Hemorrhagic diathesis classification. Differential diagnosis of hemorrhagic diathesis

GBOU VPO "Bashkir State Medical University"

Ministry of Health of the Russian Federation

DISEASE HISTORY

Patient: M. Ch. Ya. (40 years old)

Primary diagnosis: right-sided cystic maxillary sinusitis

Curator, student Buvaeva E.K.

Medical Faculty

Group 411B

I. Passport part:

Name: M.Ch.Ya.

Age: 40

Gender Female

Date of receipt: 02.09.2015

Place of work, profession: Dyurtyuli, Central Regional Hospital. Medical technologist.

Place of residence: Dyurtyuli

The main diagnosis: right-sided cystic maxillary sinusitis.

Concomitant diseases: Atopic bronchial asthma, allergic rhinitis, SVD.

There are no complications.

II. Patient complaints upon admission to a medical institution:

At the time of admission, pain in the right side of the head (especially in the orbit), congestion, cough, general malaise, weakness, heaviness when talking.

Complaints at the time of supervision:

The patient experiences moderate pain in the right side of the head, notes the peculiarity of pain in the parietal region and orbit. Nasal congestion, dry cough, weakness, fever.

III. Anamnes morbi:

For a year, the patient experiences pain in the right side of the head, especially in the orbit, the vertex also had a pain in the neck and increased blood pressure. The pain began in November 2014. The patient consulted a neurologist in December, and she was diagnosed with autonomic dysfunction syndrome, intracranial hypertension. On January 26, 2015, MRI was performed. In June 2015, the patient began to worry about nasal congestion, runny nose, decreased sense of smell, and the same pain. At the end of July, according to the patient, she caught a cold, she had a cough, runny nose, temperature 39C. The therapist at the local hospital prescribed antibiotic therapy. Within three months the patient took vasoconstrictor nasal drops. 08/10/15, the patient went to the hospital and she was prescribed a planned operation. 09/02/15 entered the ENT department of the RKB im. G.G. Kuvatova.

IV. Anamnes vitae:

Born on 06/29/1975 in the Republic of Belarus. She grew and developed according to her age. Has two educations: secondary specialized and higher. Has been working since the age of 18. Social and living conditions are good.

Past diseases: ARVI (sick about 1 time per year), redness, chicken pox, gastritis. The operation was performed cholecystectomy. Hereditary history is not burdened.

V. Allergic history: Allergic rhinitis, pollen sensitization with broncho-obstructive syndrome. According to the patient, he has no allergic reactions.

Vi. Objective research:

General condition is satisfactory

Consciousness is clear

Active position

Facial expression is calm

Free gait

Posture straight

Correctly oriented in space and time

The physique is correct, the constitution is normosthenic. Height 165, weight 67 kg.

The skin is of normal color, there are no pathological rashes, there is no excessive sweating, no visible tumors, no edema. The subcutaneous fat layer is moderately developed.

Female pattern hair growth. The nail plates are normal.

The sclera is yellowish.

The thyroid gland is not enlarged.

The submandibular lymph nodes are palpable.

Body temperature 37.2 C. BP 110/70 mm Hg, heart rate 79 beats per minute.

Vii. Examination of organ systems

)Respiratory system:

The nose is straight, breathing through the nose is difficult, there is a discharge. No bleeding. The larynx is not deformed, there is no swelling. The voice is quiet.

The chest is normosthenic. The supraclavicular and subclavian fossa are moderately concave, the width of the intercostal spaces is 1.2 cm, the direction of the ribs is moderately oblique. The epigastric angle is straight, the scapula and clavicle protrude moderately. The rib cage is symmetrical. The movements of the chest during breathing are even, the intercostal spaces do not sink or protrude. The number of respiratory movements is 21 per minute. Breathing is deep, rhythmic, no shortness of breath, no wheezing. The breathing type is mixed.

)The cardiovascular system:

In the region of the heart, the chest is not deformed, no pulsation is visible. There is no visible pulsation, no epigastric pulsation.

A localized apical impulse is palpable in the 5th intercostal space, 1 cm medially from the left mid-clavicular line, with an area of 2 cm2, of moderate strength. hearts, heart sounds are muffled, rhythm is correct. Heart rate 78 per minute. Noises were not detected either in a standing position, or sitting, or lying on the left side.

When examining the vessels, no visible pulsation and pathological changes are observed. There is no visible pulsation of the arteries of the jugular fossa and the epigastric region. The arterial pulse is the same on both radial arteries, 78 per minute, rhythmic, satisfactory filling and tension. Arterial pressure on the brachial artery: 110/70 mm Hg. on both hands.

)Digestive system:

The appetite is saved. Heartburn, belching, nausea, flatulence are absent. The stool is normal.

The tongue is bright pink, moist, coated with a white coating, the papillary layer is pronounced. Teeth: no carious changes were found, no dentures. Gums pink, firm, without bleeding symptoms.

The abdomen is normal, no swelling, no pain.

The gallbladder was removed.

Intestines, liver, pancreas - no features.

)Urinary organs:

There are no pains in the lumbar region, urination is not disturbed. Pasternatsky's symptom is negative on both sides. The kidneys are not detected by palpation.

VIII. Examination of ENT organs.

1) Nose and paranasal sinuses:The nose is of the correct shape. The skin of the nose is flesh-colored, normal moisture. There is a slight swelling of the skin in the projection area of the right maxillary sinus. Palpation of the nose is painful. There is pain on palpation of the maxillary sinus region. Breathing is difficult, more weakened on the right side. The sense of smell is slightly reduced.

Anterior rhinoscopy: The vestibule of the nose is free, with hair on the skin. The mucous membrane of the turbinates on the right is hyperemic, on the left is pale pink. The lumens of the middle and lower nasal passages on the right and left are narrowed, the surface of the mucous membrane on the nasal concha is covered with mucous discharge, and there is also an accumulation of discharge at the bottom of the nasal cavity. The nasal septum is in the midline, does not have significant curvatures.

Pharynx:

The mucous membrane of the oral cavity is of normal color, there are no pathological changes. The teeth are sanitized, the tongue is clean and moist. The mucous membrane of the oropharynx is pink, without pathological changes.

Oropharynx:The mucous membrane of the soft palate, palatine arches is pink, moist, clean. The palatine tonsils do not protrude beyond the arches, there are no adhesions to the arches, the lacunae are without pathological changes. The bows are pink, no pathological changes are detected.

Nasopharynx (posterior rhinoscopy):The vault and choanas are free. There is no drainage of pus along the back of the pharynx. The pharyngeal tonsil is pink, not enlarged. The posterior ends of the turbinates are not enlarged, the mucous membrane is hyperemic, edematous.

Laryngopharynx: The mucous membrane of the laryngopharynx (valleculus, piriform sinuses) is smooth, pink in color. The lingual tonsil is pale pink in color, normal size.

Larynx:

AD: The skin of the auricle is pale pink in color, the relief is not changed, pressure on the tragus is painless. On external examination, the skin of the mastoid region is pale pink in color, there is no swelling, palpation is painless.

With otoscopy: the external auditory canal is normal, no wall infiltration is observed, no pathological discharge. There is a slight accumulation of sulfur. The tympanic membrane is not changed, gray in color. The following identifying elements are visible on the surface of the tympanic membrane: the navel, the light cone, the handle of the malleus, the short process of the malleus, the anterior and posterior folds. Perforations and scars were not found .: The skin of the auricle was pale pink in color, the relief was not changed, pressure on the tragus was painless. On external examination, the skin of the mastoid region is pale pink in color, there is no swelling, palpation is painless.

Auditory passport.

AD PARAMETERS AS Abs.noise in the ear Abs. 6 meters whisper speech 6 meters - spoken speech - VKSVK45 s15 s45 s15 s45 sC 2048 (aerial) 45 s + Rinne experience ++ Federici experience + Weber experience + Jelle experience ++ Schwabach experience +

Vestibular passport.

Dizziness, vomiting, loss of balance - periodically.

Spontaneous nystagmus is not.

Finger test is normal.

There are no coordination disorders in the Romberg position.

The straight gait is not changed.

The flank gait is not disturbed.

Dysdiadochokinesis has not been identified.

Fistula test (not performed).

IX. Preliminary diagnosis: Maxillary hemisinusitis.

X. Laboratory research methods:

General blood analysis:

Indicators Result Normal Leukocytes 5.24.0-9.0 Erythrocytes 3.853.9-5.0 Hemoglobin 121 g / l 110-160 g / l Platelets 220 150-400 Lymphocytes 29% 19-37% Rod neutrophils 4% 1-4% Segmented neutrophils 62% 47-72% Monocytes 5% 3-11% ESR 12 mm / hour Up to 15 mm / hour

General urine analysis:

Color - straw yellow

Transparent

Specific gravity 1018

Leukocytes 1-0-2

B / x blood:

Total protein - 82.6

Glucose - 3.94

Urea - 5.2

Cholesterol - 4.2

Total bilirubin - 13.2

Rheumatoid factor - neg.

C-reagent. Protein - neg.

Coagulogram:

Fibrinogen - 2.8

Prothrombin time -13

Prothrombosed index - 90

X-ray examination:

On the roentgenogram in the nasolabial projection, a homogeneous globular darkening of the right maxillary sinus is determined. In the left maxillary, frontal, sphenoid sinuses, as well as in the cells of the ethmoid labyrinth, no pathological changes were found.

Conclusion MRI: MR picture of the cyst of the right maxillary sinus, left-sided hemisinusitis. Minor external hydrocephalus.

X. Clinical diagnosis and its rationale:

Main disease:right-sided cystic maxillary sinusitis

Concomitant disease:Atopic bronchial asthma, allergic rhinitis, SVD.

The diagnosis is based on

Anamnesis of the disease: patient complaints (constant profuse nasal discharge of a mucous nature, constant congestion of both halves of the nose, pain in the right side of the head, orbit, crown). From the history of the disease.

Objective research data: anterior rhinoscopy.

Additional study data: X-ray of the nose and paranasal sinuses in the nasal projection, MRI data.

XI. Differential diagnosis.

Maxillary sinus polyp. Polyp usually has an irregular shape on radiographs. The polyp usually penetrates through Hiatus sinus maxillaris into the nasal cavity (middle nasal passage). Puncture of the maxillary sinus with a polyp usually produces blood. The polyp on the roentgenogram gives a characteristic aciniform darkening.
Right-sided sinusitis. With sinusitis also nasal congestion, irradiation of pain, purulent discharge from the nose. On the roentgenogram, sinusitis is visualized in the form of darkening with an upper horizontal level in the lower and middle third.

XII. Treatment:

)Surgery:

Operation No. 847 was carried out

Name of the patient: Murtazina Ch. Ya.

Surgeon: Yanborisov T.M.

Operating sister: Syundyukova A.

Operation: right-sided endoscopic sinusitis

Duration: 40 min.

Operation progress:

Sol injected. Novocaini 2.0% - 5.0 ml see the addition of Sol. Adrenalini 0.1% in "projection points": the place of attachment of the middle turbinate, the anterior end of the middle turbinate, the nasal septum;

Removed the uncinate process, polyps of the middle nasal passage, sphenoethmoidal space. Under the control of an endoscope, the pathological contents from the right maxillary sinus were carefully removed using Blexley forceps, the sinus was flushed. The anastomosis of the frontal sinus, the maxillary sinus are freely probed. Tamponade with a homestatic sponge. Transferred the operation satisfactorily. The material was sent to the hist. Study.

)Drug treatment:

Rp .: Dr. Diazolini 0.1 N 10. S. 1 tablet 2 times a day ..: Sol. Naphthizini 0.1% 10 ml. S. Drops in the nose (3 drops 3 times a day in each nasal passage).

Rp .: "Cefotaxim" 1,0.t.d.N. 10

S. Dissolve the contents of the vial in 5 ml of physiological solution, inject intramuscularly 3 times a day.

Lubrication of the nasal mucosa with 10% silver nitrate solution.

The general condition is satisfactory, the consciousness is clear, the position is active. The patient complains of pain near the eye socket, in the right side of the head, nasal congestion, cough and general malaise. BP 110/70, temperature 37.2 C. BH 21, HR 78.

Nose - the mucous membrane on the right side is hyperemic, on the left is pale pink, there is a discharge. Larynx - vocal folds are gray, symmetrically closed. The palatine arches are slightly hyperemic.

The general condition is satisfactory, the consciousness is clear, the position is active. Complaints about a runny nose, headaches. BP 120/70, temperature 37.0 C. RR 21, heart rate 80.

Nose - the mucous membrane on the right side is hyperemic, on the left is pale pink, there is a discharge. Larynx - vocal folds are gray, symmetrically closed. Pharynx - the palatine arches are slightly hyperemic.

The general condition is satisfactory, the consciousness is clear, the position is active. No complaints. BP 120/70, Temperature 36.8 C. BH 18, HR 80.

The nose is a pink mucous membrane, there is a discharge. Larynx - vocal folds are gray, symmetrically closed. Zev - no change.

XIV. Prevention:

Prevention will be of a non-specific nature. Immunostimulating therapy.

XV. Forecast:

For life - favorable.

For recovery - favorable.

For labor activity - favorable.

patient analysis diagnosis therapy

List of used literature

1.http: //lookmedbook.ru/

Ovchinnikov Yu.M., Lopatin A.S., Gamov V.P. Diseases of the nose, pharynx, larynx and ear. (2008).

Otorhinolaryngology: textbook Palchun V.T., Magomedov M.M., Luchikhin L.A., 2011.

Surgical dentistry: textbook (Afanasyev V.V. and others); under total. ed. V.V. Afanasyeva. - M.: GEOTAR-Media, 2010

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PSU im. T.G. Shevchenko

Faculty of Medicine

Department of "Surgery with the cycle of oncology"

Head chair

Disease history

Start of supervision: 10/14/15.

End of supervision: 10/17/15.

Date of delivery of the medical history: 10.24.15.

1 Passport part

1. Surname, 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: early. honey. sl.

9. Referring institution diagnosis: Acute respiratory illness.

10. Clinical diagnosis: Chronic bilateral sinusitis in the acute stage.

II. Complaints

Complaints at the time of supervision:

For nasal congestion.

General weakness.

Increase in body temperature (38 0 С)

Profuse mucopurulent discharge.

Headache in the forehead, worse bending forward.

Complete lack of smell (anosmia).

III. History of the present disease

(Аnamnesis morbi)

According to the patient, the disease began acutely, 12.10.15. 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. He did not take independent treatment, he turned to the head of the medical center. service to a therapist. Was sent to hospitalization in the ENT department of the State University. RSC. to clarify the diagnosis and provide appropriate treatment.

IV. Life story(Аnamnesis vitae)

Was born in 1996, on time. He was breastfed and did not get rickets. From the age of 7 I went to school, I studied well, I did not lag behind peers in physical and mental development. Living conditions and food during childhood and adolescence are good. The family environment is favorable.

Family history. He lives in Tiraspol in a separate apartment, living conditions are satisfactory, the general budget is satisfactory, the situation is favorable. Eats at home, food is satisfactory. The use of alcohol, drugs and smoking is denied.

Past illnesses. According to the patient, in childhood he suffered from rubella, chickenpox. He denies HIV, hepatitis, tuberculosis. The presence of operations is denied.

Allergic history. Allergic reactions to drugs, food, pollen, etc. are not swept aside.

Insurance history.

V... Present state (Status praesens)

GENERAL INSPECTION:

General condition: moderate severity.

Consciousness: clear.

Position: active.

Physique: asthenic. Height 190cm, weight 70 kg.

Body temperature: 38.5C

Skin: pale pink; peeling, focal pigmentation, rashes, hemorrhages, "spider veins", angiomas, scars, scratching, rash, itching, no.

Visible mucous membranes: no changes, pale pink color, normal humidity.

Hair growth: the type of hair growth corresponds to the gender.

Nails: correct shape - oval, smooth surface, transparent. There is no streaking, brittleness, or dullness.

Subcutaneous adipose tissue is moderately developed.

No edema.

Peripheral lymph nodes (cervical, occipital, submandibular, axillary) are palpable, not enlarged.

Muscular system: the degree of muscle development is moderate, there is no pain on palpation of the muscles, the strength of the muscles in the hand, hips, and legs is moderate.

Osteoarticular system: no deformity 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 deformities or swelling in the larynx region. The voice is quiet, clear.

Chest: asthenic chest shape.

Breathing: type of breathing - chest. The auxiliary muscles are not involved in breathing. The number of respiratory movements is 18 per minute. Breathing is rhythmic. There is no apparent difficulty in breathing.

Chest percussion.

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 standing apexes of the lungs behind is 1 cm higher than the spinous process of the VII cervical vertebra.

The width of the fields of Krinig: on the right - 6cm, on the left - 7cm.

Lower boundaries of the lungs:

Topographic lines Right lung Left lung

Active mobility of the lower edges of the lungs (cm):

Topographic

L medioclavicularis
L axillaris media

Auscultation of the lungs.

With 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 area of the sternum handle, in the interscapular region at the level of 2-4 thoracic vertebrae. There are no additional respiratory sounds, crepitus, wheezing. Bronchophonia in symmetrical areas of the chest is not changed.

CIRCULATORY SYSTEM

Complaints:

The patient had no complaints of pain in the region of the heart.

No choking .. There are no complaints about the appearance of edema.

Inspection:

Neck examination: external jugular veins and carotid arteries without visible pathological changes. There is no swelling of the veins of the neck or increased pulsation of the carotid arteries.

Inspection of the heart area: the apical impulse is visible in the V intercostal space on the left, 2 cm outward from the mid-clavicular line. Cardiac impulse, epigastric pulsation are not visually identified.

Palpation:

Apical impulse: palpable 2 cm outward from the mid-clavicular line in the 5th intercostal space, somewhat strengthened, occupies the area of the 2 terminal phalanges of the middle finger of the right hand.

Cardiac impulse: not detected.

Epigastric pulsation: absent.

Palpation pain and areas of hyperesthesia in the heart are absent.

Percussion:

The diameter of the relative dullness of the heart is 17 cm. The width of the vascular bundle is 6 cm. The configuration of the heart is normal.

Auscultation Heart sounds are rhythmic, clear, sonorous; the tone ratio is not changed. Blood pressure 120/70 mm Hg. Art .. Heart rate (HR) - 65 beats / min.

Digestive system

GASTROINTESTINAL TRACT

Complaints:

There are no abdominal pains.

Dyspeptic symptoms, including difficulty in swallowing, nausea, vomiting, belching, heartburn and abdominal distention are not present.

The appetite is preserved, there is no aversion to food (fatty, meat, etc.).

Stool: usually once a day, the amount is moderate. The feces are shaped, brown in color, of the usual odor. There is no admixture of blood and mucus in the feces.

Bleeding: There are no signs of esophageal, gastric, intestinal and hemorrhoidal bleeding (vomiting of blood, "coffee grounds", red blood in the feces, melena).

Inspection:

Oral cavity: pink tongue with a slight cyanotic tinge, moist, without deposits. Dentures. Gums, soft and hard palate of normal color, no hemorrhages or ulceration.

Abdomen: normal shape, subcutaneous fat layer is developed moderately, evenly. The abdomen is symmetrical, there are no bulging or retraction. The abdomen participates in the act of breathing. There is no visible intestinal peristalsis. There are no venous collaterals of the anterior abdominal wall.

Percussion:

Percussion sound - tympanic over the entire surface of the abdomen. There is no free or enclosed fluid in the abdominal cavity.

Palpation:

Superficial approximate: 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 between the rectus abdominis muscles, no umbilical hernia, no hernia of the white line of the abdomen. There are no superficial tumor-like formations.

Methodical deep sliding palpation according to V.P. Obraztsov and N.D. Guard: The sigmoid colon is palpable in the left iliac region in the form of an elastic cylinder, with a flat surface 2 cm wide. Mobile, not rumbling, painless.

The cecum is palpated in a typical place in the form of a cylinder of elastic consistency, with a flat surface, 2 cm wide, mobile, not rumbling, painless.

The transverse colon is not palpable.

The ascending colon is not palpable.

The descending colon is not palpable.

Stomach: greater curvature by auscultation-percussion and splash noise, halfway between the umbilicus 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 rubbing noise. Vascular murmurs in the area of the projection of the abdominal aorta, renal arteries are not heard.

LIVER AND GALL BLADDER

Complaints:

Complaints of pain in the right hypochondrium, dyspeptic disorders, nausea, vomiting, belching, pruritus, icteric staining of the skin and visible mucous membranes, the patient does not present.

Inspection:

There is no protrusion in the right hypochondrium. There is no restriction of this area in breathing.

Percussion: Borders of the liver according to Kurlov

Ortner's symptom is negative.

Palpation: The lower edge of the liver protrudes from under the costal arch by 1 cm, painless on palpation, elastic consistency with a rounded edge.

Liver size according to Kurlov:

The gallbladder is not palpable. Kerr's symptom and Phrenicus symptom are negative. Symptoms of Ortner, Vasilenko are not detected.

Auscultation:

There is no peritoneal friction in the right hypochondrium.

SPLEEN

Complaints pain in the left hypochondrium is absent.

Inspection: There is no protrusion in the area of the left hypochondrium, there is no restriction of this area in breathing.

Percussion: The longitudinal size of the spleen along the X edge is 7 cm, the transverse size is 5 cm.

Palpation: The spleen is not palpable.

Auscultation: There is no peritoneal friction in the left hypochondrium.

PANCREAS

Complaints no pain and dyspeptic symptoms, nausea and vomiting, diarrhea and constipation. No thirst and no dry mouth.

Palpation: The pancreas is not palpable.

There is no pain in the pancreatic points of De Jardin and Mayo.

URINE SYSTEM

Complaints there is no girdle 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. Cutting, burning, pain during urination, false urge to urinate are absent. 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 deformities of the bones and cartilage of the walls were detected visually or palpably. Palpation of the anterior wall of the frontal sinuses at the exit site of the first and second branches of the trigeminal nerve is painless.

Moderate soreness of the anterior wall of the maxillary sinuses is noted.

With anterior rhinoscopy, the entrance to the nose, the free nasal septum is not displaced, located in the midline. The mucous membrane is hyperemic, moderately edematous. Breathing is difficult, there is abundant mucopurulent discharge.

Oral cavity.

The oral mucosa is pink, moist, clean. The mouths of the excretory ducts of the salivary glands are clearly visible. The teeth were 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. The posterior wall of the pharynx is moist, pink. Lymphoid tissue is not changed. The pharyngeal reflex is preserved.

Nasopharynx.

The vault of the nasopharynx is free. The pharyngeal tonsils are not changed. The mucous membrane is pink, moist. Center line opener. Joanas are free. The turbinates are not hypertrophied. The mouths of the auditory tubes are well differentiated and free. Tubal tonsils and lateral ridges are not enlarged.

Laryngopharynx.

The mucous membrane is pink, moist, clean. The lingual tonsil is not hypertrophied. The Vallecules are free. The piriform sinuses are free.

The epiglottis is mobile, the passage to the larynx is free.

Regional lymph nodes (submandibular, deep cervical, pre-laryngeal, pretracheal) are not enlarged. The larynx is regular in shape, passively mobile, pink mucus, moist and clean. With laryngoscopy, the mucous membrane of the epiglottis, the area of the arytenoid cartilage, the inter-head space and the vestibular folds is pink, moist with a smooth surface, the vocal folds are gray, not changed, symmetrically mobile during phonation, close completely.

The subglottic space is free.

Right ear.

Left ear.

The auricle is of the correct shape. The contours of the mastoid process are not changed. Palpation of the auricle, mastoid and tragus is painless. The external auditory meatus is wide. Contains moderate amounts of sulfur. There is no pathological content. The eardrum is gray with a pearlescent tint. The short process and handle of the malleus, the light cone, the anterior and posterior folds are well contoured.

Vestibular functions are not impaired.

V11. Provisional diagnosis

Based on the patient's complaints (nasal congestion, general weakness, profuse mucopurulent discharge, an increase in body temperature up to 38 ° C, a headache in the forehead, intensifying when leaning forward, a complete lack of smell), it is possible to conclude about acute bilateral sinusitis.

V111 . Additional research methods

X-ray of the paranasal sinuses: intense homogeneous darkening of both maxillary sinuses compared to the orbits.

Anterior rhinoscopy hyperemia and edema of the mucous membrane in the region of the inferior turbinates on both sides, narrowing of the lumen of the nasal passages.

1 X. Clinical diagnosis.

Chronic bilateral sinusitis in the acute stage

Based:

- complaints(nasal congestion, general weakness, profuse mucopurulent discharge, headache in the forehead, aggravated by leaning forward, complete absence of smell).

-history data(the disease began acutely, due to hypothermia 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).

-radiographysinuses(intense homogeneous darkening of both maxillary sinuses in comparison with the orbits).

- laboratory research data:

- data of anterior rhinoscopy: hyperemia and edema of the mucous membrane in the region of the inferior turbinates on both sides, narrowing of the lumen of the nasal passages.

XTreatment.

1) general mode -2

2) diet number 15

4) Symptomatic treatment:

5) Surgical treatment - puncture of the maxillary sinuses.

Indications for puncture: for diagnostic and therapeutic purposes. Consent received. There are no contraindications. Prepared for the operation.

Technique of carrying out. The puncture is performed under local anesthesia, for which a 10% lidocaine solution is used. The patient sits in front of the doctor in a chair. The puncture is performed with a special needle (Kulikovsky's needle). It has a bend at the tip, so it can be brought under the inferior turbinate, and a guidewire can be passed through its wide lumen into the maxillary sinus.

Puncture of the maxillary sinus is performed in the area of the lower nasal passage, for which about 2 cm recede from the anterior end of the lower turbinate. Here the bone has the smallest thickness.

In order for the needle to overcome the 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 feeling of failure indicates the penetration of the needle into the maxillary sinus. Once the needle has entered the sinus, you can attach a syringe to it and pull on its plunger. If air or pathological secretions enter the syringe, this indicates correct needle insertion. They wash the sinuses, for which they use a mixture of dexamethasone and dioxidine... The mixture is poured into the sinus through a syringe, and it is 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 outside. When flushing the sinus, the patient's head should be slightly tilted forward so that the contents of the sinus flow out through the nose and not enter the nasopharynx.

Punctured maxillary cavity on the left, VD / VS = 9 cm 3. In the wash fluid, mucopurulent discharge. Punctured maxillary cavity on the right, VD / VS = 8 cm 3. In the wash fluid, mucopurulent discharge.

A mixture of dexamethasone and dioxidine was introduced into the cavity, and Teflon drains were installed.

6) physiotherapeutic effect (UHF, UFO)

Diaries

1 day. 10/14/15.

The general condition of the patient is of moderate severity. HELL 120/80, Ps 70 beats / min, body temperature 38 0 С, headaches in the forehead area are observed, aggravated when bending forward, difficulty in nasal breathing. The volume of the injected liquid VD / VS 10 cm 3. Mucopurulent discharge is visible in the lavage fluid. Stool and urine output are normal, there is no edema, Pasternatsky's symptom is negative. The abdomen is soft and painless. Heart and lungs unchanged.

2nd day. 10/15/15.

Mucopurulent discharge is visible in the washing fluid.

Stool and urine output are normal, there is no edema, Pasternatsky's symptom is negative. The abdomen is soft and painless. Heart and lungs unchanged.

3rd day. 17.10.15.

The patient's condition has improved, body temperature is 36.8 0 C, blood pressure is 120/80,

Ps 70 beats / min. Stool and urine output are within normal limits, Pasternatsky's symptom is negative. The abdomen is soft and painless. Heart and lungs unchanged. No edema. The volume of the injected liquid VD / VS = 15 cm 3. Mucopurulent discharge is visible in the washing fluid.

Epicriz

The patient was admitted on 13.10.15. at 14 40 with a diagnosis of chronic bilateral sinusitis in the stage of exacerbation. Treatment was prescribed and carried out:

1) general mode -2

2) diet number 15

3) Etiotropic treatment - antibiotics (cefazolin IM)

4) Symptomatic treatment:

Non-narcotic analgesic (analgin 2ml.im)

Desensitizing (diphenhydramine i.m., loratadine, 1 tab. 3 times a day)

Mucolytics (ambroxol 1 tab. 3 r / d)

Sulfanilamide preparations (sulfadimezin 1 t. 3 times a day)

Irritating agents (sinupret, 2 tablets / day)

5) Surgical treatment - puncture of the maxillary sinuses.

The general condition of the patient has improved. Body temperature N. Covers of normal color. Lymph nodes are not palpable. Rhythmic pulse 76 / min, satisfactory filling. HELL 120/80. The lungs and heart were normal. The abdomen is soft and painless. Pasternatsky's symptom is negative. No edema. Stool and urine output are normal.

ENT status. The external nose is of a regular shape. The nasal mucosa is hyperemic, mucopurulent discharge in the nasal passages. Nasal breathing is difficult. When punctured in the wash water VD / VS = 8 cm 3, mucopurulent discharge is visible. The AC mixture (dioxidine + dexamethasone) was introduced.

The following research methods were carried out:

X-ray of the paranasal sinuses: intense homogeneous darkening of both maxillary sinuses compared to the orbits.

Anterior rhinoscopy: hyperemia and edema of the mucous membrane in the region of the inferior turbinates on both sides, narrowing of the lumen of the nasal passages.

chronic sinusitis treatment disease

Discharged on 19.10.15. in a satisfactory condition, the prognosis for life is favorable.

Vitamin therapy (compliant for 1 tab. 2p / d, vit. C 500mg 2p / day)

Fortifying (echinasal 1 tablespoon 3-4 times. \ Day).

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