GOU VPO Altai State Medical University
Department of Otorinolarningology
Head Department: Khrustaleva E. V.
Lecturer: Gerber V.Kh.
Curator: Student 412 gr.
lea. Faculty of Perov A.A.
Disease history
Barnaul 2008.
Passport details:
Date of Birth:
Place of residence: Pavlovsky district with.
Date of Curation: 04/09/2008
Complaints:
To the difficulty of nasal breathing, mucous-purulent discharge on the left, periodic headaches.
Anamnesis.Morbi.
He considers himself to be patients since 2002. When first noted the difficulty of nasal respiration, the mucinous-purulent separated on both sides. He appealed to the hospital - the catheterization of both topless sinuses was performed.
In December 2008, aggravation again happened. After the survey, the CRH was sent to the CCB GUC for treatment.
Anamnesis.Vitae.
There were no injuries of the spine and skull. Venusical diseases, tuberculosis, Botkin's disease denies. According to the patient, allergic history is not burdened, blood transfusions and its substitutes were not conducted. Walnut illness suffers 2-3 times a year.
There is no drug intolerance.
Harmful habits, according to the patient, no. Alcohol, and narcotic drugs, with the words of the patient, does not use.
Hereditary history is not burdened.
Status.Praesens.Communis
LOR.- Status.
External changes in the form of the external nose and the areas of projections on the face of the walls of the frontal and maxillary sinuses are not. Palpation of the front and lower walls of the frontal sinuses, the releases of the I and II branches of the trigeminal nerve, the front wall of the maxillary sinus is painless.
With anterior rososcopy, a small amount of the mucous-purulent separated yellow color is observed, odorless. Displacement of the upper departments of the nasal partition to the right, the mucous membrane is hyperemic, wet, edema on both sides, nasal moves are narrowed.
Rotoglot
Pale pink oxide mucosa, wet, pale pink gums. The tonsils are not enlarged, the almond mucosa is pink, wet, the surface is smooth. Signs of Giza (resistant hyperemia of the edges of the front mead), Zack (swelling of the edges of the upper departments of the sky meek), Preobrazhensky (infiltration and hyperplasia of the edges of the front mead) are negative. Lacus free, no purulent content. The mucule of the rear wall of the pharynx: pink, wet, smooth.
Nasopharynx
The nasopharynge vault is free, pink mucosa, wet, boasts are free. The mouths of the hearingpipes are well contoured, free.
GARTANTROGLE
The sand is rolled, the mucule is pale pink. Between the label and the root of the language are visible Valkes. When the lanterns are well considered, pear sinuses free from content. The mucosa in the field of pear-shaped sinuses is smooth and pink.
Larynx
When examining the area of \u200b\u200blarynx pathological changes was not detected. When palpation, the larynx is painless, passively moving to the right and left, when displaced, the characteristic crunch of cartilage larynx is determined. Pill-pink mucosa, clean.
Right ear (AD): Own sinks of the right shape, an exhaust area without visible deformations, with palpation. Ear shell, a kozel, a mastoid process is painless. The outer hearing pass is wide, about 2.5 cm. In length. Contain a large number of ear sulfur. The eardrum of gray with a pearl tint, all the identification signs are clearly visible on it: the handle and a short step hammer. Front and back folds, light cone and navel.
Left ear (AS): Own sinks of the right shape, an exhaust area Without visible deformations, with palpation, ear sink, kozelok, a mastoid process is painless. The outer hearing pass is wide, about 2.5 cm. In length. Contain a large number of ear sulfur. The eardrum of gray with a pearl tint, all the identification signs are clearly visible on it: the handle and a short step hammer. Front and back folds, light cone and navel.
Additional examination methods
1. Diagnostic puncture of maxillary odds
2. Radiography of the maxillary sinuses
3. Computer tomography maxillary sinuses
Clinical diagnosis and its rationale
Clinical diagnosis: chronic left-sided purulent sinusitis, aggravation stage.
Related diagnosis: congenital hearing liness I degree.
Based on the complaints of the patient for the difficulty of nasal respiration, mucous-purulent discharge on the left, periodic headaches
Based on the history of the disease: he considers himself to be patients since 2002. When first noted the difficulty of nasal respiration, the mucinous-purulent separated on both sides.
In 2005 - exacerbation. The difficulty of nasal breathing, the mucous-purulent discharge left, headaches noted. He appealed to the hospital. During the examination, the cyst was found to the left maxillary sinus and the operational treatment was performed.
In December 2008, the aggravation again happened
Based on the front rosicopy data: there is a small amount of the mucous-purulent yellow-colored, odorless. The mucous membrane is hyperemic, wet, edema on both sides, nasal moves narrowed
I make a diagnosis: chronic left-sided purulent sinusitis, aggravation stage.
TREATMENT
Department mode.
Medical therapy: vasoconducting drugs (naphtizin 5 cap. In each half of the nose 3 times a day 10 days), local antibiotic therapy (bioparox 4 times a day 4 injection into each half of the nose and a throat of 10 days), total antibiotic therapy (spiriricin 1500.000 2 tablets 2 times a day in the morning and evening before meals).
Therapeutic and diagnostic puncture of the left gaimor sinus with washing with a disinfectant solution of furacililline 1: 5000 + 2 ml 3% hydrocortisone suspension.
Literature:
ON THE. Preobrazhensky, V.P. Gamps. Ear disease, throat, nose. M.: Medicine 1992
Yu.M. Ovchinnikov. Otaginolaryngology M.: Medicine. 1995.
V.T. Palchun, A.I. Hooks. Otorinolaryngology M.: Letter. 1997.
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Ministry of Health of Russia
Ivanovo State Medical Academy
Department of otorinolaryngology.
Head Department: Lopatin S.B.
Lecturer: Kotylenkov MK
Disease history
Diagnosis: acute bilateral hymorite.
Curator: Student of the 4th course of the 5th group
Mikheev M.E.
Ivanovo 1997.
1. Passport part.
Age: 13 years.
Place of residence: Ivanovo region, P. Podstaznovo
Place of school school.2
2. Date of receipt.
3. Complaints of the patient.
It makes complaints of nasal mortgage, not abundant mucinous-purulent discharge ..
4. Anamnesis of the disease.
He fell ill a month ago: a runny nose, cough, temperature rise to 37.5 were observed. The patient was prescribed the following treatment of the nose warming, vasoconducting drops in the nose (Pinasol). The effect was insignificant. During the month, a subfebrile temperature was kept. There was an abundant discharge from the nose of the mucous-purulent nature, a headache in the forehead region was appeared, increasing when the slope forward. To clarify the diagnosis and conduct
the patient was aimed at relevant treatment to the district doctor
in ENT branch of the OKB.
5 Anamnesis of Life, Family Anamnesis.
6. Allergological anamnesis.
Allergies to medicinal substances (Penicillin) and food products (sweet, citrus, milk), as well as animal wool.
7. Transferred diseases.
Wind gas, lymphadenitis. Previously, ORZ was sick once a year, the last two years - once a month. From three years suffers with neurodermit.
Alcohol uses moderately.
9. Objective study.
The general condition is satisfactory. The position is active. Expression
persons - meaningful. Behavior - normal. Attitude towards the disease is adequate.
Consciousness is clear. Nutrition is normal. The physique is correct.
The constitution is asthenic.
Skin surfaces dry, natural color. In the field of flexure surfaces of the elbow and knee joints there is a Papulose-Cork rash. Mucous
pink wet.
Peripheral lymph nodes are not increased when palpation
painless.
Muscles are well developed, normal tone, when palpation
painless.
The cardiovascular system.
Pulsations and scathes of the cervical veins are not observed, "heart hump"
absent. The precartial area during palpation is painless.
The topping push is located in the inter estreon on the left of the average
the lines, unpleasant, resistant, low, 2 square-square cm.
Absolute stupidity boundaries:
Right: in IV interdepender on the right edge of the sternum
Left: In V Interdepender on the left midcoluchic line
Upper: on 3 ribs on the left ocolatified line.
Heart tones are clear, rhythmic, no side noises. Pulse 80 per minute
rhythmic, synchronous, normal filling and voltage, wall
artery Elastic. HELL
110/70 mm RT Art.
Respiratory system.
The nose is straight, breathing through the nose is difficult, there is a scarce mucous-purulent discharge. GORTAN -
forms. In the act of breathing, both halves of the chest participate evenly and
equally. Type of breast breath. Auxiliary muscles in the act
breathing does not participate. Chdd - 20 per minute. Palpation chest
comparative percussion heard clear pulmonary sound in all areas
chest. Upper and lower lung boundaries with topographic
percussions are not changed. Breathing vesicular, there are no wheezes.
Digestive organs.
Appetite is not reduced. Pink oral cavity, without damage, shiny.
Pink language, wet. Teeth are saved. Gums, soft and solid
sky of pink color, wet, without raids, cracks, ulcers. Stomach rounded shape,
not increased, participates in the act of breathing. Stomach and intestine peristals not
it can be seen, venous collaterals on the front abdominal wall are absent. For
surface palpation belly painless, soft, muscle tension
the front abdominal wall is not marked; tumors, hernia, divergens of direct
there is no abdominal muscles. With deep palpation of abdominal organs
paoleless, soft consistency, not increased. Edge liver
arcs. Percussively borders of the liver are not changed. The spleen is not palpable. For
auscultation listened to the intestinal peristalsis and stomach. Friction noise
abnorts and vascular noises are absent.
uriction authorities.
Plows, redness in the area of \u200b\u200brenal projection. Urination
free, painless, 6-7 times a day, straven-yellow urine color, without
pathological impurities. Kidney palparato is not defined. Symptom
Pasternatsky negative on both sides.
10. Investigation of ENT organs.
Nose and slide sinuses.
Form of external nose Correct, deformations of bones and cartilage walls
visually and palpatorously not detected. Palpation of the front wall of the frontal sinuses
at the place of the release of the first and second branches of the trigeminal nerve is painless. There is a moderate soreness of the perdney wall of the veneranous sinuses.
With anterior rososcopy entrance to the nose, a free nose partition is not
it is shifted, located in the middle line.
The mucosa is hyperemic, moderately swelling.
nasal moves are free, the sinks are not changed. Breathing is difficult, there is a scarce mucous-purulent
separated, the smell is not violated.
Oral cavity.
Oral mucosa pink wet, clean. The mouth of derivatives
the salivary glands are clearly visible. Teeth are sanitized.
Clean, pink, wet, nipples are expressed moderately.
Rotoglot.
Sky alignments are contoured. Wet, clean, pink. Almonds are not increased. The rear wall of the throat is wet, pink. Lymphoid fabric ne.
changed. Plug reflex is saved.
Nasopharynx.
The nasoplary is free. Plug almonds are not changed. Mucous
pink, wet. Middle line couch. Hoans are free. Nose
shells are not hypertrophied. The mouth of the hearingpipes is good
differentiated, free. Pipe almonds and side rollers are not
enlarged.
GARTANTROGLE.
Pink mucosa, wet, clean. Pethennaya Almond N.
hypertrophied. Valvechaly free. Pear-shaped sines are free.
Movable nastrostic, stroke into the larynx free.
Regional lymph nodes (submandibular, deep cervical,
prelarseal, pretrachial) are not enlarged. Lanes the right form
passively moving, mucated pink color, wet and clean. With laryngoscopy, the mucous membrane of the nastestrian
Complaints of the patient.
It makes complaints of nasal mortgage, not abundant mucinous-purulent discharge ..
He fell ill a month ago: a runny nose, cough, temperature rise to 37.5 were observed. The patient was prescribed the following treatment of the nose warming, vasoconducting drops in the nose (Pinasol). The effect was insignificant. During the month, a subfebrile temperature was kept. There was an abundant discharge from the nose of the mucous-purulent nature, a headache in the forehead region was appeared, increasing when the slope forward. To clarify the diagnosis and conduct
the patient was aimed at relevant treatment to the district doctor
in ENT branch of the OKB.
5 Anamnesis of Life, Family Anamnesis.
Allergies to medicinal substances (Penicillin) and food products (sweet, citrus, milk), as well as animal wool.
Wind gas, lymphadenitis. Previously, ORZ was sick once a year, the last two years - once a month. From three years suffers with neurodermit.
Alcohol uses moderately.
The general condition is satisfactory. The position is active. Expression
persons - meaningful. Behavior - normal. Attitude towards the disease is adequate.
Consciousness is clear. Nutrition is normal. The physique is correct.
The constitution is asthenic.
Skin surfaces dry, natural color. In the field of flexure surfaces of the elbow and knee joints there is a Papulose-Cork rash. Mucous
pink wet.
Peripheral lymph nodes are not increased when palpation
painless.
Muscles are well developed, normal tone, when palpation
painless.
The cardiovascular system.
The pulsations and empty of the cervical veins are not observed, "heart hump"
absent. The precartial area during palpation is painless.
The topping push is located in the inter estreon on the left of the average
the lines, unpleasant, resistant, low, 2 square-square cm.
Absolute stupidity boundaries:
- Right: in the IV interdepender on the right edge of the sternum
- Left: in V interdepender on the left midcurbicular line
- Upper: on 3 ribs on the left ocolatified line.
Heart tones are clear, rhythmic, no side noises. Pulse 80 per minute
rhythmic, synchronous, normal filling and voltage, wall
artery Elastic. HELL
- 110/70 mm RT Art.
Respiratory system.
The nose is straight, breathing through the nose is difficult, there is a scarce mucous-purulent discharge. GORTAN -
forms. In the act of breathing, both halves of the chest participate evenly and
equally. Type of breast breath. Auxiliary muscles in the act
breathing does not participate. Chdd - 20 per minute. Palpation chest
comparative percussion heard clear pulmonary sound in all areas
chest. Upper and lower lung boundaries with topographic
percussions are not changed. Breathing vesicular, there are no wheezes.
Digestive organs.
Appetite is not reduced. Pink oral cavity, without damage, shiny.
Pink language, wet. Teeth are saved. Gums, soft and solid
sky of pink color, wet, without raids, cracks, ulcers. Stomach rounded shape,
not increased, participates in the act of breathing. Stomach and intestine peristals not
it can be seen, venous collaterals on the front abdominal wall are absent. For
surface palpation belly painless, soft, muscle tension
the front abdominal wall is not marked; tumors, hernia, divergens of direct
there is no abdominal muscles. With deep palpation of abdominal organs
paoleless, soft consistency, not increased. Edge liver
arcs. Percussively borders of the liver are not changed. The spleen is not palpable. For
auscultation listened to the intestinal peristalsis and stomach. Friction noise
abnorts and vascular noises are absent.
uriction authorities.
Plows, redness in the area of \u200b\u200brenal projection. Urination
free, painless, 6-7 times a day, straven-yellow urine color, without
pathological impurities. Kidney palparato is not defined. Symptom
Pasternatsky negative on both sides.
Nose and slide sinuses.
Form of external nose Correct, deformations of bones and cartilage walls
visually and palpatorously not detected. Palpation of the front wall of the frontal sinuses
at the place of the release of the first and second branches of the trigeminal nerve is painless. There is a moderate soreness of the perdney wall of the veneranous sinuses.
With anterior rososcopy entrance to the nose, a free nose partition is not
it is shifted, located in the middle line.
The mucosa is hyperemic, moderately swelling.
nasal moves are free, the sinks are not changed. Breathing is difficult, there is a scarce mucous-purulent
separated, the smell is not violated.
Oral cavity.
Oral mucosa pink wet, clean. The mouth of derivatives
the salivary glands are clearly visible. Teeth are sanitized.
Clean, pink, wet, nipples are expressed moderately.
Rotoglot.
Sky alignments are contoured. Wet, clean, pink. Almonds are not increased. The rear wall of the throat is wet, pink. Lymphoid fabric ne.
changed. Plug reflex is saved.
Nasopharynx.
The nasoplary is free. Plug almonds are not changed. Mucous
pink, wet. Middle line couch. Hoans are free. Nose
shells are not hypertrophied. The mouth of the hearingpipes is good
differentiated, free. Pipe almonds and side rollers are not
enlarged.
GARTANTROGLE.
Pink mucosa, wet, clean. Pethennaya Almond N.
hypertrophied. Valvechaly free. Pear-shaped sines are free.
Movable nastrostic, stroke into the larynx free.
Regional lymph nodes (submandibular, deep cervical,
prelarseal, pretrachial) are not enlarged. Lanes the right form
passively moving, mucated pink color, wet and clean. With laryngoscopy, the mucous membrane of the nastestrian, the area of \u200b\u200bthe sneak-shaped cartilage, intersperpalotic space and vestibular folds of pink color, wet with a smooth surface, voice folds of gray, are not changed, during the lantern symmetrically moving, closed completely. Signping space freely.
Right ear.
Left ear.
Own sink is the right form. Contours of the deputyid process not
changed. Palpation of ear shells, minced path and goat
painless. External hearing pass is wide. Contains a moderate amount of sulfur. There is no pathological content. Harmony eardrum with pearl tint. Short process and handle hammer, light cone, front and rear folds are well contacted.
Hearing passport.
Right ear
Left ear
AD + 30 15 C \u003d 64 C \u003d 2048 6m\u003e 6m
W CA CM JI JS V V
AS + 30 15 C \u003d 64 C \u003d 2048 6M\u003e 6M
Conclusion: sound-perception and sounding is not violated.
Vestibular passport.
AD - - - - 20 60ml
ST M NUS NUP NUR NUCAL
AS - - - - 20 60ml
Conclusion: The vestibular functions are not violated.
a) radiography of the apparent sinuses of the nose: intense homogeneous darkening of both topless sinuses compared to the eyelids.
Acute bilateral hymorite.
The diagnosis is made on the basis of:
3) X-ray of the apparent sinuses of the nose: intense homogeneous dimming of both topless sinuses compared to the eyewear.
Conservative treatment. It is aimed at improving the outflow of the secrets from the upper-jaw sinus by expanding the ignition connecting the sinus with the nasal cavity.
Passport part:
Female gender
Age: 29 years
Location: Republic of Kalmykia
Profession: Bank employee
Date of appeal to the clinic: 09/09/2011
Complaints of the patient at the time of arrival:
To the difficulty of nasal respiration, nasal congestion, periodically mucous-purulent discharge from the nose, decrease in the smell.
Complaints of the patient at the time of the corporation:
No complaints places.
Anamnes. morbi. :
He considers himself a patient since 1999, when after a long stay in the cold there was a nasal congestion that did not take for a long time. In 2000 he turned to hospital for help. There she took a picture. The image was visible in the maxillary sinuses. The patient was prescribed puncture of the maxillary sinuses. Next, the patient conducted courses of treatment with topical steroids with an insufficient positive effect. Received for surgical treatment.
Anamnes. vitae. :
Born the second child in the family. Physically and mentally developed normally, the peers did not lag behind.
Past illnesses:ORZ, ARVI.
Heredity: Not burdened
Allergic history:allergic reaction in the form of edema of hand and face on dairy products, pollen, grass.
Harmful habits and professional harmfulness: denies.
Accompanying illnesses: In the history of chronic pyelonephritis, there are no exacerbation for many years.
Tuberculosis, hepatitis, HIV:denies.
Status. pRESENS. :
The overall condition is satisfactory, stable, skin cleaning clean, physiological color. Rhythm heart tones, clear. CSS 72 impact per minute. The liver around the edge of the rib arc, the spleen is not enlarged. Chair, diuresis normally. The symptom of Pasternatsky is negative on both sides.
Respiratory system:
Breast shape: conical. Rhythm of breathing: the correct one. Both halves evenly participate in the act of breathing.
Circulation organs:
Rhythmic pulse. Frequency 72 per minute.
Digestive Organs:
Appetite is good, there is no disgust for food. Regular chair. Swallowing and passing food on esophagus free.
Uriyal organs:
There are no pain when urine. The symptom of the self-lumbar region is negative.
Nervical psychic status:
Consciousness is clear. There is no headache. Good performance. Sleep is not broken. Intellect corresponds to the level of its development. Memory is not reduced.
Endocrine system:
Tremor of the eyelid, language, fingers - no. The thyroid gland is not increased.
LOR-STATUS:
NOSE: Outdoor nose is not deformed. Nasal breathing is difficult through both halves of the nose. In medium nasal turns, dense mucous membrane detachable, gray formation, smooth with an elastic consistency. The nasal partition is not significantly twisted. The mucous membrane is pale, with agencies is reduced satisfactory. The lower nose sinks are somewhat edema, after agencies are reduced.
PHARYNX: The almonds protrude beyond the sky, lacques without caseaseic content. The rear wall of the pharynx is clean. Pink language, nipples are well pronounced, without fallow.NASOPHARYNX: Dome and arch are free. The mucous is wet, pale, no pathological discharge. The rear ends of the lower nose shells are not increased.
LARYNX: Voice sound. The entrance is free, the native is not changed, the mobility of voice folds is preserved in full. Pear-shaped sines and valkes are free. The mucous larynium is wet, pink. The respiratory gap is wide.
Ears: AD \u003d AS in the hearing aisle of the discharge. The skin of the auditory passage is not changed. Drum blades are light gray, movable, slightly drawn. The identification circuits are clearly contoured.
Hearing research: Research of the vestibular apparatus:
ADAsSpontaneous subjective and objective
4m Snove speech4m vestibular symptoms is absent.
Colloquial speech
Loud speechDizziness, nausea, vomiting is not.
Equilibrium is not violated.
O. Deber
+ O. RIN+ Spontaneous Nistagm is missing.
Finger-nasal sample normal. In pose
Romberg is stable.
+ O. Federichi+
+ O.Zhele+
VC. VC. Adiadochokiese is absent.
29 17 From 512.32 17 Pressorny test negative test.
Vestibulose:
1. There is no dizziness.
2. There is no spontaneous nastagm.
3. Spontaneous deviation of hands is absent.
4. Palcepan sample positive with open and closed eyes.
5. Finger-finger test positive with open and closed eyes.
6. Resistant to Romberg Posse.
7. The trial on adiodochokinesz is negative.
8. Lit is direct, without pathological changes.
9. Flange gait without pathological changes.
10. The pressor test is negative.
Conclusion:pathological changes were not identified.
Data of computed tomography, radiography of the incomplete sinuses from 09.09.11:
Thickening of the mucous membrane of both maxillary sinuses, the cells of the lattice labyrinth.
Diagnosis: Bilateral chronic maxillary sinusitis, bilateral etmoiditis.
Justification of the diagnosis:
1. Complaints: the difficulty of nasal respiration through both half of the nose, the feeling of nasal congestion, periodic mucous-purulent discharge from the nose, decrease in the smell.
2. Anamnesis: considers himself a patient since 1999, when after a long stay in the cold, a nose has appeared, which has not passed for a long time. In 2000 he turned to hospital for help. There she took a picture. The picture was visible liquid in the maxillary sinus. The patient was prescribed puncture of the maxillary sinuses. Next, the patient conducted courses of treatment with topical steroids with an insufficient positive effect. Received for surgical treatment.
3. Clinical data: nasal breathing is difficult through both half of the nose. In medium nasal turns, dense mucous membrane detachable, gray formation, smooth with an elastic consistency.
4. CT dated 09.09.2011: Thickening of the mucous membrane of both maxillary sinuses, the cells of the lattice labyrinth.
Differential diagnosis:
It is carried out with sinusitis of other localizations (in the differential diagnosis, the leading role is played by the methods of radiation diagnostics - CT and X-ray of skulls, which confirm the presence of pathological changes in the appropriate sinuses), as well as with acute maxillary sinusitis (in this case, in addition to the methods of radiation diagnosis, the patient has anamnesis, in which the process rate and its nature of the flow is indicated - a recurrent process) and an odontogenic hymitorite (anamnesis data - the lack of interconnection with dental intervention)
Survey and treatment plan:
1. Surgical: Endoscopic operation on both topless sinuses under local anesthesia.
Operation is carried out using special equipment - Endoscope.It is a flexible tube, in the thickness of which there is a fiber. At one end endoscope there is a lens. At the other end - the eyepiece, which is watching the doctor. The endoscope allows you to see the pathological process that flows in the sinus.
One of the advantages of endoscopic surgery of the incomplete sinuses compared to the traditional method is that it does not require a surgical cut. Another advantage of the endoscopic method is that it allows you to treat directly the cause of the sinusitis. With it, it is possible that the doctor can see directly pathological foci and remove it, due to the expansion of its own tile of the maxillary sinus, which significantly reduces excessive trauma, accelerates the postoperative period, reduces the risk of the operation itself and postoperative complications. The method is characterized by the absence of an outdoor scar, a small edema after surgery and a smaller intensity of pain.
2. Locally, the toilet of the nasal cavity, anemization of the mucous membrane, washing the maxillary sinuses with a solution of chlorhexidine.
3. Symptomatic therapy.
Recipes:
1. RP.: SOL. Calcii Ehloridi 10% 10 ML
D.T.D.N. 6 in ampulis.
S. 5 - 10 ml in Vienna.
2. RP: SOL. Chlorhexidini bigluconatis 0,005 - 100 ml
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Passport part
Age: 49 years
Place of residence:
Profession: Engineer
Place of work: Design Institute
Status Praesens Subjectivus.
Complaints: permanent, intense, pulsating pains in the area of \u200b\u200bthe left maxillary sinus and in the area of \u200b\u200bprojection of the lattice labyrinth cells, amplifying when exiting the cold air, on the nasal congestion on the left, to the purulent separated from the left nasal stroke, on the headache in the area of \u200b\u200bthe pattern Weakness and increase body temperature up to 37.5 (p.
He considers herself to be sick from October 29, when for the first time in the evening I felt the new in the area of \u200b\u200bprojections of the left maxillary sinus and the nasal congestion on the left. Noted the increase in body temperature and starting headache. In the morning of the next day there was an abundant mucous membrane separated from the left nasal stroke. The beginning of the disease associates with supercooling. In the future, the well-being was impaired: pain in the area of \u200b\u200bthe design of the left maxillary sinuses became permanent, intense, pulsating, began to increase when exiting the street, pain in the area of \u200b\u200bprojection of the lattice labyrinth cells were joined, weakness, the drunks separated became the mucous-purulent. In this regard, he turned to the attending physician, since he was treated in the endocrinological department of the hospital. Peter the Great about the subacute thyroiditis. After his inspection, the patient was aimed at consulting the otorinolarningologist. At the height of the pain on October 31, the patient was examined by a otorhinolarningologist, a diagnosis was diagnosed with: "acute left-sided swivel", and a further examination and puncture of the gaimore sinus followed by treatment (vasoconstrictors, antibacterial therapy). After that, the health of the patient improved: the pain became moderate, the body temperature decreased, the weakness decreased.
Born in 1947 in the Tikhvin district in the family of workers 2nd child. Physically and intellectually developed normally, the peers did not lag behind. With 7 years I went to school. She studied well. At the end of the school he entered the Polytechnic Institute. At its end, it works as an engineer at the Design Institute. Materially secured, lives in a three-bedroom apartment with a family of 4 people. Nutrition is regular-3 times a day, full, diverse.
PAST ILLNESSES
Children's infections. Appendectomy in 1985. The operation of eliminating the curvature of the nasal partition in 1985. In 1988, treatment for the right-hand hymorite and cyst of the right gaimore sinus. In 1990, the removal of the fibroadenoma of the uterus. The stomach ulcer in 1994, in the same year pyelonephritis and nephroptosis.
HEREDITY
Nearest relatives are healthy.
Family history
Married, has two adult sons.
BAD HABITS
I do not smoke. Alcohol does not use. Drugs do not use.
Allergological anamnesis
Allergic reactions Food products do not mark. From medical drugs allergic to ascorbic acid.
Gynecological anamnesis
Pregnancies-2, Rodov-2, abortion-0. Monthly from 13 years old, regular, moderate, painless.
Epidemiological anamnesis
Hepatitis, venereal diseases, malaria, typhus and tuberculosis denies. Over the past six months, blood was not overflowed, the dentist was treated 3 weeks ago, the injections were not produced, no contact with infectious patients did not have any contact with infectious patients. Stool regular-1 time per day, brown, decorated, without impurities.
Insurance anamnesis
Status Praesens Objectivus
General inspection
Satisfactory condition. Consciousness is clear. The situation is active.
Skin of bodily color, ordinary moisture. The skin is elastic, tours of fabrics saved. The subcutaneous fat fiber is satisfactorily expressed, the thickness of the folds at the navel level is 1.5 cm. Visible mucous pink, wet, clean. The thyroid gland is sensitive when palpation is dense, increased in size, more right share. Pulse 90 UD / min, symmetrical, rhythmic, satisfactory filling and voltage. Hell 120/70 mm.rt.st. Clear heart tones, sonorous, rhythmic.
Respiratory frequency 22 / min. With a comparative percussion over the symmetric points, a clear pulmonary sound is listened. Breathing vesicular. The belly of the right shape, soft, painless. The liver around the edge of the rib arc, the edge is sharp, elastic, painful. Visible changes in the area of \u200b\u200bthe belt are not detected. Symptom of squeezing on the lumbar region is negative.
Nose and apparent nose sinuses
Nose of ordinary shape. Skin of corporal nose, ordinary moisture. It has hyperemia and lightweight skin in the area of \u200b\u200bprojection of the left maxillary sinus. Palpation of the nose is painless.
Sensity is detected during palpation area of \u200b\u200bthe projection of the Gaimore sinus and the cells of the lattice labyrinth on the left.
Front rosicopy: the retail of the nose on the right and on the left is free, on the skin it is hair. On the right, the mucous membrane of the nose pink, smooth, moderately wet, the sinks are not enlarged, the lower and general nasal moves are free. The nasal partition is located in the midline, does not have significant curvature. On the left mucous membrane of the nose is hyperemic, edema, the sinks are increased, the accumulation of the purulent secret is revealed in general, more in the middle nose flowing from under the middle shell.
Breathing through the right nose is free, through the left - difficult. The smell is not changed.
NASOPHARYNX
Rear Rososcopy: Hoans and nasopharynge hollows are free, the mucous membrane of the pharynx and shells pink, smooth, the rear ends of the shells do not leave the Hoan, the couch stands in the midline. The mouth of the hearingpots is closed. Pink sipboard, not increased.
ORAL CAVITY
The shape of the lips is correct. Lip mucosa and solid sky pink, smooth, wet, clean. Desna without changes. Teeth are saved. The language of ordinary sizes, wet, covered with a white bloom, nipples are expressed.
Rotoglot
Soft heaven mucosa, pink sky, wet, clean.
Almonds do not go beyond the limits of the sky. Regional lymph nodes are not palpable.
GORTAN AND GARTANTOT '
Neck area without visible changes. Chip-colored neck, ordinary moisture. The submandibular lymph nods of oval shape, 2 cm long, 1 cm wide, elastic consistency, with subjectable tissues are not fast, movable, painless.
Indirect laryngoscopy: the epiglotter is visible in the form of a deployed petal, two tuberculos of sneak-shaped cartilage. The mucosa them, as well as the mucousness of the vestibular and cherpelonadectural folds, pink, smooth, clean. Mysculous voice folds of white color, smooth. Voice slot triangular shape. Voice folds and sneak-shaped cartilage movable.
The mucous membrane of the alcohol mill (Vallechaul, pear-shaped sinuses) is smooth, pink.
Ear shells are symmetrical, without deformations. The skin of the ears of the shells, the earliest areas and the areas in front of the body of a bodily color, ordinary moisture. Palcenerable palpation is painless.
Otoscopy: (Right and left ear) An external hearing pass is covered with skin of pink color, clean, in the web-to-carting part there are hair and a small number of ear sulfur. The drumpacker of pale gray with a pearl tint, a short process is visualized on it, the handle of the hammer and the light cone.
Hearing passport.
| Tests | Right Ear | Left ear |
| Noise in the ear | - | - |
| Whisper speech | 6 m | 6 m |
| Spoken speech | 20 m | 20 m |
| Creek at the sink when masking the opposite | + | + |
| ear rattles lamb | | |
| Tambleton C128 | 30 C | 30 C |
| Tambleton C2048 | 60 C | 60 C |
| Bone conductivity in Schwabach experience | Normal | Normal |
| Lateralization of sound in Weber Executive | No | No |
| Rinne Experience | + | + |
| Bing Experience | + | + |
| Wanted experience | + | + |
| Patency of auditory pipes | Passing | Passing |
Audiogram.
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Staffinitic passport.
Spontaneous vestibular disorders.
| Tests | research results |
| Dizziness | No |
| Spontaneous Nistagm | No |
| Body Deviation in Romberg Pose | No |
| Hand Deviation at Index Table Bashere | No |
| Body Deviation when walking with open eyes | No |
| Body Deviation when walking with closed eyes | No |
| Violation of the phalange gait | no |
LABORATORY RESEARCH
1. Clinical blood test.
Erythrocytes - 4,18x10 ^ 12 / l
Color. indicator 0.95
Leukocytes - 9.2x10 ^ 9 / l
cauccoidal - 1%
segmenteer- 73%
Lymphocyte- 25%
Monocytes - 1%
COE-25 mm / h
2. Urine analysis.
Color Yellow Squel 0.033 g / l
Transparency of weakly-muddy sugar 0
Acute urobilin reaction (-)
UD. weight 1,026 bile. Pigments (-)
Leukocytes 1-3 in sight
Erythrocytes are fresh. 0-1 in sight
X-ray study
In the maxillary sinus on the left, the horizontal level of the fluid.
The cells of the lattice labyrinth are visualized. Frontal sinus pneumotized.
Clinical diagnosis and its rationale
Given the complaints of the patient for permanent, intense, pulsating pain in the area of \u200b\u200bprojection of the maxillary sinus and in the area of \u200b\u200bprojection of the lattice labyrinth cells, increasing when exiting the cold air, on the nose of the nose on the left, on the purulent separated from the left nasal stroke, on the headaches in the area of \u200b\u200bthe pattern on weakness and increasing body temperature; Considering the history of the disease: the acute development of all the symptoms, and treatment of the patient in the endocrinological department about the subacute thyroiditis (a predisted factor - a decrease in the resistance of the body), long-term supercooling; history of life - transferred to
1988 right-sided hymorite, treatment of a dentist three weeks ago; An objective study data: Identification of hyperemia, swelling of the left nasal mucosion, increasing shells, accumulation of the purulent secret, more in the middle nose, flowing from under the middle shell; data clinical analysis of blood - detection of leukocytosis; and X-ray data - detecting in the topless sinus to the left of the horizontal level of the fluid, we can talk about acute inflammation of the left maxillary sinus.
The main diagnosis: acute left-sided swivel.
Related diagnosis: subacute thyroiditis.
Treatment of the patient:
1. Purpose of vasoconstrictors (adrenaline, naphtizin, sanarine) to improve the outflow of the secrets from the maxillary sinus.
RP.: SOL. Naphthyzini 0.1% -10 ML
D.s. Two drops in the left nasal stroke 3 times a day.
2. Purpose of antibacterial therapy, since there is an inflammatory process and purulent discharge.
Cefotaxim.
Rp.: "Cefotaxim" 1.0
S. The content of the bottle is dissolved in 5 ml of saline
rA, introduce intramuscularly 3 times a day.
Sulfopyridazin.
RP.: TAB. Sulfapyridazini 0,5
S. on the first reception of 2 tablets, then 1 tablets 4 times in the day
3. Diagnostic and therapeutic punctures of the left gaimor sinus with washing with a solution of furacillin.
4. On the area of \u200b\u200bthe sinus, physiotherapeutic effects (UHF, ultraviolet irradiation).
Prevention
Prevention is only nonspecific. Treatment of subacute thyroiditis.
Treating all chronic foci of infection. Hardening the body and prevention of infectious diseases. Reception of polyvitamins. Complete recovery of performance is possible when excluding hypothermia.
