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History of the disease. Closed fracture VI, VII, VIII edges to the right with lung damage.

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Closed fracture VI, VII, VIII edges to the right with lung damage.

Surname, first name, patronymic
Age (full years) 59 years
Place of residence
Place of work disabled group II
Profession or position miller
Date of arrival
Who is sent to the patient MSM
Delivered to the hospital for emergency indications after 2 days
Diagnosis of the injured chest with a fracture V, VI
institution of the ribs on the right
Diagnosis at the onset of fracture VI, VII, VIII ribs, joint with
offset with lung injury
Diagnosis Clinical closed fracture VI, VII, VIII ribs
right to lung injury
The diagnosis is the final
clinical
a) the main closed fracture VI, VII, VIII ribs
with lung damage
b) complication of the main hydro pneumoniax on the right, subcutaneous
emphysema
c) concomitant coronary heart disease: angina pectoris

Complaints at admission
The patient complained of severe persistent pain in the chest on the right, intensifying with breathing, shortness of breath, general weakness.

Complaints at the time of the curia
The patient complained of blunt pains in the chest to the right, intensifying when breathing.

The history of the present disease (Anamnesis morbi)
18. 02. 05 in the morning, according to the patient, he smoked on the staircase, his head was spun, fell. Immediately felt the pain in the right half of the chest, and after a few minutes, shortness of breath joined. In the aftermath of 2 days, the complaints remained the same, with a subfebrile temperature. I took analgin. For help turned 20. 02. 05 to the SCMP, from where it was sent to the BSMP for admission to extraordinary indications.

History of life (Anamnesis vitae)
Place of birth – Ryazan region. Born from the first pregnancy, which proceeded without pathology. At the time of the birth of the patient, the mother’s age was 22 years old, and the father was 24 years old. Weight at birth is 3.5 kg, height 51 cm. It was found in natural feeding for up to six months. Ros and developed in accordance with age. The peculiarities of development in adolescence are not revealed. Vaccinations are performed according to the calendar.
Housing conditions are satisfactory.
Meals are satisfactory.


Before receiving the II group of disability worked on a working grid (miller, excavator).


Harmful habits: smoking, alcohol denies.
Transferred and concomitant diseases: colds, angina pectoris, hypertension since 1990, disabled group II for this disease since 1997, suffered an acute myocardial infarction in 2003.
No allergic reactions detected.
Family history and heredity: the patient’s mother for 25 years suffered from hypertension.

Present state of the patient (Status prazens)

General condition of moderate severity. Condition forced (orthopnea). Consciousness is clear. Proportional body, weight 72 kg, height 183 cm. Nomosthenic constitution. Body temperature 37, 20С. Skin-covered and visible mucous membranes of normal color, without rashes, normal humidity. Elasticity of the skin is normal, no edema. Subcutaneous tissue is developed moderately. Peripheral lymph nodes are not palpated. Sickness and crepitation with palpation of the chest on the right are noted.


No muscular atrophy. Cranial articular deformities have not been revealed. It is noted pain in palpation of the edges on the right.
System of respiratory organs.


The circle of the chest is equal to 98 cm. The breath is independent, superficial, in the breathing of the muscles of the right half of the chest. The frequency of respiratory movements is 20 in 1 minute.
Form of the chest normostenic, type of respiration of the abdominal. When palpation in the region of the V-IX ribs along the axial axillary line, sharp pain, abnormal mobility of the ribs, skin crepitation is determined. Percussion is noted for blunting the sound at the level of X-XII ribs on the right in the posterior, middle, front axillary lines, timpanic sound at the level VI-X of the ribs on the right, on the posterior, middle, and the nearsighted axillary lines. The edges of the lungs in the front are determined 3 cm above the clavicle, at the back – at the level of the spinal cord VII of the cervical vertebra. The Krenig fields are 6 cm from each side. The width of the top of the left and right lungs is 2.5 cm. The lower boundary of the left lung passes along the anterior axillary line at the level of the VII rib, on the middle axillary – VIII, on the posterior axillary – IX, on the scapular – X rib, on paravertebral – at the level of the spinal cord XI thoracic vertebra. The lower boundary of the right lung passes along the parasternal line in the fifth intercostal space, on the midlectric line at the level V of the rib, along the anterior axillary VI rib, on the middle axillary – VII ribs, on the posterior axillary – on the VIII rib, on the shoulder – IX rib, on the parasternal – osteous process X thoracic vertebra. The motility of the lower edge of the left lung is within the normal range of 3 cm on the middle axillary line at the inhalation and 2 cm on the exhalation, the maximum is 5 cm. The mobility of the lower edge of the right lung is reduced and is 3 cm in the midlectric line at the inhalation and 2 cm at the expiration , maximal – 3 cm. Auscultatory hears the vesicular respiration, weakened over the lower parts of the right lung, where also single scattered dry wheezes are heard. In the remaining parts of the lungs breathing vesicular, rhinestones are not listened.
Cardiovascular system.


No visible pulsations of peripheral vessels. Pulse on arteries of good filling, rhythmic. Often, the pulse is 92 in 1 minute. The heart area is not altered. At palpation, the apical and the heart-th impulses are not determined.
Percussion bounds of absolute and relative dullness are normal. The boundaries of relative dullness are located: right – 1 cm from the right edge of the sternum, the left – 1 cm from the left mid-clavicular line, the upper – at the level of the third rib. The diameter of the relative dullness is 11 cm. The boundaries of absolute dullness pass: the right – on the left edge of the sternum, the left – 2 cm from the border of relative dullness, the upper – at the level of the IV rib. Heart tones are muffled at all points, the rhythm of cardiac activity is correct. Arterial pressure 130/90 mm. ht Art. The noises are not listened. The heart rate is 92 in 1 minute. There is no pulse deficit.


The appetite is stored, the amount of liquid consumed per day is 1.5 liters. Defecation daily, fecal, brown.


Examination of the oral cavity: a tongue of ordinary color, moist, teeth carious, no prosthesis. Zev is not hyperemic, plaques, puffiness is not present. The tonsils are not enlarged, clean.


The stomach is not enlarged in size, it participates in the act of breathing. The peristalsis of the stomach and intestines does not determine the-Xia.
Palpation of the abdomen in the position on the back, lying on the right and left side is painless. Tone of the abdominal muscles is normal. Symptoms of irritation of the peritoneum are absent. During auscultation the peristalsis of all sections of the small and large intestines is heard. Percussion sound dull over all sections of the intestine.


The percutaneous boundaries of the liver: the upper boundary of the absolute dullness of the liver passes along the right parasternal line at the upper edge of the VI rib, on the midlectric line – by VI rib, along the anterior axillary line – on the VII rib. Height of hepatic dullness, determined from the distance between the lower and upper limits of absolute dullness, is 10 cm along the front axillary line, 10 cm along the midline line, 9 cm along the parasternal line. With palpation of the liver, its surface is smooth, the consistency is dense, the edges are rounded. The liver is painless. Palpation in the projection of the gallbladder is painless. Palpation of the spleen region is painless, percussion longitudinal size is 8 cm, transverse – 4 cm.


The rectum: when an external examination of visible changes is not present. When a finger study, the normal tone of the sphincter is determined; internal hemorrhoidal nodes, infiltrates, swelling are not detected.


Urinary excretory system.
Dysuric phenomena do not mark the patient. Palpation of the area of ​​the kidneys, the bladder is painless. Urine straw-yellow.
Endocrine system.


The thyroid gland is not palpable.
Nervous system.
Consciousness is clear, memory is not changed. Shell Symptoms No. Focal neurological symptoms are not detected.

Preliminary diagnosis.
On the basis of the patient’s complaints of chest pain, shortness of breath, data of anamnesis (drop with thoracic impact), data of objective examination (pain in the region of the V-IX ribs on the right, skin crepitation, pathological edema of the ribs, frequency of respiratory movements up to 20 in 1 minute, respiratory depression in the lower parts of the right lung with auscultation, increased heart rate to 92 in 1 minute), it is possible to suspect the fracture of the V-IX ribs to the right with lung damage.

Survey plan.
Рентгенография грудной клетки в двух проекциях.
General blood test.
ECG

Survey data
X-ray diffractogram from 20. 02. 05 .: in the picture of the right half of the chest cell to the right of the fracture of the VI-VIII ribs, the fragment VI with a loss of fractures along the length and displacement along the width. At the fracture site, subcutaneous emphysema is detected. Pristonovaya pleura subjected medially to 1.0 cm; in the third sinus of pleura up to 100 ml of fluid with a mountain-horizontal internal border along the VII rib.
Conclusion Restricted septal pneumohydrotax with subcutaneous emphysema on the right.


Blood test:
MRI with cardiolipid antigen – negative
erythrocytes – 4,0×1012 / l
hemoglobin – 117
CP – 0.8
leukocytes – 5,1×109 / l
eosinophils – 4%
rod-core – 15%
Segment Nuclear – 64%
lymphocytes – 15%
monocytes – 2%
SOE – 53 mm / h
Electrocardiogram:
sinus tachycardia, deviation of EOS to the left, blockade of the anterior branch of the left leg of the hyza beam. Transition zone V5. Changes in the myocardium after an infarction.

Rationale for a clinical diagnosis.
On the basis of the patient’s complaints of pain in the chest, shortness of breath, anamnesis data (drop with breast thinning), data of objective examination (pain in the region of the V-IX ribs on the right, skin fixation, pathological mobility of the ribs, increased frequency of respiratory movements up to 20 in 1 minute, respiratory depression in the lower parts of the right lung with auscultation, heart rate up to 92 in 1 minute), additional study data (increase in ESR to 53 mm / hr in blood tests, signs of VI-VIII rib fractures, c welcome m fragments VI rib along the length and width offset, with hydro- and pneumothorax), a clinical diagnosis is established: closed fracture VI, VII, VIII edges to the right with lung damage.

Etiopathogenesis.
The cause of this disease is a mechanical damage due to the patient’s fall, a chest-block injury – a fracture of the ribs with damage to the pleura and pulmonary tissue.

Treatment.
Table number 10;
thoracentesis with drainage of pleural effusion;
antibacterial therapy (gentamicin 2.0 three times a day from 20. 02. to 28. 02);
bronchodilator therapy (a medicine of lasolvana for 1 table spoon 3 times a day from 22. 02 to 05. 03, erespan – a course);
analgesic therapy (ketorol 1.0 intramuscularly daily);
therapy of concomitant diseases (1 tablet 2 tablets per day, verapamil 1 tablet (40 mg) 2 times a day, thrombotic ACC 1 tablet (100 mg) at 22.00, nitrosorbid 2 tablets 3 times a day from 22. 02 on 05.03);
table number 10.

Diary

22. 02.
There are complaints of pain in the right half of the chest, shortness of breath.
The situation is relatively satisfactory. Body temperature 37.10С. Creation remains in the projection of broken edges. Ausculatory breath is vesicular, weakened in the lower parts of the right lung, isolated dry wheezing. ЧДД 18 in 1 minute. The heart tones are muffled, the rhythm is correct. BP 130/80 mm.rt. Art. Heart rate 82 in 1 minute. Antibacterial therapy is being conducted.

03.
Pain in the chest cavity on the right when deep breathing persists, does not feel shortness of breath. The general condition is satisfactory. Body temperature 36.80С. The weakened breath in the lower-posterior sections of the thoracic cord is maintained. ЧДД 18 in 1 minute. The heart tones are muffled, the rhythm is correct. BP 130/80 mm. ht Art. CHSS 76 in 1 minute. The thoracocclusion with drainage of the pleural cavity, antibacterial therapy was performed in the patient. Hydrotax is eliminated. Exit of the patient is scheduled for 5. 03. to continue the treatment outpatiently under the supervision of a traumatologist at the place of residence. Recommended: curative and protective regime; control and correction of blood pressure; cardiotropic therapy.


Disseminated epicrisis.

Loktaev I.A., 59 years old, was treated at the I traumatology department of the BSMP from 20. 02. 05. to 05.03. 05 with a diagnosis: closed fracture VI, VII, VIII ribs right to lung damage complicated by the hydropnevmotorax on the right; concomitant illness – coronary heart disease: angina pectoris.
Acted with complaints of pain in the chest, shortness of breath that appeared after the fall. Clinically determined by pain syndrome, respiratory failure. On the chest X-ray shows signs of fracture VI-VIII ribs with a shift of fractures and lung damage. Thoracocentesis was performed with drainage of the chest, antibacterial, bronchodilator therapy. During treatment, hydrotoraks were eliminated. Vipi-san to continue the treatment outpatiently under the supervision of a traumatologist at the place of residence. Re-commended: therapeutic and protective regime; control and correction of blood pressure; cardiotropic therapy.

Forecast.
For the life of the patient is favorable; health may require rehabilitation for several months; for labor – the ability to work with this disease can be restored in 1-2 months.

 
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