CRIMEAN STATE MEDICAL UNIVERSITY

NAMED AFTER S.I.GEOGIEVSKY

DEPARTMENT OF PEDIATRICS

TEACHER: EULIANA SHRAMKO

CASE REPORT

Patient : Klimchuk valarie valerivich

Clinical diagnosis
Main disease : Acute viral infection

Complication : pneumonia

Accompanied disease : Type-2 Diabetes mellitus

Student: Mohammed

Course : 5th

Group : 181-1

PASSPORT DATA
Full name : Klimchuk valarie valerivich
Age : 60 years old
Gender : male
Nationality : russian
Date of birth : 24th September 1963
Home address : Simferopol
Date of admission : 27/09/2023(time: 12.10p.m.)

Complaints
The patient complaints of high temperature, Patient had high fever
Patient complaints of loss of appetite,headache.Patient complains of
weakness.

History of the present disease (anamnesis morbi)

Patent have high temperature with headache and breathlessness and

weakness.

Life history (Anamnesis Vitae)

Patient works as a electrician had a smoking history 40 years ago .patient

had COVID-19 2 years ago and soon after COVID-19 a year later he got
diabetes mellitus type-2.

PHYSICAL EXAMINATION
General condition of patient is satisfactory. Patient has a normosthenic body
structure. Consciousness is clear, posture is active. Facial expression is
good /healthy. Patient nourishment is satisfactory.

Temperature : 36.9ºC.
Height : 186
Body weight : 90kg

System review
Respiratory system

Tympanic sound of Traube’s space can be heard during percussion.

During auscultation of the chest, vesicular breathing is heard over s.

AUSCULTATION:
 Normal vesicular breathing was heard
 Crackle sound was heard at the lower lobe posteriorly at
right lung

Cardiovascular system
Pulse rate was 110.
Blood pressure was 100/80
Pulse was irregular

INITIAL DIAGNOSIS
Analysis of the symptoms, received during inquiry, inspection, palpation
and auscultation of the patient:

 pneumonia
 To confirm the diagnosis Additional Plan of Investigation should be
carried out in order for the Final Diagnosis.

PLAN OF ADDITIONAL INVESTIGATIONS

 General analysis of blood.

 General analysis of urine.
 Stool Test
 Biochemical analysis of blood
 ECG
 X-ray

Analysis of laboratory investigation

02. URINE TEST :

Urine Analysis

Density - 1.018
Colour - light yellow
Transparence - clear
Reaction – neutral
Protein – 0.066
Glucose – present
Epithelial cell – small quantity
Leucocytes – 2.4 in v.f
Bacteria – 2 v . f .

Daily Amount Of Glucose In Urine

2%
Conclusion: Presence of glucose indicates glucosuria.

Nechiporenko’ Test
Erythrocytes – 0.5 x 106/L
Leucocytes – 2.5 x 106/L
Conclusion: Normal

Biochemical Test
Transaminase – ALT – 0.18
AST – 0.1
Urea- 4.5
Potassium - 5
Sodium - 139
Conclusion : Normal

05. ECG

Conclusion: rhythm sinus , atrial fibrillation was seen

FINAL DIAGNOSIS
Patient had pneumonia wita diabetes mellitus type -2 accompaniying

TREATMENT

a) Regime – wad
b) Diet – 13
c) Drugs: tab glycosilide tab 2t/d
antispasmolytic were prescribed
for pneumonia combination therapy with a beta-lactam plus a macrolide are
prescribed