Found and form clinical diagnosis according to Classification.

The patient’s symptoms: a moderate stabbing, chest pain in the right side without irradiation that increases due to cough and deep breathing, mixed dyspnea which increase due to physical exertion, a permanent cough with purulent sputum without smell; the moderate severe general condition, pale cyanotic wet and hot skin, flash on the right cheek, lagging right part of the chest from the left one, tachypnea (36 per min), participating accessory muscles (neck, back and nose muscles) in breathing by visual inspection, amplifying vocal fremitus over the right lung, painful point along the right axillary line from 4^th till 7^th intercostals spaces, the positive Potenzher’s sign of the right side by palpation; dull sound over the right lung, upward shift of the right lower border of the lung, limiting excursion of the right lungs edge by percussion; the pathological bronchial breathing is heard over the right lung by auscultation allow suggesting the syndrome of the consolidation of the lung tissue. The syndrome has been confirmed by X-ray examination: intensive and homogeneous infiltration of the lower lobe of the right lung.

The patient’s symptoms: mixed dyspnea which increase due to physical exertion, the moderate severe general condition, pale cyanotic skin, tachypnea (36 per min), participating accessory muscles (neck, back and nose muscles) in breathing by visual inspection, tachycardia by examination of the cardiovascular system allow suggesting the syndrome of the severe respiratory failure. The syndrome has been confirmed bypulseoximetry: Sa O₂ 90%.

The patient symptoms: light headache, malaise, fever with body temperature 38,0-38,8 °C during a day, and chill which developed during a couple of days; the moderate severe general condition, body temperature 38,2°C pale cyanotic wet and hot skin by visual inspection are the symptoms and signs of the acute inflammation. The syndrome has been confirmed by full blood test – leucocytosis (15,6x19²/L), increased band neutrophils (17%), ESR (60 mm/hour), C-reactive protein (++++), fibrinogen A (7,0g/L) and B (+++), protein in urine (0,66 g/L), tachycardia by ECG.

Sputum examination has revealed bacterial character of inflammation of the respiratory system and founded pathogen – S.pneumoniae in diagnostically significant concentration.

Taking into account all received data of examination clinical diagnosis is

The community-acquired pneumococcal pneumonia of the lower lobe of the right lung IV group. Severe respiratory failure.

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Дата добавления: 2015-11-14