Uneversitatea-de-stat-de-medicina-si-farmacie-new-pneumo.docx

UNEVERSITATEA DE STAT DE MEDICINA SI FARMACIE“ NICOLAE TESTEMITANU “ DIN REPUBLICA MOLDOVA

Department Of Pneumophtisiology Medical Report

Patient's Name: Simin Andrei Teacher: Presented to Dr. Osipov Tatiana Name : Sirhan Mohammad

Group: M1549 Faculty: Medicine Nr.2

Chisinau 2018

I. Inquiry - interview 1) GENERAL DATA: Name: Simin Andrei Gender: Male Age: 35 years old Date of birth: 27/12/1983 Date of admission: 11/03/2019 He don’t work now Weight: 80kg Height: 182cm

2) COMPLAINS:        

Epigastric pain Coughing Hemoptysis Headaches Slightly increase in temperature 37-37.5 Thoracic pain Pain in foot during walking Visual disturbances in morning

3) History of the present disease:  Onset of the disease: before 8 years and its get worse by time (chronic).  First symptoms: Hypertension, nicturia – frequent nighttime urination, epigastric pain.  by time these symptoms increase and get more severe.  For hypertension he take captopril  Dialyze for kidney failure.

4) Past patient history:  Birth place – Chisinau  Patient health in birth – normal physical and mental development.  Normal life conditions  Stopped working  Normal patient diet  No physical activity  No previous operations/trauma  Parents and family members are healthy  No food or drugs allergy  Harmful habits: smoking and alcohol consumption.

II.

Objective examination

1. General inspection:            

Mental status: patient is fully conscious. Posture of patient: Active. Constitution: Asthenic. Temperature: 37-38 C Body movement: the patient walks normally State of nutrition: normal 1.5cm Tegument: intact (normal color of the tegument). Edema: had. Abdominal mass / lesion: absent. Thorax: no scars or lesions. Skin: pale, elastic, cyanotic in the morning around eye. Peripheral edema is present in the morning in the face especially around eyes and in legs.  Lymph node are not palpate able

 Muscular system with normal development and normal strength.  Bones with no deformities or defects.  Joints are normal  No abnormalities in the extremities

2. Respiratory system a. Complains:      

Dyspnea: present Cough: present Sputum: present Expectoration with blood: present Pain in the chest: present in different location Asphyxia: sometimes

b. Inspection:      

Normal configuration of the thorax symmetric Asthenic chest No spine deformities Abdominal breathing Normal breathing rhythm 20 times per min Involvement of thoracic muscles during breathing

c. Palpation:    

The chest is elastic Some pain by checking the painful points vocal fremitus decreased a little pit The vertebral column is straight, no deformities, no kyphosis, no lordosis, and no scoliosis.

d. Percussion:  Dull sound instead of resonance in some point of the thorax

e. Auscultation:  Bronchial in the trachea in neck

 Broncho vesicular breathing  Crepitation + moist rales (crackles)  Bronchophony increased

3. Cardiovascular system a. Complains:  Pain in the heart: no      

No dyspnea No cardiac asthma No palpitation Cough Hemoptysis Edema in face and legs

b. Inspection:  The condition of the neck vessels: no pathological pulsation of the carotid artery, no dilation of veins and jugular veins, no positive pulse.  Normal carotid pulsation  No cardiac beat  No epigastric pulsation was observed  No cardiac humpback  No edema  No orthopnea

    

The skin is pale No observed pulsation of the aorta Normal posture, not orthopnea. No caput medusa Visible pulsation on his left hand due to the presence of fistula and catheter for dialysis of the blood brachial artery

c. Palpation:  Heart apex: was felt in the left 5th intercostal space 1,5cm toward the sternum from the left midclavicular line. Width=1,5-2cm height=moderate strength= moderate resistance=moderate  Pulse 84 per min  No systolic and diastolic thrill was felt (cats purr)  No strong abdominal aorta pulsation was felt  No strong pulsation of the RV was felt  No strong pulsation of the portal vein was felt  Brachial artery

d. Percussion:  During percussion we revealed that the heart is slightly enlarged due to hypertension and it deposited slightly to the left.  Other border of the heart is normal except left one  Normal vascular bundle length

e. Auscultation:  Regular rate and rhythm  regular S1 and S2 in the auscultation points

 mitral valve at 5th intercostal space to the left of midclavicular line - normal  aorta 2nd intercostal space in midclavicular line to the right of sternum which is slightly increased  pulmonary trunk 2nd intercostal space in midclavicular line to the left of sternum - increased  tricuspid valve at the lower part of xiphoid process – normal  Murmurs: no systolic murmur , best heard above the heart apex ( 5th left intercostal space ) and it radiate to the axilla.

4. Gastrointestinal system a. Complaints:  Pain in abdomen: epigastric pain  Dyspeptic manifestation: no belch, heartburn, sickness, or vomiting  Appetite: no change  Swallowing: no swelling  Thirst : there is no dryness in the mouth  Weight: increase when water is accumulated without dialysis  Bleeding : no esophageal or gastrointestinal bleeding , no blood observed in the stool or with the vomited content

b. Inspection: Examination of the oral cavity:  Oral cavity: no smell , rose mucous membranes, no ulcers were observed  Tongue : slightly white , normal not enlarged or atrophied nipples, moist , no ulcers  Gum : paleness  Teeth: the patient didn't pass some dental therapies. Examination of abdominal cavity: The patient has a soft abdomen, it is participating normally in the respiration, symmetric, no development of venous collaterals (caput medusa), no visual peristalsis of the stomach and intestine. No painful point by coughing.

c. Auscultation: The intestinal peristalsis were auscultator one every 8-10 second, clear sound.

d. Percussion: By percussion was relived tympanic sound, there is signs of the presence of liquid in some region due to decreased tympanic sound and no fecal gas in the abdomen.

e. Palpation: Superficial palpation: there is pain in epigastric region, the abdominal muscles are not tensed, no infiltration or tumorshaped formation, no divergence of abdominal muscles. Negative Blumberg symptoms. No hernias. Deep palpation: by sequenced palpation (Obraztsov-Strajesco) of : sigmoid , cecum , terminal position of ileum , ascending and

descending colon, large curvature of the stomach , pylorus were observed that the borders of the intestine are well felt , smooth not hard , no dislocation , no pain and no additional masses .pain only in epigastric region.

f. Succession: No splash murmurs in the stomach and intestine

Liver and Gallbladder: Some disease of liver but the patient didn’t know the type of disease. Palpation of the area of Gallbladder: Can’t fell its enlargement, but the patient fells pain by palpating this area Spleen: The spleen wasn’t accessible for palpation. Normal Pancreas: With palpation, there is no enlargement or pain in it.

5. Endocrine system a.

Complaints: There is nothing of these signs: thirst , polyuria , skin itching , accelerated appetite , loss of weight , excessive eating , perspiration , shiver , muscle fatigue .

b. Inspection: No observed weight loss, the patient well developed, no acromegaly, normal face shape ( not moon shape ), no

exophthalmia , no enlarged thyroid gland , no cicatrices from stretching the skin. Normal distribution of the hair on the patient's body.

c. Palpation: The thyroid gland is soft, not enlarged, without any nodules

6.

Nerve-Psychic condition & sense organs

Consciousness: clear Mood: stable Sleeping: good, 5-7 hours per day. Headaches: present By the examination of the sense organs hearing, vision, smell, speech, feeling (skin) -- normal sensation was obtained.

7. Urinary System: a. Complaints: - Edemas: edemas under the eye or in the face and legs - Pain: moderate pain in the lumbar area. - Urination: Dysuria

b. Inspection: No swelling or hyperemia in the lumbar area Also no edemas on the lumbar area and other places sometimes in abdomen.

c. Palpation:

The right kidney can be palpated. In case of enlarged kidney hypertrophied, kidney was palpated slight pain; also there is slightly pain by palpating the area over the pubis.

d. Percussion : Positive symptom of pasternanacki's (Giordano) at right side (pain).

8. Laboratory tests a. General blood analyze  Hematologic:              

02/11/2018: RBC -2.38*10^3/uL decreased WBC – 9.36 *10^6/uL increased HB – 6.8 g/dL decreased Ht – 24.21% decreased MCV – 101.7 increased MCH – 28.56 pg normal MCHC – 28.07 g/l decreased Neutrophils – 77% increased Lymphocyte – 11.6% decreased Monocyte – 7.97% normal Eosinophils – 1.95% normal Basophils -1.5% increased ESR – 32mm/h increased

 Morphology:  Hypochromic++  Poikilocytosis +

 Biochemic:  Uree – 30.1µmol/l very high

   

Creatinine – 776.8 µmol/l very high ALT +AST – normal Amylase – normal;

Glucose – normal  Total protein – normal  Potassium – 6.4 µmol/l increased  Sodium – normal

 Immunologic:     

Total PSA – 0.75 ng/ml normal MRS – negative Blood group – O Rh + HIV - negativ Fibrinogen – 4g/l normal

 Urine test:     

Urination 24hours – 800-1000 ml RBC – present Red cell cast – present WBC – present Protein – present increased in 24 h

 Sputum test:        

Red Seropurulent Viscous Small epithelium Unique macrophage Leucocyte 3-5 c/v Erythrocyte >150c/v Neutrophils 100%

9. Instrumental investigations *) Chest - Xray: left segment 6 bronchopulmonary opacity 1 cm , near this opacity small nodular opacities , different size and intensity with unclear borders , induration of the helium. *) Pulmonary CT: In left lung S6S8S9 , multiple nodular opacities , Infiltration zone from 0.4 – 2.7 cm with zone of destruction. Mantoux test: positive 16 induration after 72 hours AFB – MBT + (bacteria is resistance to isoniazid , rifampicin . streptomycin) according to the results of clinical and paraclinical investigations it can be established the diagnosis : Pulmonary infiltrtive Tuberculosis, Round type, left lung , progressive phase (iniltration, dissemiantion) , AFB negative, new case.

10.

Diagnosis:

Treatment :

Pharmacological treatment:

• The treatment deal in that case is to deal with Multi drug resistance mycobacterium Tb, which can’t be treated with the first line anti tuberculosis drug . •

Initial phase:

6 months at the hospital : Kanamycin Levofloxacin Parazynamide Cyckoserin Ethinamide Contiuation phase: Levofloxacin Parazynamide Cyckoserin Ethinamide follow up by chest x-ray and smear microscopy

My conclusion: According to the result I think the best way to treat the patient is to reduce the fluid retention to avoid appearing of edemas of face and legs that is by providing the patient to do every day at least one dialysis and blood transfusion of 250 ml per day because of the blood loss from cough and from urine so that will reduce most of the symptoms which appear.

In the end he should stay under vision and to give him enough attention to prevent him from getting worse and worse until the end of treatment ,after that during his normal life he should be long time under attention of the hospital to avoid any future reoccurrence or evolution of the diseases.