CRIMEAN STATE MEDICAL UNIVERSITY

NAMED AFTER S.I. GEORGIEVSKY

DEPARTMENT OF INTERNAL DISEASE

TEACHER : Kaliberdenko Vitaly Borisovich

CASE REPORT

NAME : MENSITOVA AVA EMURISIVNOVNA

CLINICAL DIAGNOSIS : BRONCHIAL ASTHMA

STUDENT :
COURSE :
GROUP
PASSPORT DATA

FULL NAME : MENSITOVA AVA EMURUVSIVNA

AGE : 44

NATIONALITY : CRIMEAN TATAR

FAMILY STATUS : MARRIED

CHILDREN : 2

WORK PLACE : NIL

ADDRESS : SHENSKAYA

DATE OF ADMISSION : OCTOBER 8, 2008

INQUIRY (INTEROGATION)

COMPLAINTS :

PATIENT COMPLAINTS OF PIERCING PAIN ON

THORAX,COSTAL ARCH DURING DEEP BREATHING AND
COUGHING.PAIN IRRADIATES TO SPINE.COUGH IS
PERMANENT ESPECIALLY IN THE MORNING.COUGH IS
ACCOMPANIED WITH POORLY EXPORATED THICK AND
TENACIOUS SPUTUM.DYSPNOE DEVELOPS ALL THE TIME AND
USUALLY AFTER COUGH.PATIENT PREFERS TO LIE AGAINST
HER LAPS.THERE IS PAIN IN HER LEGS DURING LONG
WALKING.INTERUPTED SLEEP DUE TO COUGH AND PAIN IN
THE THORAX.COUGH IS DUE TO REFLEX ACT WHICH IS A
DEFENCE REACTION AIMED TO CLEAR THE
LARYNX,TRACHEA AND BRONCHI FROM MUCUS OR FOREIGN
PARTICLES.

ANAMNESIS MORBI

PATIENT SUFFERS FROM ASTHMA FOR THE PAST 13

YEARS.ATTACKS OCCUR WHEN THE WEATHER IS COLD AND
DAMP.SHE GOT HERSELF ADMITTED IN THE HOSPITAL DUE
TO ASTHMA ATTACK WHICH WAS PROLONGED ( STATUS
ASTHMATICUS).ON THE 26TH 0F APRIL SHE WAS ADRESSED
TO HOSPITAL.SHE WAS DIRECTED TO THE BRONCHOSCOPY
EXAMINATION.
ANAMNESIS VITAE

PATIENT IS MARRIED AND CURENTLY STAYING IN

SIMFEROPOL.HUSBAND IS AN ELECTRIC ENGINEER AND
SHE HAS 2 CHILDREN.ELDER SON IS 15 YEARS OLD AND
SECOND DOUGHTER IS 12 YEARS OF AGE.CONFLICTS IN
THE FAMILY IS NORMAL.
NUTRITION IS REGULAR MAINLY AT HOME.PATIENT DOES
NOT SMOKE,DOES NOT CONSUME ALCOHOL DRINK.
SHE IS JUST AN OCCASIONAL DRINKER.NO PAST ILLNESS
REVEALED.AT PRESENT HUSBAND AND CHILDREN ARE
HEALTHY.
IN THE FAMILY, HER MOTHER AND SISTER SUFFER FROM
ASTHMA.
SHE BEARS MEDICAL PREPARATIONS WELL WITHOUT
ALLERGIC REACTIONS.SHE DID NOT UNDERGO BLOOD
TRANSFUSSION.ALLERGIC REACTIONS ARE SEEN WHEN
CONSUME CITRIC FOOD, EGGS .NO ALLERGIC REACTION
TO CHEMICAL SUBSTANCE.
DATA OF PHYSICAL EXAMINATION
(STATUS PRAESENS)

GENERAL CONDITION OF THE PATIENT IS

SATISFACTORY.CONSCIOUSNESS IS CLEAR,POSTURE IS
ACTIVE AND GAIT NOT CHANGED.FACIAL EXPRESSION IS
NORMAL.BODY BUILD IS HYPERSTENIC.
SKIN IS CLEAN,ELASTIC AND NORMAL HUMIDITY.VISIBLE
MUCOUS ARE PINKISH AND MOIST.SUBCUTANEOUS FAT IS
DEVELOPED MODERATELY.OEDEMA IS ABSENT.
SUBMANDIBULAR,BACK CERVICAL,AXILLARY AND
INGUINAL LYMPH NODES ARE ROUNDED FORM WITH
SMOOTH SURFACE,ELASTIC CONSISTENCY,MOBILE,NOT
ADHERED TO SKIN,SURROUNDING SUBCUTANEOUS FAT
AND TOGETHER IS PAINLESS.SKIN OVER THEM IS NOT
CHANGED.
THE MUSCLES ARE DEVELOPED MODERATELY,TONE AND
MUSCLES FORCE ARE IDENTICAL ON BOTH SIDES.PARTS
OF SKELETON ARE PROPORTIONAL .PALPATION AND
TAPPING OF 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.PATHOLOGICAL DEFORMATION OF SPINAL COLUMN
ARE ABSENT.ITS FUNCTION IS NORMAL.

TEMPERATURE OF THE BODY: 37.5

HEIGHT:156 CM WEIGHT : 68 KG
RESPIRATORY SYSTEM

SHE BREATHES THROUGH NOSE,NOSE WINGS IN

BREATHING DO NOT PARTICIPATE.FORM OF CHEST IS
REGULAR,HYPERSTENIC AND THE EPIGASTRIC ANGLE
NEARS 90.THE CHEST IS SYMMETRIC.
SUPRACLAVICULAR FOSSA IS NOT RESLLY
PRONOUNCED.RIBS ARE MODERATELY INCLINED AS
VIEWED FROM SIDE.
SHOULDER BLADE CLOSELY FIT TO THE CHEST AND ARE
ON TH SAME LEVEL.RESPIRATION TYPE IS
THORAXIC.BREATHING IS RHYTHMIC,DEEP.INSPIRATION
AND EXPIRATION ARE EQUAL.
VOCAL FREMITUS TO THE RIGHT IN THE LOW SIDE
REGION AND UNDER SCAPULAR IS INCREASED.
PERCUSSION OF THE LUNGSGIVES BAND BOX
SOUND,LOWER MARGINS OF THE LUNGS ARE BELOW
NORMAL.
LOWER BORDERS OF THE LUNGS

LINES RIGHT LUNG LEFT LUNG

PARASTERNAL 5th RIB -

MIDCLAVICULAR 6th RIB -
ANT AXILARY 7th RIB th
6 RIB
MID AXILARY 7th RIB 8th RIB
POST.AXILARY 7th RIB 9th RIB
SCAPULAR 7th RIB 10th RIB
PARASPINAL SPINOUS PROCESS SPINOUS
OF THE 8th THO PROCESS
OF THE 11
THO

AUSCULTATION REVEALS WHISTLING RALES AND

WEAKENED VESICULAR RESPIRATION WITH PROLONGED
EXPIRATION.HIGH AND DRY RALES IN THE LUNGS
DETERMINED BY AUSCULTATION DECREASE TO GIVE
WAYS TO LOW BUZZING AND OFTEN MOIST NON
CONSONANT RALES OF VARIOUS CALIBRES.

CARDIOVASCULAR 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 5th INTERCOASTAL SPACE
1cm INSIDE FROM THE LEFT MIDCLAVICULAR LINE
“CATS MURMUR” WAS NOT DETERMINED.EPIGASTRIC
PULSATION IN BREATHING IS NOT PALPABLE.THERE ARE
BORDERS WITH RELATIVE CARDIAC DULLNESS.

RIGHT: EDGE OF STERNUM

UPPER: ON THE LOWER EDGE OF THE RIB ON THE LEFT
PARASTERNAL LINE
LEFT: 1cm INSIDE FROM BORDER OF THE RELATIVE
DULNESS

THE RIGHT AND LEFT BORDERS OF VASCULAR DULLNESS

ARE FOUND ALONG THE EDGES OF STERNUM.IN
AUSCULTATION OF THE HEART OF TWO SOUNDS ARE
HEARD IN ALL POINTS.SOUNDS ARE RHYTMIC.CARDIAC
RATE IS 62 PER MINUTE.THE 1st SOUND IS LOUDER THAN
THE 2nd ONE AT TH HEART APEX.2nd SOUND IS LOUDER
THAN 1st AT HEART BASE.
PULSE IS EQUAL ON BOTH ARMS.ITS RATE IS 62 PER
MINUTE.PULSE IS RHYTMIC,PLENUS,MOLIS.TEMPORAL
AND CAROTID ARTERIES ARE WELL
PALPATED.PULSATION ON THE BOTH SIDES ARE EQUAL.
INITIAL DIAGNOSIS

1.PAINFULL SYNDROME DUE TO PLEURA

AFFECTION.PIERCING PAIN IN THE LOWER PART OF THE
CHEST TO THE RIGHT INCREASING DURING COUGHING
AND BREATHING .

2.ATTACKS OF DYSPNOE DEVELOP AS A COUSE OF

CHRONIC INFECTIOUS DISEASE OF RESPIRATORY DUCTS.
(SIGNS OF INFECTIOUS ALLERGIC ASTHMA)

3.SEVERE COUGHING WITH THICK AND TENACIOUS

SPUTUM DUE TO ACUTE INFLATION OF THE LUNGS.

THUS,PAIN,DYSPNOE,COUGH WITH SPUTUM ALLOW

MAKING FOLLOWING INITIAL DIAGNOSIS: BRONCHIAL
ASTHMA

PLAN OF ADDITIONAL INVESTIGATIONS

1. GENERAL ANALYSIS OF BLOOD

2. GENERAL ANALYSIS OF SPUTUM AND ITS
BACTERIOSCOPIC STUDY FOR IDENTITY THE
MICROBES AND PRESCRIPTIONS A CORRECT
MEDICAMENTOUS THERAPY
3. ANALYSIS OF URINE
4. SPIROGRAPHY FOR ASSESING OF THE EXTERNAL
RESPIRATORY SYSTEM FUNCTION
5. EXAMINATION OF THE CHEST
DIFFERENTIAL DIAGNOSIS (Since we need to do more test
before we can confirm Bronchial asthma)

BRONCHIAL ASTHMA