Conclusion: the lower border of the lungs are shifted downwards.
When auscultation above the area under investigation, weakened vesicular breathing is determined, and dry dry wheezes are heard in all the pulmonary fields.
The cardiovascular system.
Subjective data: palpitation, pressing pains in the region of the heart, arising during walking and irradiating to the left shoulder, left arm, left half of the neck and head. Attacks of pain are stopped by the ingestion of nitroglycerin under the tongue. Mostly in the evening, there are swelling of the legs. Notes the presence of shortness of breath, both after physical exertion, and at rest.
Objective data: The arterial pulse is the same on both radial arteries, 90 blows per minute, rhythmic, corresponds to the heart rate, full, good filling and tension. Arterial pressure, measured by the method of Korotkov, is: systolic 140, diastolic 80 mm Hg.
Thoracic cage barrel-shaped, with palpationpainless. Heart hump is absent. There was no epigastric pulsation. The apical impulse is palpated in the 5 intercostal space on the left by 1 cm. Inside of the mid-succinic line, moderate, limited.
Limits of relative cardiac dullness;
Conclusion: the area of absolute cardiac dullness is reduced. With auscultation: heart sounds are muffled, cardiac murmurs and pericardial friction noise are not determined.
Subjective data: there is no pain, the appetite is not lowered, nausea and vomiting are not noticed, after eating - belching, sensation of fullness in the abdomen and gastric discomfort is not present. The chair is irregular, decorated. There are no bleeding from the intestine.
Objective data: the language is clean, moist. Pathological changes from the teeth and gums were not detected. The abdomen is rounded, symmetrical, and evenly participates in the act of breathing. Dents and protrusions of the abdomen in certain areas are not observed. The skin of the abdomen is not changed. With superficial palpation, the tension of the anterior abdominal wall is not revealed, the abdomen is soft, painless. Free fluid in the abdominal cavity palpation and percussion is not determined (there is no splashing noise, there is no dullness in the abdominal areas of the abdomen).
Dimensions of the liver according to Kurlov:
on the right mid-clavicular line
When palpation of the liver at the height of inspiration is palpatedthe lower edge of the liver along the edge of the costal arch is an acute, dense elastic consistency, smooth, painless. The spleen is not palpable, percussionally its dimensions are 5 * 7cm. Peristaltic intestinal sounds are heard.
Subjective data: no pain. Urination is regular, painless, free, with a feeling of complete emptying of the bladder after urination. According to the patient, urine is light yellow.
Objective data: the kidneys are not palpable. Pasternatsky's symptom is negative on both sides.
Signs of thyrotoxicosis (exophthalmos), acromegaly, skin pigmentation, thirst and polyuria are absent. Obesity of the degree is defined (body mass index is 33).
The memory is saved. Sleep calm. Disturbing periodic headaches associated with an increase in AD. The state is calm.
Objective research: state of moderate severity, attention is not violated. In space and in time, the patient is oriented well. Criticism of the surrounding world, facial expressions are preserved. Mental development corresponds to age. Speech disorders, letters are not observed. There is no euphoria.
Breathing movements are active. Muscle tone in normotonia. The strength of the muscles in the limbs is D = S. Movement in full.
Tactile, pain, temperature sensitivity is preserved.
5. Local signs of the disease (on the day of supervision)
In the right hypochondrium, a semilunar line haswound 5 * 4 * 3cm. in the stage of scarring. On the front abdominal wall there is a gauze dressing, located on the upper middle line, blotting, gray-yellow color. Under the dressing, a wound located along the upper median line, of the longitudinal direction, of a linear shape, 30 cm long, is visible. The upper edges of the wound for 7 cm were healed. Further, for 15 cm, the wound gaps. The lower edges of the wound for 8 cm were healed. Bleeding and signs of penetration of the wound into the cavity (presence of an epiploon in the wound, subcutaneous emphysema, leakage of synovial fluid) are absent. The walls of the wound in the place of gaps are evenly covered with a thin layer of fibrin plaque, the bottom of the wound is made with islands of granulation tissue of pink color. The granulation tissue is elastic, bleeds with minor damage, convex. Wound secret has a serous character. Its amount is moderate. There is a presence of marginal epithelization in the place of gaping of the wound.
With bimanual palpation, the edges of the wound are densified, mobile with respect to the underlying tissues and each other. There is a local increase in temperature.
6. Justification of the preliminary diagnosis
Based on the patient's complaints about moderatesoreness in the area of a postoperative wound in the anterior abdominal wall in the first days after the operation, general weakness, the presence in the anamnesis of an operative intervention for an acute phlegmonous-calculous cholecystitis and injured umbilical hernia, as well as the results of an objective investigation: the presence of a postoperative wound in the anterior abdominal wall in the regeneration stage (the bottom of the wound is made with islands of granulation tissue of pink color.) The granulation tissue is elastic, bleeds with minor damage, release bark), you can make a preliminary diagnosis: aseptic wound on the anterior abdominal wall in the recovery stage after surgery.
7. Data from special research methods
Conclusion: increase in thymol assay.
On the roentgenogram of organs of the abdominal cavity pathologies are not revealed.
On the radiograph of the lungs in the straight and left lateral projections - signs of venous congestion are moderate, the walls of the bases. bronchus massive, left in S1-2 the focus of the Gon, the aorta and aortopulmonary ligament are calcified, the posterior and lateral sinuses are soldered, the roots are "chopped off", structureless, with calcification, and the interlobar pleura is thickened on both sides.
Conclusion: X-ray signs of COPD, post-tuberculosis changes.
8. Instrumental methods of research
Ultrasound of the liver: right lobe-136mm. the left share-68mm. Ehostruktura not homogeneous. The bile ducts are not dilated, there are no signs of biliary hypertension in both lobes. The portal vein is 11mm.
The gall bladder is 105 * 34mm. deformed by kinks in the neck. Walls up to 7 mm. thickened. Content is non-uniform, echogenic bile? lumen. Concrements up to 13 mm in diameter.
Conclusion: acute calculous cholecystitis.
Ultrasound of the pancreas: head-25mm.,
Echogenicity increased. Ehostruktura not homogeneous. There are no outbreaks.
ECG: sinus tachyarrhythmia with a frequency of 109 beats per minute. Blockade of the anterior branch of the left branch of the bundle.
Pathoanatomical study of surgical material:
Gallbladder: the wall is compacted, edematous, purple, purulent, mucous edematous with a purple-black patch.
Pathological diagnosis: acute phlegmonous-ulcerative cholecystitis, pericholecystitis.
Bacterial culture on the isolation of microorganisms and the determination of their sensitivity to antibiotics:
Sensitivity to gentamicin, levomycetin has been determined.
9. Clinical definitive diagnosis
- Diagnosis of the underlying disease: an aseptic wound in the anterior abdominal wall in the regeneration phase after surgical treatment.
- Complications of the underlying disease is not revealed.
- Concomitant diseases: type 11 diabetes, bronchial asthma, arterial hypertension of the 3rd degree, OBI, IHD, stable angina.
aseptic wound regeneration treatment
10. Patient care plan
1. General principles of wound healing:
- prevention of secondary infection;
- acceleration of healing processes in the wound;
- correction of the general condition of the patient.
During first aid: