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History of the disease by pulmonology Diagnosis: right-sided lower limb pleuropneumonia

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History of the disease by pulmonology

Diagnosis: Right-sided lower limb pleuropneumonia at the stage of resolution. Right-sided posterior-lower-marginal undressed pleurisy stage. 

COMPLAINTS FOR THE CURRENCY DAY

For general weakness, a cough with a release of a viscous, difficult detachable sputum, difficulty breathing during physical activity, pain in the right half of the chest, sweating.

ANAMNESIS MORBI

She considers herself ill since February 1999. The illness began acutely, when for the first time there was pronounced weakness, cough, hyperthermia 39-390 C, sweating, pain in the chest on the right. He was treated by his own penicillin, after which the condition worsened. For “ambulance” was sent to 1 GKB, stayed in the hospital for the treatment department for 3 days, was discharged due to the lack of a policy. Then he turned to Avtdorr Polyclinic where Rg of the thoracic cavity was performed and right-sided pneumonia was detected. In the future, in spite of the deterioration of the state, medical institutions did not apply because of the absence of an insurance policy. After obtaining the policy, he turned to the TCDP Polyclinic, where the direction for hospitalization was issued to the hospital’s therapeutic section of the railway hospital on April 14, 1999 in the planned order.

ANAMNESIS VITAE

Born in Turinsk. I lived in a private home with stove heating. In my childhood I was suffering from measles, colds. There were no operations.

I started my career from the age of 14. The working conditions are associated with frequent overcooling, heavy physical labor. From occupational hazards it gives off dust, noise, drafts, contact with harmful substances. Currently living in a well-kept house, a separate 2-bedroom apartment of 28 sq.m. together with my sister. Has three children who live separately. Eats regularly 3-4 times a day. In the food there are both vegetable and meat products. The chair is regular, decorated, of ordinary color and color. Diuresis is normal. From transmitted diseases it notes: ORZ, flu, radiculitis. Alcohol takes holidays in the amount of 1 liter. Smokes with 10 years of cigarette with a filter in the amount of 1 pack a day. Strong tea and coffee consumes in moderate quantities. Heredity along the lines of father and mother is not burdened. They died at an old age. Has older 4 brothers and sisters – healthy. Venous diseases, tuberculosis, hepatitis, mental illness denies. During the year before admission to the clinic at the hospital was not. Allergic history is not burdened.

General inspection:

The general state is satisfactory, the position is active, the consciousness is clear, in the place and time is oriented, when contact is adequate, the expression of the person is benevolent, the physique correct Constitution: normostenic. Height 165 cm, weight 65 kg Skin covers are clean, dark, moist, pathological rashes are not present. No pigmentation is detected, turgor is normal. Nails are not deformed. Mucous membranes of the lips, oral cavity are pink wet, no rashes. The expression of the subcutaneous tissue is normal, the thickness of the fold on the abdomen at the level of the navel is 1.5 cm. Lymph nodes – subclavian, supraclavicular, axillary and Zorgius nodes are not palpated. Muscles are developed symmetrically according to sex and age, the tone and strength are not changed, with palpation pain is not present. Bone system: palpation of the bone skeleton is not marked, with percussion of long tubular bones there is no pain.

Breathing system: the shape of the chest corresponds to body composition, no deformation, right half of the chest when breathing falls behind the left, the type of respiration is mixed, the epigastric angle 900. Supraclavicular fossa are symmetrical, depressions and protrusions are not observed. Intercostal gaps are the same throughout the chest cavity. Breath of rhythmic, superficial, auxiliary respiratory muscles participates in the act of respiration, the frequency of respiratory movements 25 in 1 minute. Palpation of the chest is painless. Except: VIII-IX-X intercostal spaces on the right on the median-clavicular, anterior axillary lines, where severe pain is determined. Elasticity of the chest is reduced both in the anterolone and in the lateral sections. Voice tremor and bronchopenia are weakened. Comparative percussion: there is a blunt percussion sound in the VIII-IX-X intercostal spaces to the right of the median-clavicular, anterior axillary lines, in the remaining sections the sound is pulmonary, symmetrical. Topographic percussion: the boundary of the upper edge of the right lung front – 3 centimeters above the collarbone, the left 3.5 centimeters above the collarbone, and at the back – at the level of the VII cervical vertebra.

Border of the lower edge of the lung:

Topographic line Right light Left light
L. parasternal 4m / p
L. mediaclavicularis 5m / p
L. axilaris anterior 6m / p 6 m / p
L axilaris media 7 m / p 7 m / p
L. axilaris posterior 8 m / p 8 m / p
L scapularis 9 m / p 9 m / p
L. paravertebral 10 m / p 10 m / p

Auscultative – breathing weakened, bronchial, there are moist, small bubbling wheezing in the region of the lower part of the right lung.

Cardiovascular system: Deformation of the thoracic cells in the projection of the heart is not present. Localization of the apical impulse of 1.5cm. Input from L. Mediaclavicularis in 5 m / p, localized, moderate strength and height.

Percussion:

Boundaries of relative cardiac dullness:

Right border – 4m / p. Pathological pulsations in the region of the neck, jugular fossa, heart, subclavian areas are not observed. at 1cm to the outside of the right edge of the sternum

upper – at the upper edge of 3 ribs in the projection of the left oblique line line

left – in 5 m / p by 1.5 cm in the midire of the median- clavicular line.

Right contour of the heart

4 m / p at 1 cm from the right edge of the sternum, 5 cm from the anterior median line of the body

3 m / p on 1 cm from the right edge of the sternum

Left heart contour

5 m / p and 1.5 cm from the left median-clavicular line, 7 cm to the left of the anterior median line of the body

4 m / p for 1 cm to the left of the left median-clavicular line

3 m / p on 1 cm to the left of the left peristaltic line

The heart diameter 12 cm.

The limits of absolute cardiac dullness:

Right: on the left edge of the sternum at level 4 m / p

Upper: at the cartilage level, 3 ribs on the left

Left: 1.5 cm in the inside of the left mid-clavicular line

The width of the vascular beam in 2nd intercostal space 5 cm.

Auscultatory – heart tones are clear, splitting and bifurcation Tone is not observed, the rhythm of quail, gallop, “schelchok discovery” is not vыyavlyaetsya. Heart rate 76 in 1 minute, no pathological noise is observed, functional systolic noise is heard on the aortic valve.

Investigation of vessels: Arteries – elastic walls, moderate filling and stress pulse, regular shape, rhythmic, synchronous on symmetrical arteries. Blood pressure on both hands is the same at 115/75 mmHg. Veins without palpation are painless, not enlarged.

Digestive system: No smell is observed from the mouth. Mucous mild, pink, cracks and ulcers are not present. A gum of ordinary color, bleeding, bloating is not present. The seed is clean, physiologically colored, tonsils without peculiarities. The language is wet, there is no plaque, there are no dental prints, taste sensitivity is preserved. There are no artificial teeth and prostheses; on the upper and lower incisors, small root teeth, there are crowns made of metal of yellow color. The belly of the right form, actively participates in the act of breathing. There is no discrepancy between the direct muscles of the abdomen, the “jellyfish heads”, hernial protrusions, scarring, hyperpigmentation. Palpation: with superficial palpation, the abdomen is a soft, painless, dough-like consistency; In deep palpation, the sigmoid colon: the surface is smooth, painless, there is no disturbance, peristaltic swollen, the colon is moderately tense, painless, the surface is even, movable; the transverse colon is moderately thickened, painless; the ascending and descending parts of the large intestine are moderately compact, painless, mobile, slightly over-stretching, the surface is even; stomach palpation painless, dough-like consistency, large curvature palpable poorly; The pancreas is painless diameter about 2 cm. The liver protrudes 3 cm from the edge of the edge arc, the edge is dense, smooth, painless, Ordinate Kurlov 12 (3) х9х8. The spleen is not palpable, percussion is ordinates by Kurlov 0 6 / 4 .|| 358

Nervous system and sensory organs:

Memory and sleep are considered satisfactory, the mood of elevated, irritability and tearfulness does not mark , willingly comes into contact. The rumor is normal; whisper speech – 6 meters. Dermofragism is red, persistent, disappears after 40 seconds, there is no tremor of hands.

PRELIMINARY DIAGNOSIS

Right-sided left-sided pleuropneumonia at the stage of resolution. Right-sided posterior-lower-marginal indigenous pleurisy

SURVEY PLAN

Clinical minimum (OAC, OAC, chest fluorogram , feces on eggs of worms, blood on RW).

Blood biochemistry (ALT, AST, SRB, serumukoids).

ECG

Pleural puncture

Examination of the contents of the puncture on m / f and the sensitivity to antibiotics

RESULTS OF THE INVESTIGATION

General blood test

dated April 15, 1999

SOE 40 mm / h, Nb 124 g / l, Er 4,3 10 12 / l, CPU 0,8

L 10,8×10 9 / л Е 1, П 2, С 63, Л 30, М 4

Leukocytes are observed oz, neutrophilia with shift to the left, lymphocytopenia, sharp increase in the ESP

dated April 29, 1999

SOE 30 mm / hr, Nb 121 g / l, er 3.75 10 || | 411 12 / l, CPU 0.8

L 8,0х10 9 / л Е 7 , P 1, C 67, L 23, M 2

 
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