Disease history

Anamnesis morbi:

He considers himself to be sick for 5 months, after becoming hypothermic for the first time he began to notice a cough with sputum, dyspnoea with physical exertion, which grew in dynamics and was periodically intensified. Later, tachypnea, pains in coughing in the thoracic region were added. Addressed to the therapist at the place of residence. He was treated out-patient (the name of the drug does not remember), without the effect the respiratory syndrome persisted. With increasing cough for a month, he took ACTS, antibacterial therapy (the name does not remember), with a short-term effect. Fluorogram of the chest from 09.01.2018: X-ray picture of chronic bronchitis in the acute stage. According to the report, he was hospitalized for inpatient treatment in the Main Military Clinical Hospital of the Ministry of Defense of the Republic of Kazakhstan in the therapeutic department. 

Anamnesis vitae

He was born on January 3, 1952 in the Taldykorgan region, in the village of Ekpendi. The general conditions of life of the patient and the state of health in childhood are satisfactory. The patient was ill with cholecystitis                                                , operations were performed to remove the gallbladder and appendix, due to appendicitis. He got a chest injury and a fracture of the lower rib on the left side. Throughout his life he worked as a mechanic, engineer, driver, builder. Currently he lives in Astana, he is married, has 2 children, does not work. He lives in a multi-storey building on the 15th floor. The last 6 months he did not leave outside the region. The chair is regular, daily, decorated, ordinary color, without pathological impurities, painless. It feeds regularly, the appetite is normal.Tuberculosis, mental, venereal diseases, viral hepatitis denies.Allergic anamnesis: not burdened.Heredity – not burdened.Habits: quit smoking 20-25 years ago, alcohol uses on special occasions.Inoculations (which, when): according to plan.   Status presence1.      Consciousness is clear, he answers to questions adequately, orientates itself in space, well-being is good.2.      Position in the bed – active.3.      The temperature is 36,4 C.4.      Constitution – normosthenic type. Height is 178 cm, weight at admission is 77 kg. Subcutaneous fatty tissue is expressed moderately (the thickness of the fold at the lower edge of the scapula is 2 cm).5.      Skin is clean, physiological coloring, warm, moderately moist, elasticity and turgor corresponds to age. The temperature of the skin is normal. On the anterior abdominal wall in the region of the cecum there is an operating scar about 12 cm long, which healed primarily. Rash, erosion, cracks, ulcers, hemorrhages, combs are not found. No abscess, no bedsores.6.      Skin attachments: Nail plates on the arms and legs are pink, smooth, shiny, the edge is even. Hair shining, do not split.7.      Mucous: conjunctiva is clean, moist, shiny. Mucous vestibules of the oral cavity, hard and soft palate is unchanged, pink, clean, moist, shiny.8.      Edema is not present.9.      Peripheral lymph nodes (supra- and subclavicular, elbow, axillary, inguinal) are not enlarged, painless, soft consistency, mobile, not soldered with skin and with each other, not palpable.10.  Muscle tone. The muscles of the trunk, upper and lower extremities, necks and facial muscles are developed sufficiently symmetrically, the tone is normal, atrophy, there are no developmental defects. In palpation are painless.11.  Musculoskeletal system. Bones: on examination and palpation, deformities and soreness of the bones of the skull, upper and lower extremities, pelvis, thorax and spine are not revealed. Joints: the configuration is normal, the joints are not deformed. The color of the skin and the temperature above the surface of the joints are not changed. Joints are painless on palpation.12.  Thyroid gland is not enlarged, painless, with surrounding tissues not soldered.

 Respiratory system

          Breathing is free, nasal passages are free, it is not separated from the nose.

The dynamic inspection:

  • Thorax: symmetrical, the respiratory act involves both the lungs
  • Type of breathing: abdominal
  • Respiratory rate: 20

    The static inspection:

  1. Subclavicular and supraclavicular hollows expressed a middle bit
  2. Intercostal intervals are 2 sm
  3. Ribs are located oblique, but the 10th rib on the right side is deformed due to an injury
  4. The thoracic parts length is equal, to abdomen parts length
  5. The epigastric angle is 90 degrees
  6. The scapula are clings tighly

Сonclusion: normosthenic, the deformities of the chest was not revealed.

 

          Palpation of the chest:

  • Painfulness is absent
  • Resistance: non-resistant
  • Voice trembling is symmetrical and saved, performed on both lungs

 

Percussion:

          Comparative percussion of the lungs: Clear pulmonary sound is observed on the both sides of the lungs.

          Topographic percussion of the lungs:

upper borderleft lungright lung
anterior3 cm above the clavicle3 cm above the clavicle
posteriorVII cervical vertebraVII cervical vertebra
lower border          left lung            right lung
Hemispheral line

(l. parasternalis)

V intercostalis intervalV intercostalis interval
Mid-clavicular line

(l. mediaclavicularis)

VI intercostalis intervalVI intercostalis interval
Front clavicle line

(l. axillaris anterior)

VIII intercostalis intervalVII intercostalis interval
Mid axillary line

(l. axillaris media)

VIII intercostalis intervalVIII intercostalis interval
Posterior axillary line

(l. axillaris posterior)

IX intercostalis intervalIX intercostalis interval
Scapula line

(l. scapularis)

X intercostalis intervalX intercostalis interval
The near-vertebral line

(l. paravertebralis)

X thoracic vertebraeXI thoracic vertebrae

 

 

Еxcursion of the lung:

  Topographic line         left lung            right lung
Middle clavicular line

(Middle clavicular line)

           4 sm             4 sm
Median axillary line

(l. axillaris media)

           6 sm             6 sm
Scapula line

(l. scapularis)

           6 sm             6 sm

 

Auscultation of the lungs: breathing above the entire surface of the lungs is vesicular with a harsh tinge. Bronchophonia is saved. Wheezing, crepitation and pleural friction noise can not be heard.

 

The cardiovascular system

          Visual inspection of the heart area:

  • Skin: cyanosis and acrocyanosis are not revealed
  • In the heart region the heart hump is not revealed.
  • Pathological pulsation is not observed:

– vascular (carotid shudder) and epigastric pulsation is absent

– Quincky`s symptom: not observed

– Myusse`s symptom: not observed

– pulsation in the 2nd intercostal interval on the right: not observed.

– pulsation in the 2nd intercostal interval on the left: not observed

  • Stock`s collar: not observed

 

          Palpation of the heart area:

  • Apex bit:
  1. Location: from the mid-clavicular line 1 cm inwards at level of 5 intercostal interval
  2. Аrea: 2.5 cm
  3. Height: medium
  4. Strength: medium
  5. Resistance: non-resistant
  • Dyastolic and systolic trembling is absent
  • Epigastric pulsation is absent
  • Heart beat is absent
  • The pulse:
  1. Synchronism: synchronous
  2. Rhythm: rhythmic
  3. Frequency: 78
  4. Tension: middle
  5. Filling: middle

 

Percussion of the heart:

The borders of comparative dullness of the heart:

left borderOn the 4th intercostal area 1 sm outwards from the sternum
upper borderOn the 3rd intercostal area
right borderOn the 5th intercostal area 1.5 sm inwards from the mediaclavicular line

 

Percussion of the vascular bundle: distance between two points is 6 sm.

          Auscultation of the heart:

           points            location            Tone
    mitral valvethe apex bit1st  tone is louder
    aortic valvethe 2nd intercostal interval on the right2nd  tone is louder
   pulmonary trunkthe 2nd intercostal interval on the left2nd  tone is louder
   tricuspid valveThe base of the xiphoid process1st  tone is louder
   Botkin-Erbleft of sternum at level 3rd  intercostal areanot heard

 

Сonclusion: pathological noise was not detected, heart tones are normal.

The digestive system

Gastrointestinal tract:

Complaints: there are no abdominal pains. Dyspeptic phenomena, including difficulty swallowing, nausea, vomiting, belching, heartburn and flatus are absent. Appetite is preserved, there is no aversion to food.

Feces: usually 1 time per day, the amount is moderate. It’s color is brown. There is no blood and mucus in the stool.

Inspection:

Oral cavity. My patients tongue is pink, moist, without plaque. All teeth are present. Gums, soft and hard palate of normal color, hemorrhages and ulcers are absent. There is any smell from the mouth.

Abdomen: my patients abdomen is  oval shaped, symmetrical, the subcutaneous fat layer is developed moderately and evenly, also participate in act of breathing.  In the abdominal area lack of vascular starlets, jellyfish head and bulging in left or right side.

Superficial palpation of abdomen: the anterior abdominal wall is not tense, painless in all departments. Divergence of straight abdominal muscles is absent. There are absent not only umbilical hernia, but also hernia of the white abdominal line.

The deep palpation of the abdomen;

 Caecum Colon

ascendens

Colon transversusColon descendens Sigmoid intestine
Diameter32Not palpated 23
ConsistencyMildDense-elasticNot palpatedDense-elasticdense
Painfulness painlesspainlessNot palpatedpainlesspainless
RumblingrumblesNot rumblesNot palpatedNot rumblesNot rumbles
SurfaceSmooth Smooth Not palpated Smooth Smooth
ShapeCylindrical Cylindrical Not palpated cylindricalCylindrical
Mobility Moveable Moveable Not palpatedMoveable Moveable

 

The lower border of stomach by methods of percussion, auscultation  and noise splash is located in 4cm from the navel.

Liver and gall bladder : in my patient  there are no complaints for the  pain in the  right side.

Inspections: there is no protrusion in region of right side.

Palpation of the liver:  in palpation the liver’s edge is painless, sharp angled, smooth and mild.

Percussion of liver by Kurlov

Distance
Mediaclavicula line9 cm
White line8cm
Left Arch rib7 cm

 

My patient’s gallbladder had removed 3 years ago. In this case the all symptoms, which are Orthner, Myussi-Georgievsky and Ker, were absent.

The spleen is not palpated. The longitudinal size of the spleen along the 10 rib is 7 cm, the transverse dimension is 5 cm.

During the painful points of pancrease my patient did not  feel a pain.

 

The urinary system

There were no complaints for pain in the lumbar region, along the ureter or in the lower abdomen. Urination: the amount of urine per day is about 1.5 liters. The urine is straw-yellow color, serence.

Inspection: there were no visible changes in the lumbar region. Limited swelling in the suprapubic region is absent.

Drub symptom is negative on both sides. There was any  dull sound above the pubic.

 

The endocrine system

Disturbances of growth, physique and proportionality of individual parts of the body are not revealed. Skin is wet. Hyper pigmentation, striae, atypical hair is not present. The subcutaneous fat layer is developed evenly. Increasing the size of the tongue, nose, jaws, ear shells, moonlike face is not.

Palpable soft painless isthmus of the thyroid gland.

 

Nervous system and organs of senses

Complaints to a headache, usually arising when lifting blood pressure. Dizziness is absent. Working capacity is reduced, attention is normal. Night sleep is not broken. The mood is cheerful. Disturbances of the skin sensitivity are absent. Visual acuity and hearing reduced.  The sense of smell is preserved.

Consciousness is clear; intelligence corresponds to the level of development. The patient is balanced, unsociable and  calm. The gait is good. The speech is clear and clean.

There are any diseases of nervous system in my patient. Because we check out some postures like Romberg, Bernike-Manna,  reflex of Babinskogo, Behtereva, Bodaka are negative.

 

The plan of examination:

Laboratory methods (was made)

  • General blood analysis
  • Blood test for the number of electrolytes
  • Biochemical analysis of blood
  • Blood test –   result of serological studies of micro-reaction
  • Total Sputum analysis
  • Urinalysis
  • Stool analysis

        

  • General blood analysis Date 10.01.18

WBC- 5.2 * 109 / L – N               NE- 50.6%- N

RBC- 4.77* 1012 / L – N

HGB- 143 g/l- N                          LY- 43.4%- N

HCT – 0.429L/L – N                   MO- 4.4%- N

MCV- 90 fL- N                           EO- 1.4%- N

MCH- 29.9 pg- N                        BA- 0.2%- N

MCHC- 333g/l – N                     ESR- 16 mm/ h-

 

RDW- 11.5%- N                          NE#- 2.62*109 / L  – N

PLT- 278 109 / L  – N                  LY#- 2.25*109 / L  – N

MPV- 7.3fL- N                            MO#- 0.23*109 / L  – N

EO#- 0.07*109 / L  – N

BA#- 0.01*109 / L  – N

Conclusion: ESR- 16 mm/ h-

 

                                                  Date 16.01.18

WBC- 5.2 * 109 / L – N            ESR- 10 mm/ h- N

RBC- 4.98* 1012 / L – N

HGB- 147 g/l- N

HCT – 0.449L/L – N

MCV- 90 fL- N

MCH- 29.5 pg- N

MCHC- 327g/l – N

RDW- 11.4%- N

PLT- 280 109 / L  – N

MPV- 7.6fL- N

  • Blood test for the number of electrolytes

Potassium            4,32 mmol/l- N

Sodium                143  mmol/l- N

Ionized Calcium   1,25 mmol/l- N

 

  • Biochemical analysis of blood

 

IndicatorUnit of measurementResults of patient
Protein totalGram per liter71.6- N
Bilirubin total

Bilirubin direct

Micromol per liter14,3-N

2.9-N

Glucosemmol/l4.9- N
Potassiummmol/l5.65-  
Sodiummmol/l144- N 
Calciummmol/l1,26-N
Chlorinemmol/l102-N
Ureammol/l4,3– N
Creatininemmol/l66,0-N
AlaTu/l20,8-N
AsaTu/l18,0-N
Cholesterolmmol/l4,75-N
Triglyceridesmmol/l0,70– N
HDLmmol/l1,25
LDLmmol/l3,18– N
VLDLmmol/l0,32– N
Atherogenicity indexEd2,8– N

Conclusion: Potassium- 5.65 mmol/l– hyperkalemia

HDL- -hypolipidemia

 

  • Total Sputum analysis

Macroscopic examination

Amount

Character             mucopurulent

Colour                 vitreous

Сonsistency         mild  

Smell

Layering

Impurities

Chemical research

Reaction

Protein

Bile pigments

Microscopic examination

Alveolar macrophages

Epithelial cell            8-7

Leukocytes                18-17-15

Erythrocytes

Tumor cells

Elastic fibers

Bacterioscopic examination

Another flora              +

Conclusion: Character is mucopurulent ,colour is vitreous ,consistency is  mild  Epithelial cell are 8-7, leukocytes  are 18-17-15, Bacteria +

 

  • Urinalysis

SG- 1.015

LEU- neg

NIT- neg

pH- 5

ERY- neg

PRO-neg

GLU- norm

ASC- neg

KET- neg

UBG- norm

BIL- neg

  • Blood test –   result of serological studies of micro-reaction

Conclusion:  micro-reaction –  negative

  • Stool analysis

eggs of helminths – not detected

protozoa – not detected

Instrumental methods (was made)

  • X-rays of lungs
  • ECG
  • Ultrasound examination of the kidneys

 

  • X-rays of lungs

Conclusion:  X-ray picture of chronic bronchitis in the stage of exacerbation. Compare with clinic

  • ECG

ConclusionSinus rhythm with heart rate 66 beats per minute

  • Ultrasound examination of the kidneys

Right kidney 11.0*5.6 cm in size

Thickness of parenchyma 1.9 cm

Renal pelvis system 2.4 cm

Left kidney 12.4*6.1 cm in size

Thickness of parenchyma 2.4 cm

Renal pelvis system 2.4 cm

Expansion of calyxes , microlites

 Conclusion: chronic pyelonephritis on the left, microlithiasis

Laboratory methods (need to make)

  • General analysis of blood:

In chronic bronchitis, a general blood test in the remission phase usually does not reveal abnormalities. In the phase of exacerbation caused by bacterial infection, a shift of the leukocyte formula to the left, a moderate neutrophilic leukocytosis (10-12 * 109 / L) and a slight increase in ESR are observed.

When the virus nature is aggravated, the rate of erythrocyte sedimentation is also increased, but the level of leukocytes is usually below the norm, and the level of lymphocytes is increased.

An increase in the content of eosinophils at a normal level of leukocytes is characteristic for bronchitis of an allergic nature. Erythrocytosis (an increase in the concentration of erythrocytes and hemoglobin to compensate for hypoxia) is typical of obstructive chronic bronchitis with impaired ventilation of the lungs.

  • Total Sputum analysis

Macroscopic examination

Amount

Character

Colour

Smell

Layering

Impurities

Chemical research

Reaction

Protein

Bile pigments

Microscopic examination

Alveolar macrophages

Epithelial cells

Leukocytes

Erythrocytes

Tumor cells

Elastic fibers

Bacterioscopic examination

Analysis of sputum during chronic bronchitis

1) sputum character – during bronchitis sputum is  mucous (less often – purulent or mucopurulent, which speaks of purulent bronchitis, bronchopneumonia);

2) the amount of separated sputum – for bronchitis is characterized by dry cough, then appears mucous, sometimes mucopurulent sputum in a moderate amount;

3) leukocytes – neutrophilic leukocytes will be determined in an amount that depends on the intensity of inflammation (normal – 1-3 leukocytes);

4) alveolar macrophages

During different forms of chronic bronchitis, sputum appears in different cells. For all forms, a significant number of macrophages, neutrophilic leukocytes, epithelial cells are present in the bronchial mucus.

Bronchial asthma: At the beginning of an attack of bronchial asthma, a small amount of sputum is separated, at the end of the attack its amount increases. Sputum in bronchial asthma is mucous. In It can be found cells of the cylindrical epithelium (both single and in the form of clusters), eosinophils, Courshmann spirals, Charcot-Leiden crystals.

  • Biochemical analysis of blood

Reveals a nonspecific marker of inflammation – C-reactive protein, a significant concentration of sialic acids, haptoglobin, acetylcholine. Serum is dominated by y-globulins and α2-globulins, and the albumin-globulin coefficient is reduced. Serological analysis supplements sputum smear, it is most informative for atypical bronchitis, as it allows to detect specific antibodies to chlamydia, mycoplasmas. In obstructive bronchitis there are changes in the blood gas composition – partial pressure, the volume content and oxygen level in it is reduced, and the partial pressure of carbon dioxide is increased. Thus, laboratory tests allow you to put the most accurate diagnosis.

  • General urine analysis.

It is used to control the reaction of the kidneys to the inflammatory process: take an urine test in an acute period, after 2 weeks (at the end of treatment) and after 1 and 2 months.

  • A blood test for total IgE

Shows the level of this immunoglobulin in the blood, which is produced during an allergic reaction. It can be increased with the help of many allergic diseases, but its normal amount does not exclude bronchial asthma and other atopic processes. Therefore, it is much more informative to determine in specific blood IgE antibodies to specific allergens.

Instrumental methods ( need to make)

  • Bronchography

X-ray diagnostic procedure using the method contrasting of bronchi.

  • Bronchoscopy

Visualization of the bronchial mucosa using a fibrobronchoscope. The procedure makes it possible to see inflamed mucous in acute bronchitis, as well as any pathological foci with other diseases of the respiratory system. The positive thing is that with this method there is the possibility of taking the altered tissue for a histological examination (bronchoscopy with tissue biopsy) in order to confirm the inflammatory nature of the changes and to exclude neoplasms.

  • Pneumatic tachometry

A method of measuring the maximum air flow rate that is achieved with forced inspiration and expiration. In practical medicine, evaluation of parameters of forced expiration is more important, they are highly informative for differential diagnosis of various types of bronchial obstruction.

  • Spirometry

Spirographic indicators, the most important are the Tiffno index, the ratio of volume of forced exhalation per second (VFE1) to vital capacity of the lungs( VCL), and the rate of air movement (ratio MVL and  VCL). The study of ventilation indicators allows to determine the degree of reversible component of bronchial obstruction.

The main analyzed index is VFE1, that is, the volume of forced exhalation per second. Simply put, this is the amount of air that a person can quickly exhale within 1 second. With bronchial spasm, air leaves the respiratory tract more slowly than in a healthy person, the VFE1 index decreases.

  • Pulse oximetry

Study performed with a small device called a pulse oximeter, which is usually worn on the patient’s finger. It determines the saturation of the arterial blood with oxygen (SpO2). If this figure is less than 92%, a study should be made of the composition of the gas and the acidity (pH) of the blood. Reducing the level of oxygen saturation testifies to severe respiratory insufficiency and a threat to the life of the patient. The decrease in the partial pressure of oxygen and the increase in the partial pressure of carbon dioxide, determined in the study of the composition of the gas, indicate the need for artificial ventilation of the lungs.

  • Computed tomography
  • Radiography of the lungs
  • Electrocardiography

ECG is necessary to detect the development of hypertrophy of the right ventricle and right atrium with pulmonary hypertension.

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Disease history

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