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История болезни Пульмо Мадалбекова.ru.en
История болезни Пульмо Мадалбекова.ru.en
I. Passport part
1. Full Name: ---
2. Age: 63 years (date of birth: 01/01/1945)
3. Female gender
4. Profession: teacher
5. Date of admission to hospital: June 4, 2008
II. Complaints
· for paroxysmal (up to 10-15 times per day) cough, which occurs regardless of
physical activity, body position, and lasts 1-2 minutes, subsiding on its own;
· for the coughing up of hard-to-separate viscous mucopurulent sputum (about 20-
30 ml per day), without admixtures of blood, food, and odorless;
· shortness of breath with slight physical exertion (walking along the corridor at a
distance of 30-50 m), subsiding at rest when stopping after 2-3 minutes;
· an increase in body temperature (up to 37.3-37.5°C), mainly in the afternoon and
persisting for 3-5 hours. A decrease in temperature occurs independently or under
the influence of antipyretic drugs and is accompanied by profuse sweating;
· weakness, increased fatigue, decreased performance.
III. History of present illness (anamnesis morbi)
She fell ill about 6-7 days ago, when, without any visible provoking factors, the
patient first developed severe chills, a feeling of shortness of breath, and weakness.
Body temperature at this point in time increased to 38.7°C. The fever persisted for
the next 2 days with fluctuations from 37.6ºС to 39°С and was accompanied by
weakness and shortness of breath with little physical exertion. She did not go to
doctors, treated herself, took aspirin and Coldrex, after which her body temperature
dropped for a short time by about 1.0-1.5ºC.
At the end of the 2nd day of illness, constant moderate nagging pain appeared in
the right subscapular region, which sharply intensified at the height of a deep
inspiration. At the same time, a cough appeared, initially dry, and the next day with
a small amount of mucous sputum. The clinic doctor was called. Treatment with
Amoxiclav orally was prescribed (the patient does not remember the dose and
frequency of taking the tablets).
During the therapy, the patient’s health improved somewhat - the fever dropped to
low-grade levels (37.2ºC-37.5ºC), chest pain decreased, but the cough became
more intense with the release of a small amount of viscous mucopurulent sputum
without blood impurities. The cough especially bothered the patient at night when
she was in a horizontal position in bed. On the 4th-5th day of illness, shortness of
breath began to increase, which is why the tolerance to physical activity noticeably
decreased. The clinic doctor was called again, who strongly recommended that the
patient be hospitalized, and therefore the patient was admitted to the therapeutic
department of the hospital.
IV. Life history (Anamnesis vitae)
1
International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"
Born in 1943 in Moscow into a family of employees, the second child. She did not
lag behind her peers in development. Education – higher: graduated from the
Moscow State Pedagogical Institute.
Family and sexual history: menstruation since the age of 14 , after 28 days, 4 days
at a time, moderate, painless. Married since age 22. She had 2 pregnancies that
ended in two term births. Menopause at 55 years old. The climacteric period
proceeded without any special features.
Work history: She began working at the age of 22. After graduating from college
and until her retirement (at 55), she worked as a biology teacher at school.
Professional activity was associated with psycho-emotional stress.
No occupational hazards noted.
Throughout her life she lived in Moscow and was not in zones of environmental
disasters.
Food: high in calories, varied. In recent years, she has been trying to follow a diet.
Bad habits: does not smoke, does not drink alcohol, does not use drugs.
Past illnesses: in early childhood suffered from scarlet fever, measles, rubella, and
diphtheria. During her subsequent life she suffered from “colds” on average 1-2
times a year.
At the age of 52-53 years, she began to notice frequent headaches, which usually
occurred on the background of an increased blood pressure to 160/95 - 170/100
mm Hg. Hypertension was diagnosed, for which enalapril 10 mg per day and
atenolol 25 mg per day were prescribed, which the patient takes to this day. The
usual (“working”) blood pressure numbers on the background of regular therapy
are 140/85 – 135/80 mm Hg. Denies other diseases (including tuberculosis,
infectious diseases, liver, kidney, heart, gynecological diseases, etc.), as well as
injuries.
Epidemiological history:was not in contact with feverish and infectious patients, in
endemic and epizootic foci. There were no transfusions of blood, its components or
blood substitutes. No injections, surgeries, sanitation of the oral cavity, or other
medical procedures that violate the integrity of the skin and mucous membranes
have been performed over the past 6-12 months.
Allergy history: there were no allergic reactions to medications or foods.
V. Present state (status praesens)
GENERAL INSPECTION
General condition of the patient: moderate severity.
Consciousness: clear.
Position: active.
Body type: normosthenic constitutional type, height 168 cm, body weight 75 kg.
The posture is stooped, the gait is slow.
Body temperature: 37.3ºС.
Facial expression: tired.
2
International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"
Skin, nails and visible mucous membranes. The skin is clean, pale with areas of
pigmentation of the skin of the feet and legs. There are no rashes or vascular
changes (rash, telangiectasia, spider veins and hemorrhages). Scars, visible tumors
and trophic changes in the skin are not detected. Moderate acrocyanosis is noted.
The skin is dry, its turgor is slightly reduced. Hair type is female.
Nails: the shape is correct (there are no changes in the shape of the nails in the
form of “hour glasses” or koilonychia). The color of the nails is pink, there is no
streaking.
Visible mucous membranes moderately bluish in color, moist; There are no rashes
on the mucous membranes (enanthems), ulcers, or erosions.
Subcutaneous fat: developed moderately and evenly. The thickness of the
subcutaneous fat layer at the navel level is 2.5 cm. There is no swelling or
pastiness. There is no pain or crepitus on palpation of subcutaneous fat.
The lymph nodes: The inguinal lymph nodes are palpable, about 1.0 cm in size,
soft, elastic, painless, easily displaced upon palpation. Occipital, parotid,
submandibular, cervical, supraclavicular, subclavian, ulnar and popliteal lymph
nodes are not palpable.
Pharynx: There is slight hyperemia of the pharynx, no swelling or plaque. The
tonsils do not protrude beyond the arches, are pink, without swelling or plaque.
Muscles: satisfactorily developed. Muscle tone and strength are slightly reduced.
There is no pain or hardness on palpation of the muscles.
Bones: Moderately severe scoliosis of the thoracic spine is noted. Palpation of the
4-7 spinous processes and paravertebral points of the thoracic spine is painful. The
shape of the other bones of the skeleton is not changed. There is no pain when
tapping the bones.
Joints: the configuration of the joints is not changed. There is no swelling and
tenderness of the joints when palpated, as well as hyperemia, or changes in the
temperature of the skin over the joints. Active and passive movements in the joints
in full. There is a crunching sound during active movements in the knee joints.
RESPIRATORY SYSTEM
Inspection
Nose: the shape of the nose is not changed, breathing through the nose is free.
There is no discharge from the nose.
Larynx: no deformation or swelling in the larynx area. The voice is quiet, clear.
Chest: the shape of the chest is hypersthenic. The supraclavicular and subclavian
fossae are pronounced. The width of the intercostal spaces is moderate. The
epigastric angle is obtuse. The shoulder blades and collarbones protrude clearly.
The chest is symmetrical. There is deformation (scoliosis) of the spinal column
along its entire length. The circumference of the chest is 86 cm during quiet
breathing, on inhalation – 89, on exhalation – 83. The excursion of the chest is 6
cm.
3
International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"
Breathing: type of breathing – mixed. The right half of the chest lags behind when
breathing. Accessory muscles are not involved in breathing. The number of
respiratory movements is 20 per minute. Breathing is rhythmic, the duration of the
exhalation phase predominates. There is no visible difficulty breathing.
Palpation:
When palpating the VIII-X intercostal spaces on the right along the scapular line,
moderate pain is noted. Pain is also detected upon palpation of the 4-7 spinous
processes and paravertebral points of the thoracic spine. The elasticity of the chest
is reduced. Voice tremor is weakened in the subscapular and axillary region on the
right. The rest of the symmetrical areas of the chest are the same.
Percussion of the lungs:
With comparative percussion, a clear pulmonary sound is determined over
symmetrical areas of the lungs, with the exception of the subscapular and axillary
region on the right, where a distinct dullness is detected below the angle of the
scapula.
Topographic percussion:
Topographical
landmarks Right lung Left lung
Upper limit of the lungs
Front height of tops 3 cm above the collarbone
Height of the tops at
the back Spinous process of the VII cervical vertebra
Width of Kroenig
margins 5 cm
Lower border of the lungs
Parasternal line VI rib —
Midclavicular line VI rib —
Anterior axillary line VII rib VII rib
Median axillary line VII rib VIII rib
Posterior axillary line VII rib IX rib
Scapular line VII rib X edge
Spinous process of the VII Spinous process of the XI
Paravertebral line thoracic vertebra thoracic vertebra
The mobility of the lower edge of the lungs along all identification lines is 5 cm,
with the exception of the posterior axillary, scapular and paravertebral, where it is
absent.
Auscultation:
Main respiratory sounds: Below the angle of the scapula on the right
(corresponding to the 9-10 segment of the lower lobe of the right lung), breathing
is sharply weakened. Over the symmetrical areas of the remaining parts of the
chest, a slight weakening of vesicular respiration is noted.
4
International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"
Adverse respiratory sounds: Below the angle of the right scapula, a moderate
amount of moist, fine-bubbling sonorous wheezing is detected. No pleural friction
rub or crepitus can be heard.
Bronchophonia: in the area of dullness and sharp weakening of breathing on the
right below the angle of the scapula, whispered speech is not carried out.
CIRCULAR SYSTEM
Complaints:
Pain in the heart area, localized in the area of the apex of the heart, without
irradiation, of a compressive nature, lasting several minutes, occasionally
occurring during emotional stress, with increases in blood pressure. They usually
go away on their own or when blood pressure normalizes. Sometimes the patient
takes Corvalol to relieve pain.
Shortness of breath with minor physical activity (walking along the corridor at a
distance of 30-50 m), relieving at rest, when stopping after 2-3 minutes.
Palpitations, occasionally occurring when blood pressure rises, during emotional
stress or physical activity. The patient does not notice any interruptions in the
functioning of the heart.
There are no complaints about the appearance of edema.
Inspection:
Neck examination: external jugular veins and carotid arteries without visible
pathological changes. There is no swelling of the neck veins or increased pulsation
of the carotid arteries.
Examination of the heart area: the apical impulse is visible in the 5th intercostal
space on the left, 2 cm outward from the midclavicular line. Heart beat and
epigastric pulsation are not visually detected.
Palpation:
Apex beat: palpated 2 cm outward from the midclavicular line in the 5th intercostal
space, intensified, occupies the area of the 2 terminal phalanges of the middle
finger of the right hand.
Heart beat: not defined.
Epigastric pulsation: absent.
Trembling in the heart area(systolic or diastolic) is not determined.
There are no palpation pain and areas of hyperesthesia in the heart area.
Percussion:
Relative dullness of the heart:
Border
s Landmarks
Right Right edge of the sternum
2 cm outward from the left midclavicular line at the level of the 5th
Left intercostal space
Upper Upper edge of the third rib
The diameter of the relative dullness of the heart is 17 cm.
5
International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"
Inspection:
Oral cavity: the tongue is pink with a slight cyanotic tint, moist, without coatings.
Dentures. The gums, soft and hard palate are of normal color, there are no
hemorrhages or ulcerations. There is no bad breath.
Stomach: normal shape, the subcutaneous fat layer is developed moderately and
evenly. The abdomen is symmetrical, there are no protrusions or retractions. The
stomach is involved in the act of breathing. There is no visible intestinal peristalsis.
There are no venous collaterals of the anterior abdominal wall.
Abdominal circumference at the navel level is 80 cm.
Percussion:
Percussion sound is tympanic over the entire surface of the abdomen. There is no
free or encysted fluid in the abdominal cavity.
Palpation:
Superficial:the anterior abdominal wall is not tense, painless in all parts.
Symptoms of Shchetkin-Blumberg, Obraztsov, Murphy, Ortner, phrenicus
symptom are negative.
There is no discrepancy of the rectus abdominis muscles, no umbilical hernia, no
hernia of the linea alba. There are no superficially located tumor-like formations.
Methodical deep sliding palpation according to V.P. Obraztsov and N.D.
Strazhesko:The sigmoid colon is palpated in the left iliac region in the form of an
elastic cylinder, with a smooth surface 2 cm wide. Movable, not rumbling,
painless.
The cecum is palpated in a typical place in the form of a cylinder of elastic
consistency, with a smooth surface, 2 cm wide, mobile, not rumbling, painless.
The transverse colon is not palpable.
The ascending colon is not palpable.
The descending colon is not palpable.
The ileocecal angle is not palpable.
Stomach: greater curvature using the ausculto-percussion method and the method
of determining the splashing noise - at half the distance between the navel and the
xiphoid process. The greater and lesser curvature of the stomach and the pylorus
are not palpable.
Auscultation:
Normal intestinal motility is heard. There is no peritoneal friction noise. Vascular
murmurs in the area of the projection of the abdominal aorta and renal arteries are
not heard.
LIVER AND GALL BLADDER
Complaints:
The patient does not complain of pain in the right hypochondrium, dyspeptic
disorders, nausea, vomiting, belching, skin itching, icteric discoloration of the skin
and visible mucous membranes.
Inspection:
7
International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"
1. Your diagnosis
2. Patient management tactics
3. Treatment
12
International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"
15