| |
Keywords: a case history, a pedonosology, a respiratory catarrh, children's diseases, an obstructive bronchitis, a vasculomotor rhinitis, a case history on a pedonosology
THE CASE HISTORY
The diagnosis: a respiratory catarrh, an obstructive bronchitis, a vasculomotor rhinitis.the Passport part.
- the Surname a name of the patient: *********** ********* **************.
- Age of the patient: 13 flying.
- Date of entering in clinic: 20.09.03.
- Age and a trade of parents: ***********************
- Visits school.
- the Address: ***************************
Complaints.
At entering in clinic: on the appreciable respiratory embarrassment, the expressed short wind, dry tussis, palpitation, delicacy, a giddiness, infringements of gait, a nausea, rise in temperature up to 37,3°Ñ, an incorporation of a nose (it is more on the right), a discharge from a nose.
At date of a curatio: on a labored goose breathing, sense of a prelum in breasts, dry tussis with difficultly abjointed sputum, the palpitation, the expressed delicacy, fast fatigability, infringements of gait, a giddiness, a headache, bad appetite, rise in temperature up to 37,0°Ñ.
the Anamnesis of life.
The boy was born from the second pregnancy, the second births in time without complications. A forwardness without features. Dews also educed in conformity with the years.
Prophylactic inoculations were carried out in time, tolerated them well. Marks an allergic response as an eruption on medicinal substance (which to tell is at a loss). Hemotransfusions, and also plasma transfusions and introduction of an immunoglobulin were not carried out.
A hereditary anamnesis: mothers 44 years, it is able-bodied. To the father 46 flying, marks presence at him often tussis though he does not smoke, at work to stimulating substances adjoins seldom. A tuberculosis, venereal, mental, endocrine diseases denies. Manifestative hereditary diseases are not present.
The child lives in complete family. Mother works as the tutor in UVK ¹ 2, father - the worker in Joint-Stock Company VKSM. Parents do not smoke, alcohol, narcotics do not use.
The child goes to school, has time on "good and excellent". It is sociable, easily converges with people, quickly is guided in a new situation. Speech figurative, is advanced well, a lexicon rich. In connection with an appreciable academic load at school the regimen is kept badly. Dream - 8-9 hours per day. A feed is not balanced. Frequently eat not washing down water, appreciable rests (up to 6-8) hours between methods of nutrition are sometimes observed.
the Epidemic anamnesis.
20.09.03 was contact to the contagious patient (the boy 12 flyings, presumably a respiratory catarrh). In an environment of the child of patients is not present.
the Anamnesis of disease.
Counts itself the patient from 20.09.03. This day (Saturday) played with friends in the street, long and ran much; after the arrest of game has frozen (the cold wind) was. Marks, that among playing there was a sick child (he coughed much, sneezed, there was an abundant mucous discharge from a nose). In the evening of this day delicacy, a mild malaise, a headache has appeared. The boy considered these signs attributes of overwork and a frigorism, any prophylaxises was not carried out. Next day the state of health has worsened, games with comrades did not bring pleasure, the mood has been reduced, by the end of day the head has strongly ached, the pharyngalgia has appeared. The patient has complained of a malaise to parents, warm tea has drunk and has gone to bed early. In the morning of the next day has gone to school, but felt like broken, tussis has appeared, the head strongly was sick, could not concentrate the attention on explanations of teachers. After 2 lessons has asked for leave home. Houses tried to fall asleep, but because of a strong headache it was not possible. Has taken temperature - 38,2°Ñ. In the evening with mum has gone to the local pediatrist. To the patient the nyxis (approximately at 18.00, presumably - a lytic admixture) has been made and the reference is given in case of downstroke of temperature in 2 hours to drink a tablet of an antibiotic (from words of the boy, Ampicillinum). The temperature has decreased up to 37,3°Ñ, at 20.00 the child has accepted an antibiotic and has gone to bed. Has woken up approximately at 21.30 from an appreciable respiratory embarrassment. Marks, that breathed with singing, strongly coughed, in a horizontal position felt like worse. At 22.00 the brigade of first aid has been caused, the child is hospitalized in OKDB ¹ 2.
A course of a disease during stay in clinic prior to the beginning of a curatio (a brief epicrisis).
At entering the patient it is examined by the doctor on duty, it is placed in chamber. The patient marks, that by the moment of his entering in hospital the condition has a little improved. Further a respiratory embarrassment were kept, but were not so expressed as an at home, and the patient could fall asleep. It is examined by the attending physician in the morning, the Euphyllinum, berodual, lazolvan is appointed.
the Present condition
the General condition of the childaverage: respiratory embarrassments, the subfebrile temperature, the expressed delicacy, a headache, the reduced appetite.
Nervous system.Consciousness clear, reaction on environmental alive, adequate. The child sociable, in detail, precisely, correctly replies, adequately estimates the state of health. The phylum of the attitude to the disease can be characterized as harmonious. The mood is a little bit reduced, delicacy and fast fatigability is marked. A pathology of cranial nerves it is not revealed. Belly superficial and deep reflexes alive, D=S. Tendon jerks (karporadialnyj, bitsipitalnyj, patellar, ahillov) are expressed moderately (2), are symmetric (D=S). Meningeal marks are not present. Coordination assays (dactyl - nasal, pjatochno-patellar, posture Romberga simple and complicated) plump well. Gait usual, without any specific features. The dermographism blended, appears in 17 seconds, proceeds about 5 minutes. Nistagmoid.
External inspection of eyes. Abjointed from an eye is not present, the conjunctiva of usual colour, an injection of vessels of scleras is not present, locomotions of eyeglobes painless, the photophobia, puffinesses of blepharons, is not present a lacrimation.
External inspection of ears.Auricles of the usual form, pink, abjointed are not present, the skin of an outside acoustic duct does not bloodshot.
Physical development.Body height of 153 sm, mass of 46 kg. IMT=19,66. Physical development average, harmonious. A stigma dizembriogeneza are not revealed.
the Skin.the Skin light pink, moderate humidity, clean. A forehead more acyanotic and wet, nosogubnyj a triangle - with a mild cyanosis.
A hair, dactyls, nails. A hair dim. Some cyanosis of tips of dactyls, nails as " hour glasses " is marked; the form of dactyls to estimate as " drum-type rods " it is impossible, but their knottiness, expansion of articulate surfaces of phalanxes is marked. Nails dim, are not present the expressed striation and a fragility of them.
the Subcutaneously - fatty tissue.the Child of a sufficient feed. The subcutaneously - fatty layer is advanced a little bit worse usual (for last year the boy has strongly grown), distributed in regular intervals, the pastosion, is not present edemas, a turgor of tissues satisfactory.
Lymph nodes.submandibular lymph nodes are well palpated: on the right 2-3, about 5-6 mm, not commissured with a skin and subject tissues, painless enlarged; at the left 3, diameter 3-4 mm, painless, easily movable. Are palpated also not changed zadne-cervical, occipital, axillary, kubitalnye lymph nodes: fine, mobile, painless, not soldered with a skin and subject tissues.
Muscles.Are advanced moderately, a tonus normal, at a palpation, a palpation, awake and passive locomotions are painless. Force of muscles sufficient (5 points) in all groups (both flexors, and extensors). The strain of muscles of a back (the expressed muscle platens along a backbone approximately from 5 thoracal up to 2 lumbar vertebra) is marked.
Osteal system.the Form of a head is closer to dolihotsefalicheskoj, bones without deformations, at a palpation and a beating are painless. Locomotions in joints of a backbone painless, sufficient on the voltage, are not present the expressed tortuosity. The chest is amplate in the peredne-back dimension (barrel), in the inferior third of breast bone it is marked mild vdavlenie, intercostal spaces are considerably amplate. Above and subclavial fossas of the usual form, probably, hardly less deep, than usually. Clavicles and scapulas are posed symmetrically, their tortuosities and deformation is not revealed. Scapulas alary: will defend from a chest, it is good konturirujutsja. An epigastric angle less than 90 ° (about 75-80 °). Garrisonovoj sulcuses and thickenings of ribs on border of osteal and cartilaginous parts it is not revealed.
System of respiration.Nasal respiration labored, especially on the right, from a nasal cavity - a mucous discharge. Respiration of blended type. The frequency of respiratory movements compounds 24 1 minute, respiration rhythmical, deep, is accompanied by singing, the expiration prolates. Both half of chest take part in the act of respiration, intercostal spaces awakely participate in respiration, the strain of gear muscles in regular intervals from both sides is marked. A short wind of blended character with predominance ekspiratornogo a component. At a palpation the chest malopodatliva, is painless, intercostal spaces are amplate, the voice tremor is weakened. It is percussion: a box note above all pulmonary fields, borders mild: on mammilar on the right - 6 intercostal space, on average axillary - 8 intercostal space, on scapular - the top edge of 11 ribs. Motility of pulmonary edge on an average axillary line compounds 5 sm (D " S).
At an auscultation above all pulmonary fields plural dry whistling, buzzing and creaking rhonchuses are auscultated and is large and srednepuzyrchatye wet rhonchuses. At a deep inspiration and the subsequent sharp expiration intensifying whistling and buzzing rhonchuses as on an inspiration is marked, and (is especial) on an expiration. Sometimes the expiration interrupts tussis. After tussis rhonchuses variate. At an auscultation of a larynx and a trachea the laryngotracheal respiration accompanying with infrequent individual sharply whistling notes is auscultated.
System of a circulation.At inspection of cardiac range: the cardiac back hollow is not present. The cardiac impulse precisely is not palpated, apical is localized in 5-th intercostal space to the left of a breast bone approximately on mammilar - on 1 sm inside, diameter about 1,5-2 see. It is percussion borders of relative cardiac dullness: dextral - by a right edge of a breast bone, top - 3 intercostal space, left - on 1 sm inside from a mammilar line. At an auscultation of heart: the tachycardia, tints rhythmical, sonorous on an apex and in Botkin - Erba point, be relative more deaf of an aorta and a pulmonary artery, hums are not auscultated. A pulsation of vessels of a neck rhythmical, uchashchennaja, a satisfactory strain. The pulsation of arterias of extremities is well palpated, in epigastri? range it is much worse (the patient is afraid shchekotki). Pulse on a radial arteria: frequency 109 1 minute, Ps (109): Frequency of respiratory movements (24)=4,5:1, rhythmical, often, average, a satisfactory strain and filling, synchronic on both arms.
System of digestion and organs of an abdominal cavity.
Labiums of red colour with a mild cyanochroic shade, dry, slightly exposed to the wind. Rashes, ulcerations, are not present bladders, cracks. Mucous oral cavities in regular intervals pink, wet, without hemorrhages, spots, ulcers. Tongue: the tip pink, starting from an average third and further is impose with a quaggy belovato-yellowish raid, is more dense and richly coating a surface of an organ on a direction to a root. Cracks, ulcers, are not present impresses of tooths, papillas slightly flattened, the put out tongue slightly shivers, settles down strictly on an average line, aside does not deviate. Tooths constants, a dentition completely safe. Desna pink, elastic, moderately dense, without pathological changes.
Mucous pharynxes it bloodshot, slightly hydropic, the hyperemia of palatal arculuses and a uvula is expressed especially brightly, mucous a firm palate on this background looks concerning acyanotic. The back wall of a pharynx also bloodshots, edematous.
Sialadens are not enlarged, at a palpation, a mastication, opening of a mouth painless.
The belly of the usual form symmetric, is not ventricose, the seen pulsation, a phlebectasia of a forward abdominal wall are absent, cicatrixes are not present, a peristalsis satisfactory. The percussion note tympanic, at a palpation is marked a strain of muscles of a belly about conforming to zone SHoffara, mild morbidity in epigastric range and under a xiphoid process is marked. A diastase of direct muscles of a belly, apostatis of muscles in range umbilical and inguinal rings it is not revealed. At a deep palpation contours ascending, descending colonic intestines, sigmoid are determined. The transversal colon is palpated badly. A deep palpation painless, infiltrates, the dense conglomerates, enlarged lymph nodes are not determined. Auscultative: the peristalsis of an intestine is kept, expressed moderately.
The seen augmentation of a liver is not present. At a percussion: the top border on a dextral mammilar line - 5 intercostal space - the top edge of 6 ribs (laying), inferior - edge of a dextral rib arch., on midline the inferior border - a point between the top and average thirds of distance of a belly-button up to a xiphoid process. The dimensions on Kurlovu: 10 - 8 - 6. At a percussion and beat (sign Ortnera) it is not marked a liver of morbidity. At a special palpation of a liver: edge equal, smooth, densely - elasticheskoj a consistence, painless. The ascites is not present.
A stool, from words of the patient, daily, made out, brown colour, without pathological admixings.
The lien is not enlarged, at a palpation is painless, edge smooth, elastic, mobile.
Genitourinary organs.the Conjoined manipulation of lumbar range is painless. Diverticulums above a pubis, in range of kidneys it is not marked. A beating above a pubis and in lumbar range painless. Kidneys are not palpated. The dysuric phenomena are not revealed
the Preliminary diagnosis.
- the Basic disease: a respiratory catarrh, an obstructive bronchitis.
- Concomitant diseases:---
- Background diseases: a rhinitis, a sinusitis?
- Complications:---
The preliminary diagnosis is based on the data of an anamnesis (possible disease of a respiratory system at the father of the child, predilection to a respiratory catarrh, a possible medicinal allergy), histories of development of the present disease (the fast development of disease accompanied with a set of symptoms of an intoxication, an obstruction of bronchuses which has amplified after method of Ampicillinum inside), an epidemiological anamnesis (contact to the contagious patient) and objective inspection (an inflation of a chest, a box note at a percussion, dry whistling and buzzing rhonchuses above all pulmonary fields from two sides, ekspiratornaja a short wind) with the count of time of disease (3,5 days) and the basic complaints (tussis, a short wind, a headache, rise in temperature).
the Plan of inspection.
- the General analysis of a blood.
- the General analysis of urine.
- Research of a feces on eggs of helminths
- Roentgenography of organs of a chest
- the Evaluation of function of an external respiration
- Consultation of the otolaryngologist
Results of laboratory, tool and other special researches.
the General analysis of urine (24.09.03):
Colour - straw-coloured;
Transparent;
Reaction alkalescent
Relative density 1013
Protein - traces
the Epithelium flat;
Leucocytes 2-3 in sight
Erythrocytes - changed 18-20 in sight
In the general analysis of urine it is marked feebly marked eritrotsiturija (erythrocytes of " a high parentage " - most likely, from glomuluses).
the General analysis of a blood (24.09.03):
the Haemoglobin - 144 g/l (N=116-135 g/l) Adult: 132-164 g/l
Leucocytes - 6,5*109/ë (8,3*109/ë); Adult: 4,0-9,0*109/ë
Relating to stab neutrophile - 4 %
Segmentojadernye - 69 % (neutrophils N=56,5 %) Adult (neutrophils): 48-79 %
Eosinocytes - 18 % (2,5 %) Adult: 0,5-5 %
Lymphocytes - 6 % (32 %) Adult: 19-37 %
Monocytes - 3 % (8,5 %) Adult: 3-11 %
a sedimentation rate - 25 mm / hour (1-10 mm / hour).
In the general analysis of a blood the relative hypergemoglobinemia, appreciable change of the leukocytic formula aside eosinophilias is marked. Rising of a sedimentation rate.
Roentgenography of organs of a chest:On a survey roentgenogram of organs of a chest in the direct projection plump by rays of high rigidity change of the form of a chest - barrel-, appreciable expansion of intercostal spaces is determined; the increased lightness (pneumatization) of a pulmonary tissue in regular intervals on all pulmonary fields without focal and infiltrativnyh shades; the vascular drawing is deformed: the expressed reaction of roots mild, an appreciable depletion of a vascular drawing on periphery is marked. Roots mild malostrukturny. A diaphragm and sine clean.
the Substantiation of the clinical diagnosis.
The diagnosis of a respiratory catarrh, the obstructive bronchitis complicated with toxi-infectious damage of kidneys is put on the establishment:
- complaints of the patient to a headache, delicacy, fast fatigability, a giddiness at walking, a mild nausea, rise in temperature; on the palpitation, the expressed respiratory embarrassment, a short wind, dry tussis with difficultly abjointed sputum;
- the data of a history of development of the present disease: development of disease is acute within 2 days after contact to contagious (respiratory catarrh) the patient, an expressiveness intoksikatsionnogo a set of symptoms, originating of an attack of an asthma at night after method of an antibiotic;
- the objective data: change of the form of a chest (barrel), ushirenie intercostal spaces, a percussion box shade of a note above pulmonary fields; at an auscultation - plural dry whistling both buzzing and wet it is large also microvesicular wet rhonchuses, nails in the form of hour glasses, ekspiratornaja a short wind, a tachycardia, a subfebrile condition;
- dynamics of patological symptoms during observation: good positive dynamics in the attitude of tussis - has become more wet, the sputum more easy departs; rhonchuses - the number of them has considerably decreased; tachycardias - the heart rate=77 (N) has disappeared, hyperthermias - is not observed;
- results of laboratory and tool methods of research: mikroeritrotsiturija (for a toxi-infectious defeat of kidneys), the expressed eosinophilia (for presence atopicheskogo a component in development of disease), presence of the diffuse increased pneumatization of a pulmonary tissue with deformation of a vascular drawing;
- an epidemiological anamnesis: disease has developed is acute after contact to the sick child.
The vasculomotor rhinitis is put on the establishment of complaints of the patient on long (about year) infringement of nasal respiration, the data of objective inspection otorinolaringologa: cyanochroic edematous mucous, presence abjointed in the general nasal passage.
The diagnosis: a respiratory catarrh, the obstructive bronchitis complicated with mild toxic damage of the glomerular apparatus of kidneys. A vasculomotor rhinitis.
the Differential diagnosis.
It is carried out with a simple bronchitis. Against him speak: expressed intoksikatsionnyj a set of symptoms, absence of productive tussis, presence expressed ekspiratornoj a short wind, an inflation of a chest (at a simple bronchitis does not variate), presence of dry whistling and buzzing rhonchuses.
It is carried out with a bronchiolitis. Against him speak: age of the patient (the bronchiolitis is recorded basically at children of early age), normal borders of cardiac dullness (at a bronchiolitis they decrease for the account giperpnivmatizatsii mild), normal borders of a liver and a lien (at a bronchiolitis they are enlarged), and also absence of crepitant rhonchuses at the patient (one of characteristic signs of a bronchiolitis).
It is carried out with a bronchial asthma. Finally to confirm or reject this or that diagnosis now it is not obviously possible, as there is no research of function of an external respiration. In the table resulted below cramps on the patient which speak well this or that disease are submitted.
A bronchitis: Development of disease after contact to a sick respiratory catarrh the child.
An asthma: the Attack can be provoked by virus agents.
A bronchitis: the Asthma has arisen for the first time
An asthma: Father of the boy frequently coughs (probably, at him kashlevoj mild variant of a bronchial asthma)
A bronchitis: Absence in an anamnesis atopicheskogo a dermatitis, an alimentary, household allergy.
An asthma: Predilection of the boy to allergic responses on medicinal substances. Provocation of the given attack by method of Ampicillinum.
A bronchitis: dry tussis Earlier arising at a respiratory catarrh passed quickly, together with other signs of a respiratory catarrh and an intoxication.
An asthma: Arising before a respiratory catarrh were accompanied by dry tussis and "podsvistyvaniem".
A bronchitis: Teenage age of the patient.
An asthma: the Expressed eosinophilia and the negative analysis of research of a feces on eggs of helminths.
An asthma: Appreciable improvement of a condition of the patient in reply to therapy bronhospazmolitikami and Prednisolonum.
A bronchitis: Connection of an attack of obstruction with a virus infection.
A bronchitis: the Expressed temperature reaction.
It is recommended to make research of function of an external respiration.
the Substantiation of treatment.
- Antiviral treatment. The virus infection has caused originating expressed bronhospasticheskogo a set of symptoms, and also a set of symptoms of an intoxication. It is recommended to apply: Remantadinum, interferons, specific immunoglobulins, atsiklovir
- Antimicrobic treatment. A virus infection almost always follows bacterial, presence of a set of symptoms of bronchial obstruction frames additional conditions for development of a bacterial infection (stagnation in bronchuses of a secret, infringement of work tsiliarnogo the apparatus of bronchuses). Taking into account predilection of the child to allergic responses on antibiotics to select them follows with the big guard.
- Bronholitiki. For liquidation of an obstructive set of symptoms, improvement of outflow of a sputum, restoration tsiliarnogo the apparatus. It is possible to appoint application GKS mestno it (is inhalation) for elimination of an aboriginal inflammation (pulmikort, Becotidum).
- Mucolyticums. For downstroke of viscosity, a colliquation of a sputum. Here - massage is necessary for the prevention of a swamping of fine bronchuses and spuskanija to an infection. Massage on a ball, clapping.
- Protivokashlevye - if noneffective excruciating tussis.
- Antipyretic - at the expressed hyperthermia. At a serious set of symptoms of an intoxication - dezintoksikatsionnaja therapy (solevyj solutions, a glucose, reopoligljukin, if necessary - an artificial diuresis).
- Immunostimuljatory. The organism of the child is weakened by an infection, toxins (apply nukleinat a sodium, a ginseng, eleuterokokk).
- the Vitamin therapy - too some kind of an immunocorrector.
- the Physiotherapy (UVCH, electrophoresis, inhalations).
- the Phytotherapy (a mallow, termopsis, mint, a cowberry, a thyme).
- the Regimen! A diet!
the Forecast.
At keeping by the patient of a correct regimen, performance of purpose - congenial. After an extract from a hospital rehabilitational treatment (better - sanatorium), occupations by sport (navigation), education is recommended to game on duhovyh musical instruments (a tube, a trombone, a saxophone), prophylaxis of virus infections (it is especial in the season of epidemies), medical gymnastics, massage. An exercise stress to enlarge gradually, on a measure of habituation to it.
the Epicrisis.
***************, 13 flying. Has acted in OKDB ¹ 222.09.03 on first aid in connection with an attack of an asthma developed during dream. Counts itself the patient from 20.09.03 when after dialogue with a sick respiratory catarrh comrade has felt delicacy, a malaise, fatigability. Within the next days the temperature up to 38,2°Ñ has risen, the throat was sick, has become to cough. Marks, that tussis was dry, with singing. Was konsultirovan the local pediatrist, the antipyretic is entered. Soon after that has accepted Ampicillinum, and the attack of an asthma at night has developed. Presumably, in more younger age there was an allergic response on medicinal substances. The respiratory catarrh is sick about 3 times in year.
The boy was born from the second pregnancy, the second births in time, protekavshih without complications. A forwardness without complications. Mothers now 44 years, it is able-bodied, to the father 46, frequently coughs, does not smoke.
Complains of sense of constraint in breasts, a respiratory embarrassment, palpitation, dry tussis with singing, delicacy, a hyperthermia, a giddiness, a nausea. At inspection: the chest is ventricose, intercostal spaces are amplate, awakely participate in the act of respiration. It is percussion a box shade of a note, at an auscultation - plural dry whistling both buzzing and wet it is large and srednepuzyrchatye rhonchuses above all pulmonary fields. A heart rate=109 1 minute, a frequency of respiratory movements=24 1 minute. Borders of relative cardiac dullness are not amplate. A belly quiet. A stool, an emiction without features.
the Literature:
- Children's diseases: the Textbook/under L.A.Isaevoj.-'s edition of M.:iNn?µ??a, 1997.-592 with.
- Nikitin A.V., Pereverzev B.M., Gusmans V.A.bas of diagnosis of diseases of an internals: the Manual. - 2 edition - Voronezh: Publishing house of the Voronezh state university, 1999. - 368 with.
- Skoromets A.A., Skoromets T.A.topic diagnosis of diseases of nervous system: the Management for doctors. - 4 izd., a stereotype. - SPb.: Polytechnique, 2002. - 399ñ.: an ooze.
- Mazurin A.V., Vorontsov I.M.propedeutics of children's diseases. - M.: Medicine, 1985. - 432 with.
- Danilova L.A.analys of a blood and urine. - 4 edition-ÑÏá.: Grease - Medkniga, 2002. - 128 with.
- Vidal 2001 (Manual VIDAL of PRACTICES).
- the Disc " the Big medical encyclopedia 2000 ".
To discuss a material at a forum of a site
Keywords: a case history, a pedonosology, a respiratory catarrh, children's diseases, an obstructive bronchitis, a vasculomotor rhinitis, a case history on a pedonosology
|
