypertonia. A fatty dystrophia of a liver, a dyskinesia of biliferous ways. An ischemic disease, a stenocardia of a strain. Normohromnaja an anemia.
Disease proceeds hardly, with a plenty of burdensome complications, the forecast unfavourable.
the Patient received preparations of an insulin (39 ED in day), an antibiotic erythromycin (2,5 g in day), dressings of wounds were carried out; the table ¹9 is appointed. During a presence in hospital the condition of the patient by way of correction diabetum melitous has improved (a level of a glucose has considerably come nearer to normal), but the general condition of the patient has become complicated by an anemia. In general treatment can be estimated as effective.
References to the local doctor: To advise the patient to carry out exercises for conservation and improvements of a trophicity of extremities, to keep to a diet, supervise a level of a glucose in a blood, to eat it is high-grade and it is various. The patient should to stop smoke. To advise it to wear convenient clothes and footwear. To supervise a blood pressure of the patient, to pick up to it antianginalnye preparations, constantly to watch a level of a cholesterin and blood lipids.
THE LITERATURE:
- Dedov And. È., Melnichenko N.I., Fadeev " the Endocrinology.
- " Algorithms of diagnosis and treatment of diseases endocrine ???ON?U" under I.I.Dedova's edition. Ì., 1995.
- G.Galstjan " Diabetic ?N®O«»aO?n".
- M.I.Balabolkin " O?n«¬O??«?«u?n", Ì., 1998.
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Keywords: a case history, an endocrinology, diabetum melitous, 1 type, the serious form, subindemnification, an angioretinopathia, an angiopathia of the bottom extremities, a distal sensory polyneuropatia
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