| |
Keywords: a case history, gynecology, an ovary, a sterility of a blended genesis, a vegetative dystonia, a case history on gynecology
the Author: Selina I.A.
the CASE HISTORY
the DIAGNOSIS: a STERILITY II, a blended genesis. A vegetative dystonia for hypertonic phylum.
THE PASSPORT PART
- the Surname, a name, a patronymic: ******* ****** *********
- Age: 31 year
- the Trade: ******************************
- the Birthplace: Voronezh
- the Address: street ************ *************
- Date of entering in clinic: 23.09.03ã.
- the Date started of a curatio: 29.09.03ã
- Complaints at entering in clinic: on a sterility 8 flying.
THE ANAMNESIS
I the Anamnesis of disease.
1. In 1995 has felt strong pains in the bottom of a belly, cold sweat has appeared, from the cervical canal abjections have appeared insignificant darkly - krovjanistye. First aid has been caused, the patient have hospitalized in GKB ¹9 where the diagnosis has been put: Tubal pregnancy on the right. It has been effected chrevosechenie, salpingoektomiju on the right concerning tubal pregnancy. Complication: tromboembolija fine branches of a pulmonary artery, an infarct a pneumonia on the right. It was observed in center of planning of family - the tube was surveyed in TST 2002ã.-is passable; received Parlodelum (hyperlactemia). It is directed on a laparoscopy 7.09.03ã. with the diagnosis: a sterility of II blended genesis, adhesive process.
2. Menstrual function. A menses have begun about 14 flying, duration of a cycle of 30 days, 5 menstrual days, moderate, morbidity in the first days of a menses was established at once.
3. Sexual function. Sexual life began in 22 years, in 1 marriage. The menstrual cycle has not changed after sexual life. Lives regular sexual life, does not protect.
4. Genital function. On the first to year of sexual life there has come the first pregnancy. It has been effected chrevosechenie, salpingoektomiju on the right concerning tubal pregnancy on the right. Complication: tromboembolija fine branches of a pulmonary artery, an infarct a pneumonia on the right. It was observed in center of planning of family.
II Anamnesis of life.
Was born in 1971 year in Voronezh 1-st child in family. Grew and educed in conformity with the years. From the diseases transferred in the childhood marks ORVI, a grippe. Mother suffers an idiopathic hypertensia. The allergological anamnesis is not burdened. The tuberculosis, venereal, oncologic diseases, at itself and denies relatives. Harmful habits are not present.
THE GENERAL INSPECTION
The general condition of the patient satisfactory. The position of the patient awake, consciousness clear, well, in detail and correctly replies. A body temperature 36,6. Body height 164 see. Weight of 83 kg. Integuments of normal colour. Lymph nodes are not palpated.
System of a respiratory organs.
A nose of a regular form, without deformations. The chest of the normosthenic form symmetric. A frequency of respiratory movements=17 1 minute. It is percussion a clear pulmonary note. Borders mild correspond to norm. At an auscultation - respiration vesicular, rhonchuses are not present.
intimately vascular system.
Borders of heart: dextral: on 0,5 sm to the left from a right edge of a breast bone, top - 3 intercostal space, left - on 1,5 sm to the right from a mammilar line. Cardiac sounds rhythmical, muffled. Pulse of 78 impacts in one minute rhythmical, moderate filling and a strain. A blood pressure at the moment of a curatio of 120 and 80 mm mercurial stolba.
System of organs of digestion.
A belly of a normal form, mild, at a palpation painless. The liver is palpated on the inferior edge of a rib arch. The lien is not palpated. The peristalsis of an intestine usual, at an auscultation is well auscultated. According to the patient, a stool regular, made out, usual brown colour, moderate amount.
Genitourinary system.
Kidneys are not palpated. A sign of a beating on lumbar range negative. An emiction painless, moderate frequency: 3-4 times day. By night of the patient it is weted not more often than 1 time.
Nervous system
The consciousness is kept, speech smooth, cohesive, expressive, emotional. The intellection is consecutive, logical, memory on streaming and past events is kept. The patient irritable. Gait usual, the walk of moderate length, locomotion of arms and legs are well compounded and co-ordinated, the patient at locomotion easily keeps equilibrium. Width of pupils identical, direct and sodruzhestvennaja photoharmoses are well-marked. Pain and the thermoesthesia is in regular intervals expressed on all body. The nystagmus is not present, assays in posture Romberga are negative, paltsenosovaja assay is negative. Pathological stopnye marks are not revealed.
Gynecologic research.
A uteral cervix cylindrical, clean, the normal dimensions. A uterus of the normal dimension, dense, at shift of senses. Abjection light. Appendages from both sides are not enlarged, painless. Vaults deep, free.
RESULTS OF ADDITIONAL METHODS OF INSPECTION
the General analysis of a blood (27.09.03):
Hb=130 g/l,
erythrocytes=4,331012/ë,
leucocytes=8,6109/ë,
a sedimentation rate=7 mm / ch.
the leukocytic formula: »-8, ?-76, Y-2, ?-2, ?-12.
the General analysis of urine (23.09.03):
a transparence - transparent,
colour - straw-coloured,
otn. Density - 1015ã/ë.
reaction - acidic,
protein - is not present,
the glucose - is not present,
ketonovye bodies - are not present,
the bilirubin - is not present,
urobilinoidy - is not present,
the Epithelium: flat - individual, transitive - is not present, renal - is not present.
Leucocytes - individual, erythrocytes - are not present.
Slime, bacteria - are not present.
Research of system of a hemostasis (26.09.03.)
IIT - 35-45 sek.
Thrombinum. Time - 16 sek.
a prothrombin ratio - 85 %
gemotokrit 0,42
Fibrinogenum 4,40 g/l
Fibrinogenum +
et. The test otr.
an electrocardiogramfrom 25.09.03 ×ÑÑ=61. A rhythm sinus.
THE DIAGNOSIS:
A sterility II, a blended genesis. A vegetative dystonia for hypertonic phylum.
THE SUBSTANTIATION OF THE DIAGNOSIS
On the establishment of complaints of the patient on a sterility 8 flying.
On the establishment of an anamnesis: in 1995 year the diagnosis has been put: Pravotrubnaja pregnancy. It has been effected chrevosechenie, salpingoektomiju on the right concerning pravotrubnoj pregnancies. During 8 flying it is observed in TSZPS. Conducts regular sexual life, does not protect.
DIFFERENTIAL DIAGNOSIS
The initial sterility from secondary is carried out first of all. The initial sterility is characterized by absence at the woman of pregnancy during 1-2 flying of regular sexual life. Secondary if the woman had even pregnancy earlier.
At the patient a secondary sterility since 8 flying there was a salpingocuesis back.
THE LEAF OF MEDICAL PURPOSES
- To accept Parlodelum.
- To be observed in center of planning of family.
To discuss a material at a forum of a site
Keywords: a case history, gynecology, an ovary, a sterility of a blended genesis, a vegetative dystonia, a case history on gynecology
|
