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History of the disease by pulmonology. Diagnosis: Idiopathic fibrosing alveolitis

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History of the disease by pulmonology

Diagnosis: Idiopathic fibrosing alveolitis. Stage of Cell Lung. Moderate erythrocytosis.

Complaints

Complaints for prolonged coughing, intensifying with physical activity, with the separation of a small amount of yellow sputum; on shortness of breath with insignificant physical activity (lifting for 1 flight of stairs) physical load; on periodic piercing pains in the region of the upper end of the heart with irradiation under the shoulder blade under load; on pulling pains at the bottom of the abdomen, not related to the body position and the load; on pasty scurvy (in the evenings).

The history of the present disease ( Anamnesis morbi)

In youth, he suffered from chronic otitis media. In 2000 there were pains in the heart, shortness of breath under load, a diagnosis of coronary heart disease: angina pectoris II f. k., examined in VKNC, prescribed cardiotocept, veroshkiron periodically, verapamil with heart attacks with an effect. In March 2002 there were attacks of cough, at the end with a slight yellow detoxification of sputum. Surveyed in 61 GKB, marked a severe condition, wheezing in the lungs, (lower bilateral pneumonia two-sided?). May 2002 – X-ray – Strengthening and deformation of the figure – Diagnosis of fibrosing alveolitis, emphysema, diffuse pneumosclerosis. After discharge, the condition improved to a relatively satisfactory, coughing attacks became less frequent (at night), sputum less, cardialgia less frequently. X-ray changes persisted, shortness of breath intensified. Since 2002, received corticosteroids, then colchicine was added to therapy. Several hospitalizations in the clinic. to them E.M.Tareyeva in connection with exacerbation of chronic obstructive bronchitis: in March 2003, in October 2003, In 2003 – biopsy – confirmed idiopathic fibrosing alveolitis. In 2003 – CT. The real deterioration of the condition during the month when it began to increase shortness of breath, cough intensified with sputum, feces of the leg appeared. Hospitalization October 27, 2004

Carried diseases

In childhood, suffered from malaria.

In youth, chronic.

Wounds, contusion not it was. Sexually transmitted diseases did not suffer. There was no contact with infectious patients.

There were no poisonings.

Disabled of group II.

Family history and heredity

Father died in war, mother died 63 years of peritonitis, brothers and sisters: brother died at the front, other relatives are healthy.

Marital status: widow.

Children: daughter 36 and 42 years old, one suffering from illness kidneys.

The history of the patient’s life ( Anamnesis | || 172 Vitae)

Date of birth 11.03.29, place of birth Moscow. Development in childhood without lagging from peers, he suffered malaria. Arthritis. Education is secondary, the profession of dyer. Occupational hazards were (acids, paint, chlorine substances) for 45 years before 1985 (age pension). Housing conditions are satisfactory. Nature of food: regular, sufficient, predisposition to meat food.

Do not smoke. Alcohol does not consume. Drugs deny.

Date of last menstruation: menopause from 45 years.

Gynecological diseases deny. Blood transfusion, donation denies, extraction of teeth were. Contact with patients with tuberculosis denies. Acute viral hepatitis was not tolerated.

III. Data of objective research

Condition of the patient satisfactory, tº of the body – 36,6 ºС.

The patient’s position is active. Consciousness is clear. The person does not express painful changes.

The body is a correct, normostenic type of constitution. Height 155 cm, body weight – 65 kg. BMI = 27. Disorders of posture and gait are not noted.

Skin coverings pale pink color. The skin is moderate in moisture, its elasticity is good. Hair is not changed. Nails in the form of watch glasses.

Subcutaneous fat layer developed excessively (the thickness of the skin fold on the abdomen at the navel level is 3 cm), distributed uniformly. Thickness of the skin folds at the lower angle of the shoulder blade 2 cm. Scabies.

Lymph nodes when viewed are not visible, they are not palpated.

General development muscular system satisfactory. There is no pain in palpation of the muscles. The muscle tone is the same on both sides. Muscular strength is satisfactory.

When examination of bones the skull, chest, spine of deformity are not marked. The fingers of the hands are “the fingers of Hippocrates.”

Joints The correct configuration is painless. Active and passive movements in full volume.

Breathing organs

Nasal breathing is free. Separated from the nose is not present. Nose shape not changed.

Chest cell of the correct configuration, normostenic type, conical, non-deformed, symmetrical. Type of breathing – thoracic. The breath is rhythmic. Respiratory rate – 24 per minute. Respiratory movements on both sides of the chest are average in depth, uniform and symmetrical. Auxiliary respiratory muscles in the act of breathing do not participate.

The chest is painless. Elasticity of the chest is normal. The voice is trembling the same on both sides.

The position of the blades on the same level, tightly adjacent to the thoracic cavity.

Cardiovascular system

Percussion of the heart

The limits of the heart have not been changed.

Auscultation of the heart

Accent of 2 tones above the lung trunk. Heart rate is 70 in 1 minute. The heart rate is correct. There is no noise.

Investigation of vessels

Pulse of 70 beats per minute, rhythmic, satisfactory filling and voltage, normal size, the same on both hands.

Arterial pressure: on the left hand 180/70 mm Hg. Art., on the right hand – 180/70 mm Hg.

In the study of veins – without features.

There is no capillary pulse.

Organs of urine output

When examined areas kidneys pathological changes are not detected. The kidneys are not palpated. The symptom of Pasternatsky is negative on both sides.

The urinary bladder percussion does not protrude above the lumbar articulation, it is not palpated.

Nervous -Physical status

Consciousness is clear, no headaches, no dizziness, sleep is disturbed due to cough attacks .. The assessment of the general condition is adequate. Intellect corresponds to the level of its development. Attention is not weakened, memory is not reduced, the mood is even, communicative, balanced, not fussy.

 Preliminary diagnosis

  • Idiopathic fibrosing alveolitis. Stage of Cell Lung.
  • Chronic bronchitis.
  • CHD: angina pectoris II f. k.

Survey plan

  1. Clinical analysis of blood, platelets, reticulocytes.
  2. Time of blood clotting, bleeding time, coagulation, PI.
  3. Blood group, Rh factor, Reaction Wasserman, HBsAg.
  4. AST, ALT, gamma-GT (justification: to determine the status of liver functions).
  5. Biochemical blood test (12-channel, 6-channel) (rationale: for determining the functions of the kidneys, liver, pancreas, estimates of homeostasis).
  6. Brainstorm: titers of ASL-O (rationale: to evaluate the activity of arthritis).
  7. General analysis of sputum (substantiation: exclusion
  8. X-ray of the chest organs (rationale: assess the stage of the process).
  9. Functional examination of the heart and lungs: ECG, monitoring of blood pressure, FVD ( justification: assess the degree of restriction and dynamics in the treatment).
  10. Ultrasound: heart, abdominal cavity, kidney (justification: lower abdominal pain).

Data of laboratory and instrumental studies of research methods

General blood test

WBC: 10,1 * 10 | || 482 3 mm 3 (4,0-9,0)
RBC: 5,16 H 10 6mm 3 (3.90-5.00)
HGB: | || 507 15,1 H g/dL (11.0-16.0)  
HCT 44.8 H% (36.0-48.0)  
PLT 220 * 10 3mm 3 (150-400)  
MCV 87 μm 3 (75-95)  
MCH 31.2 pg (24.0-34.0)  
MCHC 35,9 g/dl (31.5-35.0)
SOE 10 mm / h & nbsp;  

Electrocardiogram

Rhythm: sinus, correct. Frequency of contractions in I minute 70.

Conclusion: EOS is located horizontally. The rhythm is sinusoid, correct. Changes in myocardium of the hypertrophied left ventricle.

FVD

Conclusion: Restriction of respiration by restrictive and obstructive types.

Clinical diagnosis

Idiopathic fibrosing alveolitis. Stage of Cell Lung. Moderate erythrocytosis.

In favor of the diagnosis: idiopathic fibrosing alveolitis testifies:

  • Anamnestic data indicating the risk factor of idiopathic fibrosing alveolitis (occupational harm);
  • Results of instrumental studies: characteristic lung changes in radiography and CT.
  • Results of biopsy.

Cell lung stage exhibited on the basis of:

  • Results of CT.

Complications:

  • Chronic lung heart;
  • Pulmonary heart failure;
  • Nidos Circulatory blood circulation on both circles.

Concomitant diseases:

  • Chronic obstructive bronchitis (according to the results of physical examination and physical examination);
  • Arthritis (anamnestic data, physical examination);
  • IHD: angina pectoris II

Appointments:

  1. Cardiot 20 mg * 2 p / day (prevention of angina pectoris)
  2. Isoptin 40 mg * 3 p / day (antianginal action, treatment of pulmonary hypertension in patients with chronic obstructive pulmonary disease of the lungs)
  3. Omega 1 capsule for the night (prophylaxis of the ulcer of the stomach)
  4. Methidred 12 mg / day (3 pills) (stop progression of lung fibrosis)
  5. Colchicine 0.5 mg / day (treatment of idiopathic fibrosing alveolitis).
 
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