Chronic left-sided purulent sinusitis, acute stage - medical history. Odontogenic sinusitis case history
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PSU named after T.G. Shevchenko
Faculty of Medicine
Department of Surgery with Oncology Cycle
Head department
Disease history
Start of supervision: 10/14/15.
End of supervision: 10/17/15.
Date of submission of medical history: 10.24.15.
1 Passport part
1. Last name, first name, patronymic:
2. Year of birth (age):
3. Gender: male.
4. Place of study:
5. Place of permanent residence:
7. Date and time of admission to the hospital:
8. Directed by: beginning. honey. sl.
9. Diagnosis of the referring institution: Acute respiratory disease.
10. Clinical diagnosis: Chronic bilateral sinusitis in the acute stage.
II. Complaints
Complaints at the time of supervision:
For nasal congestion.
General weakness.
Increased body temperature (38 0 C)
Copious mucopurulent discharge.
Headache in the forehead, worsening when bending forward.
Complete lack of sense of smell (anosmia).
III. History of present illness
(Anamnesis morbi)
According to the patient, the disease began acutely on 10/12/15. with an increase in body temperature to 39 0 C, accompanied by general weakness, lethargy, pain when pressing in the sinuses on the cheeks. Hypothermia contributed to this. Self-treatment didn’t take it, turned to the chief of medicine. service to a therapist. He was sent for hospitalization to the ENT department of the State University. RKB. to clarify the diagnosis and carry out appropriate treatment.
IV. Life story(Anamnesis vitae)
Born in 1996, on time. Was on natural feeding, did not suffer from rickets. From the age of 7 I went to school, studied well, physically and mental development did not lag behind his peers. Housing conditions and food during childhood and adolescence are good. The family environment is favorable.
Family history. Lives in Tiraspol in a separate apartment, living conditions are satisfactory, the overall budget is satisfactory, the environment is favorable. He eats at home, the food is satisfactory. Denies the use of alcohol, drugs and smoking.
Past illnesses. According to the patient, in childhood he suffered from rubella and chickenpox. Denies HIV, hepatitis, tuberculosis. Denies the presence of operations.
Allergological history. Allergic reactions to medications, foods, pollen, etc. are not brushed aside.
Insurance history.
V. Present state (Status praesens)
GENERAL INSPECTION:
General state: medium degree gravity.
Consciousness: clear.
Position: active.
Body type: asthenic. Height 190 cm, weight 70 kg.
Body temperature: 38.5C
Skin: pale pink; peeling, focal pigmentation, rashes, hemorrhages, " spider veins", angiomas, scars, scratches, rashes, itching, no.
Visible mucous membranes: no changes, pale pink, normal humidity.
Hair growth: hair type corresponds to gender.
Nails: regular shape - oval, smooth surface, transparent. There is no striation, fragility, or dullness.
Subcutaneous fatty tissue moderately developed.
There is no swelling.
Peripheral lymph nodes (cervical, occipital, submandibular, axillary) are palpable and not enlarged.
Muscular system: the degree of muscle development is moderate, there is no pain on palpation of the muscles, muscle strength in the hand, hips, and lower legs is moderate.
Osteoarticular system: no deformation or curvature of the bones.
RESPIRATORY SYSTEM.
Inspection
Nose: the shape of the nose is not changed, breathing through us is difficult. Mucopurulent discharge from the nasal cavity is observed.
Larynx: no deformation or swelling in the larynx area. The voice is quiet, clear.
Chest: the shape of the chest is asthenic.
Breathing: type of breathing - chest. Accessory muscles are not involved in breathing. Number breathing movements- 18 per minute. Breathing is rhythmic. There is no visible difficulty breathing.
Percussion of the chest.
Comparative percussion: clear pulmonary sound in symmetrical areas.
Topographic percussion.
The height of the apexes of the lungs in front is 5 cm above the edge of the clavicle.
The height of the apexes of the lungs behind is 1 cm above the spinous process VII cervical vertebra.
Width of Krinig fields: right - 6cm, left - 7cm.
Lower borders of the lungs:
Topographic lines Right lung Left lung
Active mobility of the lower edges of the lungs (cm):
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Topographical |
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L medioclavicularis |
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L axillaris media |
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Auscultation of the lungs.
During auscultation, unchanged vesicular breathing is heard in symmetrical areas of the lungs. Bronchial breathing is heard on the lateral surface of the larynx in front, at the level of the 7th cervical vertebra in the back, in the region of the manubrium of the sternum, in the interscapular region at the level of 2-4 thoracic vertebrae. There are no additional respiratory sounds, crepitations, or wheezing. Bronchophony in symmetrical areas of the chest is not changed.
CIRCULAR SYSTEM
Complaints:
The patient had no complaints about pain in the heart area.
There is no suffocation.. There are no complaints about the appearance of edema.
Inspection:
Neck examination: external jugular veins and carotid arteries without visible pathological changes. Swelling of neck veins or increased pulsation carotid arteries No.
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. Cardiac impulse and epigastric pulsation are not visually detected.
Palpation:
Apex impulse: palpated 2 cm outward from the midclavicular line in the 5th intercostal space, somewhat intensified, occupies the area of the 2 terminal phalanges of the middle finger of the right hand.
Cardiac impulse: not detected.
Epigastric pulsation: absent.
There are no palpation pain and areas of hyperesthesia in the heart area.
Percussion:
The diameter of the relative dullness of the heart is 17 cm. Width vascular bundle 6 cm. The heart configuration is normal.
Auscultation Heart sounds are rhythmic, clear, sonorous; the tonal ratio is not changed. Arterial pressure 120/70 mm Hg. Art.. Number of heart contractions (HR) - 65 beats/min.
DIGESTIVE SYSTEM
GASTROINTESTINAL TRACT
Complaints:
There are no abdominal pains.
There were no dyspeptic symptoms, including difficulty swallowing, nausea, vomiting, belching, heartburn or bloating.
The appetite is preserved, there is no aversion to food (fatty, meat, etc.).
Stool: usually once a day, the amount is moderate. Feces decorated, Brown, normal smell. There is no blood or mucus in the stool.
Bleeding: There are no signs of esophageal, gastric, intestinal and hemorrhoidal bleeding (vomiting blood, “coffee grounds”, scarlet blood in the stool, melena).
Inspection:
Oral cavity: the tongue is pink with a slight cyanotic tint, moist, without plaque. Dentures. The gums, soft and hard palate are of normal color, there are no hemorrhages or ulcerations.
Stomach: regular form, 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. Venous collaterals of the anterior abdominal wall No.
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 indicative: 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, umbilical hernia, there is 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 typical place in the form of a cylinder of elastic consistency, with a smooth surface, 2 cm wide, mobile, not rumbling, painless.
Transverse colon not palpable.
The ascending colon is not palpable.
The descending colon 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 abdominal aorta projection, renal arteries are not listened to.
LIVER AND GALL BLADDER
Complaints:
Complaints of pain in the right hypochondrium, dyspeptic disorders, nausea, vomiting, belching, itchy skin, the patient does not present with icteric discoloration of the skin and visible mucous membranes.
Inspection:
There is no protrusion in the area of the right hypochondrium. There is no restriction in this area of breathing.
Percussion: Boundaries of the liver according to Kurlov
Ortner's sign is negative.
Palpation: The lower edge of the liver protrudes from under the costal arch by 1 cm, is painless on palpation, elastic in consistency with a rounded edge.
Liver dimensions according to Kurlov:
The gallbladder is not palpable. Kerr's symptom and phrenicus symptom are negative. Symptoms of Ortner and Vasilenko are not detected.
Auscultation:
There is no peritoneal friction noise in the area of the right hypochondrium.
SPLEEN
Complaints there are no signs of pain in the left hypochondrium.
Inspection: There is no protrusion in the area of the left hypochondrium, there is no restriction in breathing in this area.
Percussion: The longitudinal size of the spleen along the X rib is 7 cm, the transverse size is 5 cm.
Palpation: The spleen is not palpable.
Auscultation: There is no peritoneal friction noise in the left hypochondrium.
PANCREAS
Complaints for pain and dyspeptic symptoms, nausea and vomiting, diarrhea and constipation. There is no thirst or feeling of dry mouth.
Palpation: The pancreas is not palpable.
There is no pain in the pancreatic points of Des Jardins and Mayo.
URINARY SYSTEM
Complaints There is no pain in the lumbar region, along the ureters or in the lower abdomen.
Urination: the amount of urine per day is about 1.5 liters. There is no polyuria, oliguria, anuria or ischuria.
There are no dysuric phenomena. Urination is not difficult. There is no cutting, burning, pain during urination, or false urge to urinate. There is no pollakiuria or nocturnal urination.
Pasternatsky's symptom is negative.
V1 . ENT status
Nose and paranasal sinuses.
The shape of the external nose is correct, no deformations of the bones and cartilage of the walls were detected visually or by palpation. Palpation of the anterior wall of the frontal sinuses at the exit site of the first and second branches trigeminal nerve painless.
There is moderate pain in the anterior wall of the maxillary sinuses.
With anterior rhinoscopy, the entrance to the nose is free; the nasal septum is not displaced, located in the midline. The mucosa is hyperemic, moderately edematous. Breathing is difficult, and there is copious mucopurulent discharge.
Oral cavity.
The oral mucosa is pink, moist, and clean. Mouths excretory ducts salivary glands clearly visible. Teeth sanitized.
The tongue is clean, pink, moist, the papillae are moderately expressed.
Oropharynx.
The palatine arches are contoured. wet, clean, pink. The tonsils are not enlarged. Back wall throat moist, pink. Lymphoid tissue is not changed. The pharyngeal reflex is preserved.
Nasopharynx.
The nasopharyngeal vault is free. The pharyngeal tonsils are not changed. The mucous membrane is pink and moist. Vomer in the midline. Choanas are free. The nasal turbinates are not hypertrophied. Mouths auditory tubes well differentiated, free. The tubal tonsils and lateral ridges are not enlarged.
Laryngopharynx.
The mucous membrane is pink, moist, clean. The lingual tonsil is not hypertrophied. Vallecules are free. The pyriform sinuses are free.
The epiglottis is mobile, the passage into the larynx is free.
Regional lymph nodes (submandibular, deep cervical, prelaryngeal, pretracheal) are not enlarged. Larynx correct form, passively mobile, pink mucus, moist and clean. During laryngoscopy, the mucous membrane of the epiglottis, the area of the arytenoid cartilages, the interarytenoid space and the vestibular folds is pink, moist with a smooth surface, vocal folds gray, not changed, symmetrically mobile during phonation, completely closed.
The subglottic space is free.
Left ear.
The auricle is of the correct shape. The contours of the mastoid process are not changed. Palpation of the auricle, mastoid process and tragus is painless. The external auditory canal is wide. Contains moderate amount sulfur. There is no pathological content. The eardrum is gray with a pearlescent tint. The short process and handle of the malleus, the cone of light, and the anterior and posterior folds are well contoured.
Vestibular functions not violated.
V11. Preliminary diagnosis
Based on the patient’s complaints (nasal congestion, general weakness, copious mucopurulent discharge, increased body temperature up to 38 0 C, headache in the forehead, worsening when bending forward, complete absence smell) we can conclude about acute bilateral sinusitis.
V111 . Additional Methods research
Radiography paranasal sinuses nose: intense homogeneous darkening of both maxillary sinuses compared to the eye sockets.
Anterior rhinoscopy: hyperemia and swelling of the mucous membrane in the area of the inferior nasal concha on both sides, narrowing of the lumen of the nasal passages.
1 X. Clinical diagnosis.
Chronic bilateral sinusitis in the acute stage
Based:
- complaints(for nasal congestion, general weakness, copious mucopurulent discharge, headache in the forehead, worsening when bending forward, complete absence of smell).
-anamnesis data(the disease began acutely, due to hypothermia on October 12, 2015, with an increase in body temperature to 39 0 C, accompanied by general weakness, lethargy, pain when pressing on the cheeks in the sinuses).
-radiographyparanasal sinuses(intense homogeneous darkening of both maxillary sinuses compared to the orbits).
- data laboratory research:
- anterior rhinoscopy data: hyperemia and swelling of the mucous membrane in the area of the inferior nasal concha on both sides, narrowing of the lumen of the nasal passages.
XTreatment.
1) general mode -2
2) diet No. 15
4) Symptomatic treatment:
5) Surgery - puncture of the maxillary sinuses.
Indications for puncture: for diagnostic and therapeutic purpose. Consent has been received. There are no contraindications. Prepared for surgery.
Technique. The puncture is performed under local anesthesia, for which a 10% lidocaine solution is used. The patient sits opposite the doctor on a chair. The puncture is performed with a special needle (Kulikovsky needle). It has a bend at the tip, so it can be brought under the bottom turbinate, and through its wide lumen a conductor can be passed into the maxillary sinus.
Puncture of the maxillary sinus is performed in the area of the lower nasal passage, for which about 2 cm are removed from the anterior end of the inferior nasal concha. Here the bone is the least thick.
For the needle to overcome bone wall, it is not inserted directly, but with light rotational movements. The direction of the needle is towards the outer corner of the eye on the side of the puncture.
A sinking sensation indicates penetration of the needle into the maxillary sinus. Once the needle has entered the sinus, you can attach a syringe to it and pull its plunger. The entry of air or pathological discharge into the syringe indicates correct insertion of the needle. The sinuses are washed, for which they use a mixture of dexamethasone and dioxidine. The mixture is poured into the sinus through a syringe, and poured out through the anastomosis (the opening through which the maxillary sinus communicates with the nasal cavity). Washing helps to remove all pathological discharge that has accumulated in the maxillary sinus. When rinsing the sinus, the patient's head should be tilted slightly forward so that the contents of the sinus flow out through the nose and not into the nasopharynx.
The maxillary cavity on the left is punctured, VD/VS = 9 cm 3. There is mucopurulent discharge in the washing fluid. The maxillary cavity on the right is punctured, VD/VS = 8 cm 3. There is mucopurulent discharge in the washing fluid.
A mixture of dexamethasone and dioxidine was introduced into the cavity. Teflon drainage was installed.
6) physiotherapeutic effects (UHF, UV)
Diaries
1 day. 10/14/15.
The general condition of the patient is moderate. BP 120/80, Ps 70 beats/min, body temperature 38 0 C, headaches in the forehead, worsening when bending forward, difficulty in nasal breathing. The volume of infused liquid is VD/VS 10 cm 3 . Mucopurulent discharge is visible in the washing fluid. Stool and diuresis are normal, there is no edema, Pasternatsky’s sign is negative. The abdomen is soft and painless. Heart and lungs unchanged.
Day 2. 15.10.15.
The general condition of the patient is moderate. BP 120/80, Ps 70 beats/min, body temperature 38 0 C, headaches in the forehead, worsening when bending forward, difficulty in nasal breathing. The volume of infused liquid VD/VS is 12 cm. 3
Mucopurulent discharge is visible in the washing fluid.
Stool and diuresis are normal, there is no edema, Pasternatsky’s sign is negative. The abdomen is soft and painless. Heart and lungs unchanged.
Day 3. 17.10.15.
The patient's condition improved, body temperature 36.8 0 C, blood pressure 120/80,
PS 70 beats/min. Stool and urine output are within normal limits, Pasternatsky's sign is negative. The abdomen is soft and painless. Heart and lungs unchanged. There is no swelling. The volume of infused liquid VD/VS= 15 cm3. Mucopurulent discharge is visible in the washing fluid.
Epicriz
The patient was admitted on 10/13/15. at 14:40 with a diagnosis of chronic bilateral sinusitis in the acute stage. Treatment prescribed and carried out:
1) general mode -2
2) diet No. 15
3) Etiotropic treatment - antibiotics(cefazolin i/m)
4) Symptomatic treatment:
Non-narcotic analgesic (analgin 2 ml i.m.)
Desensitizers (diphenhydramine IM, loratadine 1 tablet 3 times a day)
Mucolytics (ambroxol 1 tablet, 3 times a day)
Sulfonamide drugs (sulfadimezin 1 t. 3 times a day)
Irritants (Sinupret 2 tablets per day)
5) Surgical treatment - puncture of the maxillary sinuses.
The patient's general condition improved. Body temperature N. Integument of normal color. Lymph nodes are not palpable. Pulse is rhythmic 76/min, satisfactory filling. Blood pressure 120/80. The lungs and heart are unremarkable. The abdomen is soft and painless. Pasternatsky's symptom is negative. There is no swelling. Stool and urine output are normal.
ENT status. The external nose is of normal shape. The nasal mucosa is hyperemic, and there is mucopurulent discharge in the nasal passages. Nasal breathing is difficult. During puncture in the rinsing waters VD/VS=8 cm 3, mucopurulent discharge is visible. An AC mixture (dioxidine + dexamethasone) was introduced.
Were held following methods research:
X-ray of the paranasal sinuses: intense homogeneous darkening of both maxillary sinuses compared to the orbits.
Anterior rhinoscopy: hyperemia and swelling of the mucous membrane in the area of the inferior nasal concha on both sides, narrowing of the lumen of the nasal passages.
chronic sinusitis treatment disease
Discharged 10/19/15. in satisfactory condition, prognosis for life is favorable.
Vitamin therapy (complement 1 tablet 2 times a day, Vit. C 500 mg 2 times a day)
General strengthening (echinasal, 1 tbsp. 3-4 times a day).
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PASSPORT PART
Age: 49 years old
Location:
Profession: engineer
Place of work: Design Institute
STATUS PRAESENS SUBJECTIVUS
Complaints: constant, intense, pulsating pain in the area of projection of the left maxillary sinus and in the area of projection of the cells of the ethmoidal labyrinth, intensifying when entering cold air, nasal congestion on the left, purulent discharge from the left nasal passage, headache in the crown of the head, weakness and an increase in body temperature to 37.5 (C.
She considers herself sick since October 29, when for the first time in the evening she felt aching pain in the area of the projection of the left maxillary sinus and nasal congestion on the left. She noted an increase in body temperature and a beginning headache. In the morning next day copious mucous discharge appeared from the left nasal passage. The onset of the disease is associated with hypothermia. Subsequently, the state of health worsened: the pain in the area of the projection of the left maxillary sinus became constant, intense, pulsating, began to intensify when going outside, pain in the area of the projection of the cells of the ethmoidal labyrinth appeared, weakness and weakness appeared, the discharge became mucopurulent. In this regard, I contacted my attending physician, since I was being treated in the endocrinology department of the hospital named after. Peter the Great regarding subacute thyroiditis. After his examination, the patient was referred for consultation to an otolaryngologist. At the height of the pain, on October 31, the patient was examined by an otolaryngologist, and the diagnosis was made: “Acute left-sided sinusitis", and further examination and puncture were prescribed maxillary sinus followed by treatment (vasoconstrictors, antibacterial therapy). After this, the patient’s well-being improved: the pain became milder, body temperature decreased, and weakness decreased.
She was born in 1947 in the Tikhvin region into a working-class family as the second child. She developed normally physically and intellectually and did not lag behind her peers. I went to school at the age of 7. I studied well. After graduating from school, she entered the Polytechnic Institute. After graduation, he works as an engineer at a design institute. She is financially secure, lives in a three-room apartment with a family of 4 people. Regular meals - 3 times a day, nutritious, varied.
PAST ILLNESSES
Children's infections. Appendectomy in 1985. Operation to correct a deviated nasal septum in 1985. In 1988, treatment for right-sided sinusitis and a cyst of the right maxillary sinus. In 1990, removal of uterine fibroadenoma. Stomach ulcer in 1994, in the same year pyelonephritis and nephroptosis.
HEREDITY
Close relatives are healthy.
FAMILY HISTORY
Married, has two adult sons.
BAD HABITS
I do not smoke. Doesn't drink alcohol. Doesn't use drugs.
ALLERGIC HISTORY
No allergic reactions to food products noted. From medical supplies allergy to ascorbic acid.
GYNECOLOGICAL HISTORY
Pregnancies - 2, births - 2, abortions - 0. Menstruation since the age of 13, regular, moderate, painless.
EPIDEMIOLOGICAL HISTORY
Hepatitis, venereal diseases, malaria, typhus and tuberculosis denies. Over the past six months, there have been no blood transfusions, she was treated by a dentist 3 weeks ago, no injections were given, she did not travel outside the city and had no contact with infectious patients. Regular stool - once a day, brown, formed, without impurities.
INSURANCE HISTORY
STATUS PRAESENS OBJECTIVUS
GENERAL INSPECTION
The condition is satisfactory. Consciousness is clear. Position active.
The skin is flesh-colored, with normal moisture. The skin is elastic, tissue turgor is preserved. Subcutaneous fat is expressed satisfactorily, the thickness of the fold at the navel level is 1.5 cm. Visible mucous membranes are pink, moist, clean. Thyroid sensitive to palpation, dense, enlarged, larger right lobe. Pulse 90 beats/min, symmetrical, rhythmic, satisfactory filling and tension. Blood pressure 120/70 mmHg. Heart sounds are clear, sonorous, rhythmic.
Respiratory rate 22/min. With comparative percussion over symmetrical points a clear pulmonary sound is heard. Vesicular breathing. The abdomen is of regular shape, soft, painless. The liver is along the edge of the costal arch, the edge is sharp, elastic, painful. No visible changes were found in the lumbar region. The symptom of rocking in the lumbar region is negative.
NOSE AND PARANARY SINUSES
The nose is of normal shape. The skin of the nose is flesh-colored and has normal moisture. There is hyperemia and slight swelling of the skin in the area of the projection of the left maxillary sinus. Palpation of the nose is painless.
Pain is detected upon palpation of the projection area of the maxillary sinus and the cells of the ethmoidal labyrinth on the left.
Anterior rhinoscopy: The vestibule of the nose on the right and left is free, there is hair on its skin. On the right, the nasal mucosa is pink, smooth, moderately moist, the turbinates are not enlarged, the lower and common nasal passages are free. The nasal septum is in the midline and has no significant curvature. On the left, the nasal mucosa is hyperemic, swollen, the turbinates are enlarged, an accumulation of purulent secretion is detected in general, more in the middle nasal passage, flowing from under the middle concha.
Breathing through the right nasal passage is free, through the left - difficult. The sense of smell is not changed.
NASOPHARYNX
Posterior rhinoscopy: The choanae and nasopharyngeal vault are free, the mucous membrane of the pharynx and conchae is pink, smooth, the posterior ends of the conchae do not protrude from the choanae, the vomer is located in the midline. The mouths of the auditory tubes are closed. Pharyngeal tonsil pink, not enlarged.
ORAL CAVITY
The lip shape is correct. Mucous membranes of lips and hard palate pink, smooth, wet, clean. The gums are unchanged. The teeth are preserved. Language regular sizes, moist, covered with a white coating, the papillae are pronounced.
OROPHARYNX
Mucous soft palate, palatine arches pink, moist, clean.
The tonsils do not extend beyond the palatine arches. Regional lymph nodes are not palpable.
LARYNX AND LYRPHYNAH
The neck area is without visible changes. The skin of the neck is flesh-colored, with normal moisture. Submandibular lymph nodes are palpated oval shape, 2 cm long, 1 cm wide, elastic consistency, not fused to the underlying tissues, mobile, painless.
Indirect laryngoscopy: The epiglottis is visible in the form of an expanded petal, two tubercles of the arytenoid cartilages. Their mucosa, as well as the mucosa of the vestibular and aryepiglottic folds, is pink, smooth, and clean. Mucous vocal folds white, smooth. The glottis is triangular in shape. The vocal folds and arytenoid cartilages are mobile.
The mucous membrane of the laryngopharynx (vallecula, pyriform sinuses) is smooth and pink.
The ears are symmetrical, without deformation. Skin ears, behind-the-ear areas and areas in front of the tragus, flesh-colored, normal humidity. Palpation of the mastoid process is painless.
Otoscopy: (right and left ear) The external auditory canal is covered with pink, clean skin, in the membranous-cartilaginous part there is hair and a small amount earwax. The tympanic membrane is pale gray in color with a pearlescent tint; a short process, the handle of the malleus, and a light cone are visualized on it.
Hearing passport.
|Tests |Right ear |Left ear |
|Noise in the ear |- |- |
|Whispered speech |6 m |6 m |
|Spoken speech |20 m |20 m |
|Scream at the sink while masking the opposite |+ |+ |
|ear rattle Barani | | |
|Tuning fork C128 |30 s |30 s |
|Tuning fork S2048 |60 s |60 s |
|Bone conduction in Schwabach's experiment |normal |normal |
|Lateralization of sound in Weber's experiment |no |no |
|Rinne's experience |+ |+ |
|Bing's experience |+ |+ |
|Jelle's experience |+ |+ |
| Patency of the auditory tubes | passable | passable |
Audiogram.
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
| | | | | | | | |
STATOKINITIC PASSPORT.
Spontaneous vestibular disorders.
|Tests |Research results |
|Dizziness |no |
|Spontaneous nystagmus|no |
|Body deviation in the Romberg pose |no |
| Deviation of the hands during the Barani pointing test | no |
|Body deviation when walking with eyes open|no |
|Body deviation when walking with eyes closed|no |
| Impaired phalangeal gait | no |
LABORATORY RESEARCH
1. Clinical blood test.
Red blood cells - 4.18x10^12/l
Color. indicator - 0.95
Leukocytes - 9.2x10^9/l
rod-nuclear - 1%
segmented - 73%
Lymphocytes - 25%
Monocytes - 1%
ESR - 25 mm/h
2. Urinalysis.
Color yellow protein 0.033 g/l
Transparency slightly cloudy Sugar 0
Acid reaction Urobilin (-)
Ud. weight 1.026 Bile. pigments (-)
Leukocytes 1-3 in the field of view
Red blood cells are fresh. 0-1 in sight
X-RAY EXAMINATION
There is a horizontal level of fluid in the maxillary sinus on the left.
The cells of the ethmoid labyrinth are visualized. Frontal sinus pneumotized.
CLINICAL DIAGNOSIS AND ITS RATIONALE
Considering the patient’s complaints of constant, intense, pulsating pain in the area of the projection of the maxillary sinus and in the area of the projection of the cells of the ethmoidal labyrinth, intensifying when exposed to cold air, nasal congestion on the left, purulent discharge from the left nasal passage, headaches in the vertex area, for weakness and increased body temperature; taking into account the medical history: acute development all symptoms, and treatment of the patient in the endocrinology department for subacute thyroiditis (predisposing factor - decreased body resistance), prolonged hypothermia; life history - transferred to
1988 right-sided sinusitis, treatment at the dentist three weeks ago; data objective research: detection during anterior rhinoscopy of hyperemia, swelling of the mucous membrane of the left nasal passage, enlargement of the conchae, accumulation of purulent secretion in general, more in the middle nasal passage, flowing from under the middle concha; data clinical analysis blood - detection of leukocytosis; and X-ray data - revealing a horizontal fluid level in the left maxillary sinus, we can talk about acute inflammation of the left maxillary sinus.
Main diagnosis: Acute left-sided sinusitis.
Concomitant diagnosis: Subacute thyroiditis.
Treatment of the patient:
1. Prescription of vasoconstrictors (adrenaline, naphthyzin, sanorin) to improve the outflow of secretions from the maxillary sinus.
Rp.: Sol. Naphthyzini 0.1%-10 ml
D.S. Two drops in the left nasal passage 3 times a day.
2. Purpose antibacterial therapy, since there is an inflammatory process and purulent discharge.
Cefotaxime.
Rp.: "Cefotaxim" 1.0
S. Dissolve the contents of the bottle in 5 ml of physiological solution
ra, administered intramuscularly 3 times a day.
Sulfopyridazine.
Rp.: Tab. Sulfapyridazini 0.5
S. For the first dose, 2 tablets, then 1 tablet 4 times a day -
3. Diagnostic and therapeutic puncture of the left maxillary sinus with rinsing with furacillin solution.
4. Physiotherapeutic effects on the sinus area (UHF, ultraviolet irradiation).
PREVENTION
Prevention is only nonspecific. Treatment of subacute thyroiditis.
Treatment of all chronic foci of infection. Hardening the body and prevention infectious diseases. Taking multivitamins. Full recovery operability is possible, provided that hypothermia is excluded.
Passport part:
Female gender
Age: 29 years old
Place of residence: Republic of Kalmykia
Profession: bank employee
Date of visit to the clinic: 09.09.2011
The patient's complaints at the time of admission:
Difficulty in nasal breathing, nasal congestion, occasional mucopurulent nasal discharge, decreased sense of smell.
The patient’s complaints at the time of supervision:
Doesn't make any complaints.
Anamnes morbi :
He considers himself sick since 1999, when, after a long stay in the cold, nasal congestion appeared, which did not go away. for a long time. In 2000, she turned to the hospital for help. There she was photographed. The image showed the level of fluid in the maxillary sinuses. The patient was prescribed puncture of the maxillary sinuses. Next, the patient underwent courses of treatment with topical steroids with insufficient positive effect. Admitted for surgical treatment.
Anamnes vitae :
She was born the second child in the family. She developed normally physically and mentally and did not lag behind her peers.
Past illnesses: acute respiratory infections, acute respiratory viral infections
Heredity: not burdened
Allergic history: allergic reaction in the form of swelling of the hands and face to dairy products, pollen, grass.
Bad habits and occupational hazards : denies.
Accompanying illnesses: in history chronic pyelonephritis, for many years there has been no exacerbation.
Tuberculosis, hepatitis, HIV: denies.
Status presentens :
The general condition is satisfactory, stable, the skin is clean, physiological coloration. Heart sounds are rhythmic and clear. Heart rate 72 beats per minute. The liver is at the edge of the costal arch, the spleen is not enlarged. Stool and diuresis are normal. Pasternatsky's symptom is negative on both sides.
Respiratory system:
Chest shape: conical. Breathing rhythm: correct. Both halves equally participate in the act of breathing.
Circulatory organs:
The pulse is rhythmic. Frequency 72/min.
Digestive organs:
The appetite is good, there is no aversion to food. Regular bowel movements. Swallowing and passage of food through the esophagus is free.
Urinary organs:
There is no pain when urinating. The symptom of tapping in the lumbar region is negative.
Neuropsychic status:
Consciousness is clear. No headache. Good performance. Sleep is not disturbed. Intelligence corresponds to the level of its development. Memory is not impaired.
Endocrine system:
Tremor of the eyelids, tongue, fingers - no. The thyroid gland is not enlarged.
ENT status:
NOSE: The external nose is not deformed. Nasal breathing is difficult through both halves of the nose. In the middle nasal passages there is a thick mucous discharge, gray formations, smooth with an elastic consistency. The nasal septum is not significantly curved. The mucous membrane is pale and contracts satisfactorily when anemized. The inferior turbinates are somewhat swollen and contract after anemization.
PHARYNX: Tonsils protrude palatine arches, lacunae without caseous contents. The back of the throat is clear. The tongue is pink, the papillae are well defined, without plaque.NASOPHARYNX: The dome and vault are free. The mucous membrane is moist, pale, and there is no pathological discharge. The posterior ends of the inferior turbinates are not enlarged.
LARYNX: The voice is sonorous. The entrance is free, the epiglottis is not changed, the mobility of the vocal folds is fully preserved. The pyriform sinuses and valculi are free. The laryngeal mucosa is moist and pink. The breathing gap is wide.
EARS: AD=AS There is no discharge in the ear canal. Leather ear canal not changed. Eardrums light gray, mobile, slightly retracted. Identification contours are clearly outlined.
HEARING STUDY: Study of the vestibular apparatus:
ADAS Spontaneous subjective and objective
4m Whispered speech 4th vestibular symptoms are absent.
Colloquial speech
Loud speech There is no dizziness, nausea, or vomiting.
The balance is not broken.
O.Weber
+ O.Rine+ There is no spontaneous nystagmus.
The finger-nose test is normal. In a pose
Romberga is stable.
+ O. Federici+
+ O.Jelly+
VC. VC. Adiadochokinesis is absent.
29 17 C 512 32 17 Pressor test is negative.
Vestibulometry:
1. There is no dizziness.
2. There is no spontaneous nystagmus.
3. Spontaneous deviation no hands.
4. Finger test is positive with eyes open and closed.
5. Finger-finger test is positive with eyes open and closed.
6. Stable in the Romberg pose.
7. The test for adiodochokinesis is negative.
8. The gait is straight, without pathological changes.
9. Flank gait without pathological changes.
10. Pressor test is negative.
Conclusion: no pathological changes were detected.
Data computed tomography, radiography of the paranasal sinuses dated 09.09.11:
Thickening of the mucous membrane of both maxillary sinuses, cells of the ethmoidal labyrinth.
Diagnosis: Bilateral chronic maxillary sinusitis, bilateral ethmoiditis.
Rationale for diagnosis:
1. Complaints: difficulty breathing through both halves of the nose, a feeling of nasal congestion, periodic mucopurulent discharge from the nose, decreased sense of smell.
2. History: considers herself sick since 1999, when, after a long stay in the cold, nasal congestion appeared, which did not go away for a long time. In 2000, she turned to the hospital for help. There she was photographed. The image showed fluid in the maxillary sinus. The patient was prescribed puncture of the maxillary sinuses. Next, the patient underwent courses of treatment with topical steroids with insufficient positive effect. Admitted for surgical treatment.
3. Clinical data: nasal breathing difficult through both sides of the nose. In the middle nasal passages there is a thick mucous discharge, gray formations, smooth with an elastic consistency.
4. CT scan dated 09/09/2011: thickening of the mucous membrane of both maxillary sinuses, cells of the ethmoidal labyrinth.
Differential diagnosis:
It is carried out with sinusitis of other localizations (methods play a leading role in the differential diagnosis radiology diagnostics– CT and radiography of the skull, which confirm the presence of pathological changes in the corresponding sinuses), as well as with acute maxillary sinusitis(in this case, in addition to the methods of radiation diagnostics, the patient has an anamnesis, which indicates the duration of the process and its nature of course - a recurrent process) and odontogenic sinusitis (anamnesis data - no relationship with dental intervention)
Examination and treatment plan:
1. Surgical: Endoscopic surgery on both maxillary sinuses under local anesthesia.
The operation is performed using special equipment – endoscope. It is a flexible tube containing optical fiber. There is a lens at one end of the endoscope. At the other end is an eyepiece into which the doctor looks. An endoscope allows you to see what is leaking in your sinus. pathological process firsthand.
One of the advantages endoscopic surgery paranasal sinuses compared to traditional method is that it does not require a surgical incision. Another advantage endoscopic method is that it allows you to treat directly the very cause of sinusitis. With its help, the doctor can directly see the pathological focus and remove it, by expanding the own anastomosis of the maxillary sinus, which significantly reduces unnecessary trauma, speeds up the postoperative period, reduces the risk of the operation itself and postoperative complications. The method is characterized by the absence of an external scar, slight swelling after surgery and less pain intensity.
2. Locally - toilet of the nasal cavity, anemization of the mucous membrane, rinsing of 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 into a vein.
2. Rp.: Sol. Chlorhexidini bigluconatis 0.005 – 100 ml
MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION
Vladivostok State Medical University
Department of Otolaryngology
Head Department : Obydennikov G. T.
Teacher : Taranova S. V.
DISEASE HISTORY
Diagnosis : Acute, purulent bilateral sinusitis
Performed :
student of group 403
Pozharskaya I. N.
Vladivostok 2006
PASSPORT PART:
Age: 14 years
Education: student of school No. 23 in Vladivostok
Home address: Vladivostok, st. Svetlanskaya, 165, apt. 16
Receipt date: 28.10.2006.
COMPLAINTS UPON ADMISSION:
Complaints: constant, intense, pulsating pain in the area of the projection of the maxillary sinus, in the area of the projection of the cells of the ethmoidal labyrinth, intensifying when exposed to cold air, bilateral nasal congestion, mucopurulent discharge from the nasal passages, headache, general weakness, increase in body temperature to 37.5°C.
ANAMNESIS MORBI
The patient is often sick colds with a frequency of about three times a year. Notes complaints of mucopurulent nasal discharge. In this situation, against the background of frequent hypothermia and weakened immunity, acute, purulent sinusitis developed. The onset of the disease is associated with hypothermia. The state of health worsened: pain in the area of the maxillary sinus became constant, intense, pulsating, began to intensify when going outside, pain appeared in the area of the projection of the cells of the ethmoidal labyrinth, weakness and weakness appeared, the discharge became mucopurulent. In this regard, they turned to the Children's City Clinical Hospital and, at a height of pain, on November 28, the patient was examined by an otolaryngologist, the diagnosis was made: “Acute, purulent bilateral sinusitis,” and further examination and puncture of the maxillary sinus with subsequent treatment was prescribed.
ANAMNESIS VITAE
Brief biographical information. Born in Vladivostok, Primorsky Territory on August 28, 1994. The first child in the family. Breastfed until 10 months. She developed normally. In mental and physical development he does not lag behind his peers. Studying in 6th grade. Performance at school is good. Attends English language courses.
Epidemiological history: not burdened
Allergy history: not burdened
Family history and heredity: not burdened
Bad habits: No
Meteorological sensitivity and seasonality: frequent colds in the autumn-winter period
DISCLOSURE BY SYSTEMS:
General state: There is general weakness, increased fatigue, a feeling of weakness, head areas in temporal region. No weight loss or development of obesity is observed. There is no thirst, no dryness or itching of the skin. There is no furunculosis or rash. Temperature rises to 37.5.
Trembling of the limbs, convulsions, and gait disturbances are not observed. Skin sensitivity is not impaired.
Respiratory system:
Cardiovascular system: There is no pain in the heart area, palpitations, or sensations of interruptions in the heart area. There is no sensation of pulsation. There is no swelling. Denies a feeling of heaviness in the left hypochondrium. There is no intermittent claudication (pain in the calf muscles when walking).
Digestive system: No complaints. There is no smell from the mouth, no dyspeptic symptoms are observed. He denies pain and burning in the tongue. There is no dry mouth. There is no drooling noted. Appetite is good; There is no perversion of appetite. There is no aversion to food, no fear of eating is observed. Swallowing and passage of food through the esophagus is free. The belly is rounded and symmetrical and is involved in the act of breathing. The subcutaneous venous network is not pronounced. There are no hernias or discrepancies of the rectus muscles.
No abdominal pain. There is no heartburn, belching, nausea, or vomiting.
Urinary excretion system. There are no complaints. There is no pain in the lumbar region. There is no swelling. Urination is free. There is a predominance of daytime diuresis. The color of urine is straw yellow. Urine without impurities. There is no involuntary urination. The lumbar region is not changed. The kidneys are not palpable while lying down or standing. The bladder is not palpable.
Musculoskeletal system. No complaints. Denies pain in bones, muscles, joints. There is no swelling or deformation of the joints. There is no redness of the skin in the joint area, no increase in local temperature. There is curvature of the spine (scoliosis). There are no restrictions on movement in the joints. There is no pain or difficulty moving in the spine. The joints are painless on palpation.
Endocrine system. No complaints. There are no growth or physique abnormalities. Weight disturbances (obesity or wasting) are not observed. There are no violations of primary and secondary sexual characteristics. There are no hair problems (excessive development, appearance in places unusual for a given gender, hair loss).
Sense organs. There are no changes in hearing, touch or taste. The sense of smell is impaired. On the part of the visual analyzer, bilateral myopia is observed.
STATUS PREASENT
General examination of the patient. General condition is satisfactory. Consciousness is clear. Position active.
The facial expression is calm. The gait is free. The physique is correct. Constitutional type – normosthenic. Height – 162 cm, weight – 46 kg.
The patient's nutrition is satisfactory. The fat layer is poorly expressed.
There is no depigmentation, skin turgor is preserved. Humidity is normal. There is no dry skin, peeling, or rash.
Groups of lymph nodes - occipital, elbow, inguinal, popliteal - are painless on palpation, mobile, densely elastic in consistency, not fused with the surrounding tissue and with each other.
Degree of development muscular system– normal, no trembling or tremor of individual muscles. Spastic paralysis limbs, flaccid paralysis, no paresis.
The bones of the skull, chest, pelvis and limbs are not deformed.
Joints: normal configuration, no swelling. Skin hyperemia and local increase in temperature in the joint area were not detected. The range of active and passive movements is free. There is no pain when feeling or moving. Crunching, fluctuation, contractures, and ankylosis are absent.
Special inspection.
Head oval in shape, normal size. The structure of the brain and facial parts of the skull is proportional. The brow ridges are moderately expressed.
Hair. Hair type is female. No hair loss is observed.
Eyes. The width of the palpebral fissure, the condition of the conjunctiva, and the reaction of the pupils to light are normal.
Nose the shape is not deformed, there is bilateral swelling.
Lips. The coloring is normal, there are no cracks in the corners of the mouth.
Neck regular shape, without visible pulsation of the carotid arteries, symmetrical.
Thyroid not enlarged, painless on palpation.
Chest examination. Static inspection: the chest is normosthenic in shape, symmetrical, pathological curvature of the spine, the shoulder blades are slightly behind the chest.
Dynamic inspection: There is no lag of one of the halves of the chest in the act of breathing. Abdominal breathing, normal depth, rhythmic, RR = 17
Palpation. The chest is painless, elastic, the intercostal spaces are not widened. Voice tremors on the symmetrical halves of the chest are felt with equal strength.
Comparative and topographical percussion lungs within the physiological norm.
Auscultation of the lungs. Vesicular breathing is heard on the anterior surface of the chest, and bronchial breathing is heard in the interscapular region at the level of the 3-4 thoracic vertebrae. No adverse breath sounds are heard.
Circulatory organs.
Inspection heart area: No complaints. The cardiac hump and cardiac impulse are not visually detected.
Palpation. The apical impulse is determined in the 5th intercostal space on the left, 1 cm medially from the midclavicular line. There is no cardiac impulse, a symptom of “cat purring” in the places where the heart valves are projected onto chest not determined.
Percussion. The boundaries of the heart are within normal limits.
Auscultation. 2 tones and 2 pauses are heard. The tones are clear and rhythmic. No heart murmurs are heard.
Digestive organs.
Oral examination. The mucous membrane of the oral cavity is pink and moderately moist. Carious teeth – 1 (seven). Gums without pathology. The tongue is free of plaque, moist, there are no cracks or ulcers, there is no swelling. The tonsils are not enlarged.
Abdominal examination. Configuration: flattened. There is no swelling. The stomach does not participate in the act of breathing. Peristalsis of the stomach and intestines is not visible. There are no dilated saphenous veins.
Superficial indicative palpation of the abdomen according to Obraztsov-Strazhesko. The abdomen is soft and painless. There is no sign of “muscle protection”. There are no symptoms of peritoneal irritation (Shchetkin-Blumberg sign). The condition of the “weak spots” (umbilical ring, linea alba, inguinal rings) is normal. There is no symptom of fluctuation. There is no discrepancy of the rectus abdominis muscles.
Deep sliding topographic methodical palpation of the intestines and stomach according to Obraztsov-Strazhesko and Vasilenko within the physiological norm.
Percussion of the abdomen characterized by determining the presence of liquid and gas in the abdominal cavity. Tympanitis is not expressed, therefore, there is no accumulation of gas. There is no ascites. No Mendelian sign was detected.
Auscultation of the abdomen. There is no peritoneal friction noise. Intestinal motility is normal.
Liver examination. No bulging, dilatation of skin veins, or spider veins are noted.
Liver percussion. Percussion: the borders of the liver are normal.
Palpation of the liver. The edge of the liver is sharp, smooth, soft, easily tucked in and insensitive. Liver dimensions according to Kurlov: first size – 10 cm; second size – 9.5; third size – 8cm.
Examination of the gallbladder. The gallbladder is not palpable. There is no protrusion in the area of the projection of the gallbladder in the right hypochondrium. There is no pain on superficial palpation in this area.
Examination of the spleen. When examining the hypochondrium in the area of the projection of the spleen onto the left lateral surface of the chest and the left hypochondrium, no protrusion is noted.
Percussion of the spleen. The length along the 10th rib is 6 cm. The diameter (perpendicular to the length) is 4 cm. The readings correspond to the norm.
Palpation of the spleen. Not palpable.
Examination of the pancreas.
Percussion of the pancreas. The following are determined: the head - the middle of the right costal arch and the navel; body – xiphoid process and navel; tail - the middle of the left costal arch and the navel.
Palpation of the pancreas. Not palpable.
Urinary organs. There is no displacement of the kidneys. Lumbar region when tapping on the right and left (Pasternatsky's symptom) it is painless. On palpation bladder painless.
Research of the neuropsychic sphere. Consciousness is clear. Intelligence is normal. Memory is good. Sleep is normal. Speech is normal. Coordination of movements is not impaired. The gait is free. There are no convulsions or paralysis. Reflexes – reaction of the pupils to light, pharyngeal, corneal – are normal. Rigidity occipital muscles not noted.
Endocrine system. The thyroid gland is normal in size and consistency. No hyperthyroidism. There are no ocular symptoms (exophthalmos, Graefe, Moebius, Stellwag). There is no skin pigmentation.
Preliminary diagnosis:
Examination plan:
General blood analysis.
X-ray.
LABORATORY RESEARCH
Clinical blood test. Erythrocytes - 4.18x10^12/l Hb - 126 g/l Color. indicator - 0.95 Leukocytes - 9.8x10^9/l
eosinophils - 1% band - 1% segmented - 72% Lymphocytes - 24% Monocytes - 2% ESR - 27 mm/h
X-ray : There is a horizontal level of fluid in the maxillary sinus on the left. The cells of the ethmoid labyrinth are visualized. The frontal sinus is pneumotized.
Final diagnosis: Acute, purulent bilateral sinusitis.
Rationale for diagnosis:
Considering the patient's complaints of constant, intense, pulsating pain in the area of the projection of the maxillary sinus and in the area of the projection of the cells of the ethmoidal labyrinth, intensifying when going out into cold air, of bilateral nasal congestion, of mucopurulent discharge from the nasal passages, of headaches, weakness and increased body temperature; taking into account the medical history: acute development of all symptoms, prolonged hypothermia; life history – often suffers from colds; objective research data: detection during anterior rhinoscopy of hyperemia, swelling of the mucous membrane of both nasal passages, enlargement of the conchae, accumulation of mucopurulent secretion in general, more in the middle nasal passage, flowing from under the middle concha; clinical blood test data - detection of leukocytosis; and radiographic data - identifying a horizontal fluid level in the maxillary sinus,
You can make a diagnosis - Acute, purulent bilateral sinusitis.
Differential diagnosis.
It should be differentiated from frontal sinusitis, ethmoiditis, and rhinitis.
Treatment plan.
Prescription of vasoconstrictors (adrenaline, naphthyzin, sanorin) to improve the outflow of secretions from the maxillary sinus. Rp.: Sol. Naphthyzini 0.1%-10 ml D.S. Two drops in the left nasal passage 3 times a day.
Prescription of antibacterial therapy, as there is an inflammatory process and purulent discharge. Cefotaxime. Rp.: "Cefotaxim" 1.0 D.t.d.N. 10 S. Dissolve the contents of the bottle in 5 ml of saline and administer intramuscularly 3 times a day. # Sulfopyridazine. Rp.: Tab. Sulfapyridazini 0.5 D.t.d.N. 20 S. For the first dose, 2 tablets, then 1 tablet 4 times a day.
Diagnostic and therapeutic puncture of the maxillary sinus with rinsing with furacillin solution.
Physiotherapeutic effects (UHF, ultraviolet irradiation) on the sinus area.
Vitamin therapy .
Hardening the body and preventing infectious diseases.
Taking multivitamins. Full restoration of functionality is possible
with the exception of hypothermia.
