Passport part

Patient’s name: Ivanov Petr Sergeevich

Patient’s age: 45 years

Patient’s address: Vinnytsia, Pyrogova str. 129

Patient’s work: private entrepreneur

Date of admission: 25MAR2009

Main complaints

The patient complains of a moderate chest pain in the right side without irradiation. It has stabbing character, increases due to cough and deep breathing. His chest pain diminished if the patient lies on the right side.

Patient fills a breathlessness, difficult inhalation and exhalation which increase due to physical exertion. Patient does not have an asthma attack.

He has a permanent cough with purulent sputum without smell. Amount of sputum is near 60 ml per day. It expectorates easy. Patient has not had rusty, bloody, foamy sputum. He could not say which posture is the best for discharge of sputum.

Patient’s voice is not change. He does not have a sore throat, cold in the head. He breathes through the nose.

Patient has light headache, malaise, fever with body temperature 38,0-38,8 °C during a day, and chill.

Cardiac system

Patient does not have heart pain, feeling of the irregularity of the heart beat.

He feels palpitation during movement that is absent in a rest. Edema, faint and dizziness do not disturb him. Heaviness at the right subcostal region and signs of the peripheral vessel spasms like cramps, intermittent lameness or Raynaud's sign, are absent.

Gastrointestinal system

Patient’s appetite is reduced. He has quick satisfaction after meal. Dryness in the mouth or increased salivation is absent. He feels a thirst sometimes. Patient does not have any taste in the mouth.

He swallows food freely. Pain, felling of overfeeding, heaviness in the epigastria are absent. Patient does not have any eructation, heartburn, nausea, vomiting.

He does not feel any pain in abdomen,excessive swelling or passing of gas. Patient’s stool is regular, every morning without any pain. Feces are formed, brown, soft, and easy defecated with common smell. Patient does not have constipation, diarrhea, tenesma, admixture to feces, blood discharge and haemorrhoid.

Jaundice, dark urine, pale stool, pruritus are absent.

Genitourinary system

Back pain does not disturb the patient.

Micturition is 4-6 times in a day.

Nocturia, strangury, painful micturution, urethral discharge, decrease of the stream size, difficulty in starting micturition, involuntary urination are absent.

Daily urine volume is 1,5 L. Urine is clear, light yellow without blood.

Nervous system and sense organs

Patient’s mood is quiet. His memory does not change. Sleep and dream are normal. He has a low intensity, periodical, short time diffuse headache without dizziness, nausea, vomiting.

Noise in the head, buzzing in the ears, faints is absent.

Weakness in extremities, shivering, convulsions, excessive sweating, disorders of skin sensitivity: hypersensitivity or hyposensitivity - hyperesthesia or hypoesthesia do not disturb.

Hearing impairment, vision impairment, olfaction (smell) abnormalities are absent. The patient weight does not change.

History of the present illness (anamnesis morbi)

Patient felt sick 4 day before, after overcooling at the work. In the evening he felt fever, chill, headache and sore throat. He measured body temperature. It was 38.3°C. Patient took tablet of paracetamol and in a 40 min body temperature decrease to normal.

In 2 days patient’s condition was worsened, the dry excruciating cough, small mixed dyspnea and dull severe intensity chest pain in the right side appeared. Body temperature increases till 38.8 °C.

Patient called the general practitioner and after examination was directed to hospital with primary diagnosis community-acquired pneumonia. At the hospital patient was performed X-ray examination of the chest, full blood test and other investigation. The diagnosis of community-acquired pneumonia of the lower lobe of the right lung was confirmed.

He was prescribed antibiotic therapy, intravenous infusion of a lot of solution, intramuscular and oral medication. After the first day of the hospital treatment his condition improved. But he notes fever, light chest pain, chough with sputum production, dyspnea.

Дата добавления: 2015-11-14