IV. Results of the additional methods of investigation

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Data of the laboratory-instrumental researches with the indication of revealed pathology are listed.

V. FINAL DIAGNOSIS AND ITS SUBSTANTIATION

One should formulate the final diagnosis on the base of the previous one and the results of the additional methods of investigation.

The clinical diagnosis includes: main disease; its complications and accompanied diseases.

VI. FUNDAMENTAL TREATMENT

It includs regimen, diet, 2–3 prescriptions of the etiologic and pathogenetic medicines.

STANDARD CASE REPORT AT THE DEPARTMENT PROPAEDEUTICS OF INTERNAL MEDICINE

TITLE LIST OF THE CASE REPORT

Medical academy
named after S. I. Georgievsky

Department propaedeutics of interval medicine

Head of the department professor E. S. Krutikov

Teacher assosiated professor L. V. Polskaya

Case report No 342

Lukianova Vera Ivanovna

(patient’s full name)

Clinical diagnosis:

Main disease: Community-acquired right side lower lobar pneumonia of pneumococcus etiology

Complication: Lung failure of the 2nd degree, restrictive type

Accompanying diseases: ___________________________

Student Petrov I. S.

Course III

group 306

faculty MMF

I. PASSPORT DATA

1. Full name: Lukianova Vera Ivanovna.

2. Age: 25.

3.Nationality: Russian.

4. Family status: married.

5. Education: secondary (10 classes).

6. Work Place and occupation: worked at the factory.

7. Home address: 17, Aircraft street.

8. The date of admission to the clinic: December 21, 2013.

INQUIRY (Interrogatio)

Complaints: The patient complains on the pricking pain in the lower part of the chest to the right during deep breathing and coughing. The pain does not irradiate. The patient prefers to lie on the right side. Cough is permanent, with small amount rusty sputum discharge. Dyspnoea develops during slow walking along the corridor or a ward. There is expressed general weakness, perspiration, giddiness while getting up of bed, decreased appetite. Interrupted sleep due to cough and pain in the thorax.

History of the present disease (Anamnesis morbi)

On the 19-th of December the patient was overcooled during her work because she often went out from the shop to the street without a coat. On the 20-th of December in the morning suddenly fever elevated to 40^oC, accompanied with chills, then persistent dry cough appeared. First days the patient was treating by herself. She drank hot milk, applied a hot water bottle to the feet, and took tablets of aspirin. However her condition did not improve. Expressed general weakness and dizziness appeared. Dyspnoea in walking arose in the evening, piercing pain in the low part of the chest to the right. On the 21st of December the patient addressed to the polyclinic. She was directed to the X-ray examination of the chest and then hospitalized.

Anamnesis vitae

She was born in Simferopol in worker family as the second child (there were 3 children in the family). She began walking and talking in time, she was breast fed. Conditions of her childhood were satisfactory. The patient went to school when she was 7; her progress at school was satisfactory.

From 17 to present time she has been a worker at the factory. Labour conditions are unfavorable (drafts and cold). Her working time-table was variable. At present she works only in a day time.

Leaves and holidays are utilized fully.

Work conflicts are rare.

She lives in private house without sewerage system. There was a stove heating earlier. There is gas heating at present. There are 4 members in her family. Sometimes there are conflicts in the family.

Nutrition is irregular (2–4 times per day) mainly at home. The patient walks in the fresh air not less than 2 hours per day, does not go for sports, does not smoke, alcohol uses in moderate amounts, mainly wine.

Past illness: measles, dysentery in childhood; acute pneumonia when she was 10, tonsillectomy in 15, appendectomy in 17. Tuberculosis, venereal diseases, acute hepatitis denied.

Sex maturity began when she was 14; it is regular, plentiful, during 4–5 days. She was married at 19. Of 3 pregnancies one ended with normal birth, other ended with medicine abortions. At present the patient has one healthy child. Her husband is healthy.

Parents of the patient are alive. She does not know something about their past illness, however tuberculosis, alcoholism and psychical diseases in her family deny.

She bears medical preparations well without allergic reactions. She did not undergo blood transfusion. Allergic reactions to various foods and chemical substances are absent.

II. DATA OF PHYSICAL EXAMINATION
(Status praesens)

General condition of the patient is middle heaviness. Consciousness is clear, posture is active, and gait is not changed. The facial expression is unhealthy. Body build is normosthenic. Skin is pale, clean, elastic, raised humidity. Lips are cyanotic, other visible mucous are pinkish, moist. Subcutaneous fat is developed moderately. Oedema is absent.

Submandibular, back cervical, axillary and inguinal lymph nodes are determined with the size from 0,5 to 1,5 сm in diameter, rounded form, with smooth surface, elastic consistence, mobile, not adhered to the skin, surrounding subcutaneous fat and together, painless. Skin over them is not changed.

The muscles are developed moderately, tone and muscles force are identical on both sides. Tenderness of the extremities’ muscles during palpation is marked. Parts of skeleton are proportional. Palpation and tapping of the bones are painless. Joints are of regular shapes, painless during palpation and movements. Temperature and skin over them are not changed. Active and passive movements in joints are full. Pathologic deformations of the spinal column are absent. Its function is normal.

Temperature of the body is 37,4^oC.

Height is 153 cm. Weight is 60 kg.

Respiratory system

She breathes thought the nose, nose wings in breathing do not participate. Voice is hoarse. Form of the chest is regular, normosthenic. The chest is symmetric. Supraclavicular fossa is moderately pronounced. The ribs are moderately inclined as viewed from the side, the epigastric angle nears 90^o. Shoulder blades closely fit to the chest and are on the same level. Respiration type is mixed. Breathing is rhythmic, deep. Respiration rate is 22 per minute. Inspiration and expiration are equal. Right half of the chest lags from the left one during breathing. Vocal fremitus to the right in the low-side region and under scapular is increased.

On comparative percussion of the lungs the percussion sound is dull to the right in axillary region of the lower VII rib and in subscapular region as well. Over the other parts of the chest there are clear lung sound. Traube’s space gives tympanic sound.

The upper level of the apices on both sides anteriorly is 3 cm, posteriorly it is at level of the spinal process of the 7-th cervical vertebra.

Lower borders of the lungs

Mobility of the lower edge of the left lung on midclavicular line is 4 cm, on scapular line is 5 cm.

Mobility of the lower edge of the right lung was not determined.

On auscultation bronchial breathing is heard in the lower-lateral parts of the chest and under scapular to the right. Slightly increased vesicular breathing is heard over other parts of the chest. Bronchophony is increased in lower parts of the chest to the right.

Cardio-vascular system

Visible arteries pulsations are absent. Vein pulse is negative. Cardiac hump back and visible pulsation in the heart region are absent.

Apex beat is palpated in the V intercostal space 1 cm inside from the left midclavicular line. It is restricted, moderate, low.

«Cat’s murmur» was not determined.

There are borders of relative cardiac dullness: right — 1 cm outside from the right edge of the sternum, upper — on the lower edge of the third rib on left parasternal line, left - 1,5 cm inside from the left midclavicular line.

There are borders of absolute cardiac dullness: right — along left edge of the sternum, upper - on the lower edge of IV rib, left — 2 cm inside from the left midclavicular line.

The right and the left borders of vascular dullness are found along the edges of the sternum.

On auscultation of the heart two sounds are heard in all points. The sounds are rhythmic, slightly weakened, peculiarly on the basis. Cardiac rate is 92 beats per minute. The 1 sound is louder than the 2 one at the heart apex and the tricuspid valve. The 2 sound is louder than 1 one on the heart base. Accent, splitting, reduplication, murmurs are absent.

Pulse is equal on both arms. Its rate is 92 per minute. Pulse is rhythmic, plenus, molis. Temporal and carotid arteries are well palpated; pulsation on the both sides is equal.

Arterial pressure: systolic - 95 mm Hg, diastolic — 70 mm Hg, pulse pressure — 25 mm Hg.

Digestive system

The tongue is of a usual size, moist, coated with white layer. Teeth are healthy.

Mucous of the mouth is light pink colour, clean. Tonsils are absent.

Abdomen is of a regular form, symmetric. A scar after appendectomy is determined in right ileac region. Abdominal wall participates in breathing. Tympanic sound is heard over all parts of the abdomen during percussion. In superficial palpation abdomen is soft, painless. Hernias and superficial tumour are absent. Mendel’s and Shchetkin-Blumberg symptoms are negative.

Deep palpation:

• the sigmoid is palpable in the left iliac region as a smooth firm cylinder 2 cm in diameter, it is painless, does not produce rumbling sounds, displaces on 1,5 cm;

• the caecum is palpable in right iliac region as a smooth soft cylinder, it is painless, produces rumbling sounds, displaces on 1 cm.

Other parts of the intestine are not palpable.

Greater curvature of the stomach is determined as soft smooth ridge 3 cm above the navel, it is painless, displaces on 1,5–2 cm, produces slightly rumbling sounds.

On auscultation of the abdomen peristalsis of the intestine of the moderate louder and frequency is heard. Vessel murmurs are absent.

Visible enlargement of the liver is absent. The liver is not palpable. Liver size by Kurlov is 8x7х7 cm. Liver size by Obraztsov is 9–8–6 cm.

Gall-bladder is not palpable. The pressing and tapping symptoms of gall-bladder are negative. Tenderness in the points of gall-bladder are not determined.

Pancreas is not palpated. Tenderness in the points of conforming to the head, to the body and to the tail of pancreas and in points of phrenic nerve and costo-vertebral to the left is not determined.

Urino-genital system

Visible pathology of the lumbar region is absent. Kidneys are not palpable. Palpation of the kidneys region is painless. Tender points of the kidneys and ureters are painless. Pasternatzky symptom is negative on the both sides. The urinary bladder is not palpable.

Blood system

Spleen is impalpable. The borders of the spleen dullness are determined between the IX and XI ribs, its size 4 -7 cm.

III. INITIAL DIAGNOSIS

Analysis of the symptoms, received during inquiry, inspection, palpation and auscultation of the patient, let us to pick out the following syndromes:

1. Painful syndrome due to pleura affection (piercing pains in the lower part of the chest to the right increasing during coughing and breathing and decreasing in lying on the affected side).

2. Infectiously — toxic (high temperature with its rapid increasing, shivering, sweating, weakness, derangement of the sleep and appetite, pale and moist skin, moderate tachycardia and hypotension). Such syndrome can develop as reaction of the body on bacterial or virus infection.

3. Consolidation of the lung (lag of the right half of the chest from the left one during breathing, increasing of the vocal fremitus and bronchophony to the right, dull percussion sound and bronchial respiration in the projection of the lower lobe of the right lung).

4. Lung failure (dyspnoea due to insignificant physical load, tachypnoea at rest — 22 respiratory movements per minute).

Thus, acute onset of diseases after overcooling, the presence of painful, infectiously - toxic, consolidation of the lung, lung failure syndromes allow making following initial diagnosis: Community-acquired right side lower lobar pneumonia.

IV. PLAN OF ADDITIONAL INVESTIGATIONS

1. General analysis of the blood.

2. Research of the blood on C-reactive protein, total plasma protein and protein fractions for the estimation organism reactivity.

3. Analysis of the sputum and its bacterioscopic study for identify the microbes and prescription a correct medicamentous therapy.

4. Analysis of urine.

5. Analysis of faeces on eggs of the intestinal worms.

6. X-ray examination of the lung for specification of the diagnosis.

7. Spirography for assessing of the external respiratory system function.

Results of supplementary researches and their clinical estimation

1. Analysis of the blood:

• Erythrocyte — 3,9x10¹²/L

• Haemoglobin — 130 g/L

• Colour index — 1,0

• Leucocytes — 22,6x10⁹/l

• Eosinophils — 0

• Stab — 12%

• Segmented — 71%

• Lymphocytes — 15%

• Monocytes — 2%

• ESR — 35 mm/h

Conclusion: Leucocytosis, neutrophil shift to the left, acceleration of ECR are characteristic for inflammatory process.

2. Analysis of the urine:

• A Colour is saturated-yellow

• Transparence is insignificant lowered

• Mucus is in moderate amount

• Specific gravity is 1,017

• Protein is 0,033 g/L

• Sugar — negative

• Erythrocytes fresh, 5–7 in f. v.

• Leucocytes 8–10 in f. v.

Conclusion: Insignificant proteinuria, microhaematuria can be due to the reaction of the organism on high fever and intoxication.

3. Analysis of the sputum:

• Amount — 14 ml

• Consistency — liquid

• Colour — rusty

• Character — mucopurulet

• Microscopic study: Leucocytes — 30–40 in f. v.

• Erythrocytes —10-20 in f. v.

Bacteriological study: pneumococcus, sensitive to ampicillin

Conclusion: This sputum is characteristic for lobar pneumonia, by pneumococcus aetiology.

4. Biochemical research of the blood:

• C-reactive protein +++

• Total plasma protein 75 g/L. Albumins — 49% Globulins — 51%

• a₁-8% a₂ —12% b — 11% g — 21%

Conclusion: Dysproteinemia is characteristic for acute inflammatory process.

5. Analysis of the faeces on eggs of the intestinal worms is negative.

6. X-ray examination of the lung:

• Marked darkness of the lower lobe of the right lung.

Conclusion: X-ray data is characteristic for lower lobar pneumonia to the right.

7. Spirography: VC — 1,7 L

• FEVC — 84% from VC

Conclusion: markedly decreasing of VC is characteristic for lung failure of the 2 degree, restrictive type.

V. FINAL DIAGNOSIS AND ITS SUBSTANTIATION

The findings of the additional investigation of the patient (X-ray: marked shadowing of the lower lobe of the right lung; analysis of the sputum: rusty colour, mucopurulent character, leucocytes 30-40 in f.v., pneumococci; spirogram: VC — 1,7 L) make it possible to formulate the following diagnosis:

Main disease: Community-acquired right side lower lobar pneumonia of pneumococcus aetiology

Complication: Lung failure of the 2 degree, restrictive type.

VI. TREATMENT

Patient should be kept in bed.

Diet №15. Light diet rich with vitamins.

Rp: Ampicillin 500 000 units

D. t. d. № 20

S: 4 times a day intramuscularly

#

Rp: Bromhexini 0,04

D. t. d. № 20 in tab.

S: 1 tabuletta 4–6 times a day.