Crimean State Medical University

Named after S.I, Georgevsky

Department of internal disease
Head of department professor
Teacher

S.N. Kutikov
Hazaeva Lilia Faizullaevna

CASE REPORT
ANASTASIA STOLA MIKHAILOVNA

Clinical diagnosis
Main disease:

Acute Lobar Pneumonia of Upper Left Lobe of Lung

Complication:

Accompanying disease: -

Student: Tan Kok Wang

Year: III
Group: 327
Date of Examination: 27th April 2007

1. Passport data
Full name: Anastasia Stola Mikhailovna
Age: 16
Nationality: Ukrainian
Family status: single
Occupation: Postgraduate of High school student.
Home address: Sportivnaya 5/24 street, Agrarnoe road, Simferopol.
Date of admission: April 19th 2007
Time of admission:

2. Inquiry
Complaints :
Patient complains of strong dry cough and later progresses to moist cough with viscous,
rusty sputum after 2-3 days, with dyspnea during coughing, and non-irradiating pain at
the upper left chest. Patient also complains of high persisting fever, shaking persisting
chills and severe headache. No haemoptysis was observed by the patient. Patient also
complains of general weakness and discomfort at the chest.

History of the present disease (Anamnesis Morbi ):

Disease started one week ago with acute onset before her administration to hospital
which patient complains of high persisting fever approximately 38 38.5 degree Celsius
in the morning and increased to 39 degree Celsius at night.

Initial symptoms where patient started with strong dry cough and after 3-4 days
progressed to moist cough with viscous sputum.
Patient had only taken medication Paracetamol but there is still no sign of recovery and
high fever is still persisting. Patient was administered to 7th hospital one week later on
19/4/07 with all symptoms mentioned and then hospitalized.
Examination of sputum and Fluorography was done and revealed Acute Lobar
Pneumonia at the Left Upper Lobe of Lung. Pleural Puncture was done too together with
administration of Lidocaine for analgesia. She was treated with antibiotics Ceftriaxone
for 5 days (3 times per day Intramuscularly).

Life History (Anamnesis vitae) :

She was born in Simferopol. According to the patient, he hasnt tuberculosis, malaria,
blood transfusion before. She has allergy to aspirin (acetylsalicylate). She doesnt smoke.
She also doesnt have any operation and any accident. State of apartment is hygienic. She
has a regular and healthy nutrition. Her mother had pneumonia 2 weeks before her onset
of disease. According to patient, her mother works most of the time outside as a hairstylist. Patient might had acquired her disease from her mother through air-droplets.
Patient doesnt have any gynecological anamnesis.

3. Physical Examination (Status Praesens)

General condition of the patient is satisfactory
Patients consciousness is clear and her posture is active and gait is not change.
The skin is pale,clean and elastic.
Lips is pinkish colour, soft and smooth.
Subcutaneous fat is developed moderately.
Thickness of subcutaneous under scapula is approximately 1.5 cm.
Hairs are female type and nails are in normal shape and color.
Oedema is absent.
Height: 157 cm
Weight: 42kg
EXAMINATION OF BODY PARTS
Head is proportional and symmetrical. Face is symmetrical, and facial expression is good.
Hair-covering is female type. No protrusions of eyeballs, normal width of eye-slit.
Expression of nasolabial folds is normal and usual size of nose. Ears are normal in size
and shape.
No presence of carotids and jugular pulsation.

LOCOMOTOR SYSTEM
EXAMINATION AND PALPATION:
The muscles are developed moderately. Tone and muscles are identical on both sides.
Palpation and tapping of bones are painless, joints are of regular shape and painless
during palpation and movements. Temperature and skin over them have not changed.
Active and passive movements in joints are full. Pathologic deformations of the spinal
column are absent. Its function is normal.

RESPIRATORY SYSTEM
INSPECTION
Patient breathes through the nose, nose wings does not participate in respiration.
Voice is normal. Form of the chest is regular, normosthenic, with epigastric angle near 90
degree. The chest is symmetrical. Supraclavicular fossa moderately pronounced.
The ribs are moderately inclined as viewed from the side.
Respiratory type is thoracic (female). Breathing is rhythmic deep with 19 per minute.
Inspiration and expiration are equal.
PALPATION
Patients chest is resistant moderately in longitudinal and transversal direction. No
tenderness along the ribs, intercostal spaces, trapezoid muscles, intercostal nerves points.
Vocal fremitus is increased at the supraclavicular area where affected left side of chest
anteriorly and posteriorly at the left suprascapular region.
PERCUSSION
Comparative percussion of lung give clear lung sound on the right side and there is
duller lung sound over the upper left side of chest till 3rd rib with tympanic effect.
Traubes space gives tympanic sound and is has semilunar shape.

Topographic percussion of the lung

The upper level of the apices on both sides anteriorly in 3cm from above the clavicle,
posteriorly at level of 7th cervical vertebra.
Lines
Parasternal
Midclavicular
Anterior axillary
Middle axillary
Posterior axillary
Scapular
Parasternal

Lower borders of lungs

Right lung
V rib
VI rib
VII rib
VIII rib
IX rib
X rib
XI rib

Left lung
VII rib
VIII rib
IX rib
X rib
XI rib

Mobility of the lower edges of left lung on midclavicular line is 4 6 cm, on scapular 5
cm.
In auscultation , normal vesicular breathing is heard over symmetrical parts of chest
except there is decreased vesicular breathing over the upper left lobe of lung.
The bronchophony is equally over other parts of symmetrical points of lungs except
upper left lobe of lung which increased sound of bronchophony.
Present of adventitious sound during auscultation. Moist rales is heard at the upper left
lobe of lung. There is also crepitation at the height of inspiration over the upper lobe of
left lung.
No pleural friction sound is heard.

CARDIOVASCULAR SYSTEM
INSPECTION
Visible arteries pulsation are absent. Vein pulse on neck is negative. Cardiac hump
back and visible pulsation in the heart region are absent. There is no epigastric pulsation
observed. There is no cyanosis of skin and swelling of fat.
PALPATION
Apex beat is palpated in the V intercostal space. It is restricted, moderate strength and
low height at the left region of thorax 1-2 cm medially from the midclavicular line. Width
of apex beat is restricted with 1-2 cm in diameter.
Cats murmur is absent. Epigastric pulsation in breathing is not palpable in deep
inspiration.

PERCUSSION
These are borders of relative cardiac dullness:
Right: 1cm outside from the right edge of the sternum,
Upper: 3rd intercostals space,
Left: 1.5cm inside from the left midclavicular line.
These are borders of absolute cardiac dullness:
Right: At the left edge of the sternum,
Upper: At the lower edge of 4th rib,
Left: 2cm medial from the left midclavicular line.
These are borders of vascular bundle:
The right and left borders of vascular dullness are found along the edges of the sternum.
AUSCULTATION
On auscultation of the heart, two sounds are heard in all points. The sounds are rhythmic,
peculiarly on the basis.
Heart rate is 90 beats per minute.
The 1st sound is louder than 2nd sound at the heart apex, at the base of xiphoid process.
The 2nd sound is louder than 1st sound at the heart bases.
No murmurs were heard on auscultation.
VESSELS INVESTIGATION
Pulse is palpated equal on both arms.
Tension of pulse is satisfactory
Pulse is rhythmic.
Temporal and carotid arteries are well palpated, pulsation on the both sides are equal.
Arterial pressure: Systolic-130 mmHg,
Diastolic-80mmHg,
Pulse-78 /minute

DIGESTIVE SYSTEM
INSPECTION:
MOUTH:
The tongue is in usual size, moist, coated with white layer, teeth are healthy. Mucous of
mouth is light pink in colour, and clean. No odour presents.
ABDOMEN:
Abdominal is regular form, symmetric. There is no scar. No pigmentation or
depigmentation. The mobility of abdominal wall during breathing was active. No visible
peristalsis. Navel is depressed and there is no hernia.
PALPATION:
SUPERFICIAL PALPATION:
In superficial palpation abdominal is soft tender and painless, no resistance, no diastasis
(hernial separation) or protrusion, presence of tumors.
Hernias and Shchetkin Blumberg symptom (peritoneum irritation sign) are negative.
DEEP PALPATION:
The sigmoid s palpated in the iliac region as smooth firm cylinder 2 cm in diameters,
displace in 1.5 cm, it is painless, does not produce rumbling sounds.
The caecum is palpable in right iliac region as a smooth soft cylindrical 2 cm in diameter,
painless, produce rumbling sound.
Other part as transverse, ascending, descending, small intestine, are not palpable.
Greater curvature of the stomach is determined as soft smooth ridge 3 cm above the
navel, it is painless, displace on 1,5 2 cm produce slightly rumbling sounds. Others part
of stomach are not palpable. (AUSCULTATION-PERCUSSION METHOD)
PERCUSSION
Tympanic sound is heard over all parts of the abdomen during percussion.

AUSCULTATION
On auscultation of the abdomen peristalsis of the intestine of moderate louder and
frequency is heard. Vessel murmurs are absent.
EXAMINATION OF LIVER
Visible enlargement of the liver is absent .
Liver is not palpable .
Upper border of absolute hepatic dullness on the right midclavicular line is on the level of
6th rib, lower border on edge of costal arch.
Liver dimension on Curlov is 8 x 7 x 7 cm. a
Liver dimension on Obraztsov is 9 7 6 cm.
EXAMINATION OF GALL-BLADDER
Gall- bladder is not palpable .
The symptoms of pressing and concussion of gall- bladder are negative.
Tenderness in the points of gall- bladder are not determined.
There is no hyperesthesia in zones of Zakharyin and Hedd
PALPATION OF PANCREAS
Pancreas is not palpated. The tenderness in the points of containing to the head, to the
body and to the tail of pancreas and in points of phrenic nerve and paravertebral points
are not determined.

URINARY SYSTEM
Visible pathology of the lumbar region is absent. Edema, hyperemia, and swelling in both
sides of loin are absent. Kidney are not palpable. Palpation of the kidney region is
painless. Palpation along the course of the ureters is painless. Pasternatskov symptom is
negative on both sides. The urinary bladder is not palpable.

ENDOCRINE SYSTEM
The height of patient is normal, according to her age. No obesity. Hair growth are normal
and no symptom of hair falling. Absence of neurophysic disorder.
Ocular symptoms (Graefes,Kochers,Moebius,Stelwags, Dalrympls) are negative She
do not suffer from exophthalmia and enopthalmus.
Secondary sexual characteristics are well developed
No enlargement of thyroid gland during palpation.

BLOOD SYSTEM
Haemorrhagia on skin and the mucous membrane are absent.
Skin is body-color pale pink with pigmentation and is dry.
The patient has normal taste or olfaction
During palpation and tapping, there are no pain and tenderness in flat bones or epiphysis of
tubular bones.
Skin above the lymph nodes not changed.
Other group of lymph nodes are impalpable except for submandibular and inguinal lymph nodes
are palpable with size of 1cm in diameter, rounded, smooth surface, elastic consistence, mobile,
not adhered to the skin, subcutaneous fat or with other lymph nodes and is painless.
Spleen is not palpable.
The borders of spleen dullness are determined between 6 cm in transverse diameter and 11 cm in
longitudinal diameter.

NERVOUS SYSTEM AND PSYCHIC STATE

The patient is fully competent in place and time. Sleep is normal. Speech is correct,
elocution. Thinking is logical. Gait is regular The patient in Rombergs pose is steady.
Paresis and paralysis are absent. Pupils are of identical size, react on light. Nystagmus is
absent.

4. Initial Diagnosis
After collecting all information of anamnesis, and also results of objective examination of
patients reveal symptoms which indicate initial diagnosis as acute lobar pneumonia at the
upper left lobe of lung. Further additional investigations will be done to confirm final
diagnosis.
Following syndromes:
1. Painful syndrome with localized, non-irradiating pain at the upper left part of
chest indicating irritation of pleura and increased pain during coughing.
2. Infectiously-toxic (high temperature with its increasing from morning to evening,
shivering, chill, general weakness) Such syndrome can develop as reaction of the
body on toxin of bacterial or virus infection.

5. RESULTS OF ADDITIONAL METHODS OF

INVESTIGATIONS
1. Analysis of Blood
Hemoglobin 120 g/L
Erythrocyte 4.1 x 1012/L
Reticulocytes 0.5%
Colour Index 0.8
Thrombocytes 190 x 109/L
Leucocytes 14 x 109/L
Eosinophils 1%
Basophils 0%
Stab 16%
Segmented 56%
Lymphocytes 23%
Monocytes 4%
ESR 28mm/h
Conclusion: Presence of leucocytosis, regenerative shift to the left, acceleration of
ESR indicate inflammatory process.

Analaysis of the urine:

a. Colour is saturated-yellow
b. Transparence is insignificant lowered
c. Mucus is in moderate amount
d. Specific gravity is 1.017
e. Protein is 0.033 g/L
f. Sugar negative
g. Erythrocytes fresh, 5-7 in f. v.
h. Leucocytes 8-10 in f.v.
Conclusion: Insignificant proteinuria, microhematuria can be due to the reaction
of the organism on high fever and intoxication.

Study of the Sputum:

Macroscopic:
Amount 15ml
Colour Rusty
Character Mucopurulent
Consistence Semifluid
Admixture Absent
Microscopic:
Curshmanns Spirals Absent
Charcot-Leyden crystals Absent
Eosinophils 2-3 in vision field
Leucocytes 30-40 in vision field
Erythrocytes 5-6 in vision field
Squamous Epithelium 20-35 in vision field
Alveolar Macrophages with crystals of hematoidine
Bacterioscopical Analysis
Tuberculosis mycobacteris absent
Another microorganisms streptococcus

Conclusion : Presence of mucopurulent character, semi fluid consistence, increased

amount of leucocytes and squamous epithelium, presence of streptococcus indicate
inflammatory process, rusty colour and alveolar macrophages with crystals of
hematoidine are characteristic of congestion in the lesser circulation. This pathology
can be in lobar pneumonia.

Biochemical research of the blood:

a. C-reactive protein +++
b. Total plasma protein 75g/L. Albumins 49% Globulins 51%
c. Alpha 1 8% Alpha 2 12% Beta 11 % Gamma 21%
Conclusion: Present of Dysproteinemia (characteristic for actue inflammatory
process)

5
6

Analysis of the feces on eggs of the intestinal worms is negative

X-ray examination of lung:
a. Marked darkness of upper lobe of left lung.
Conclusion: Characteristic for upper lobar pneumonia of left lung.

6. FINAL DIAGNOSIS AND ITS SUBSTANTIATION

The findings of the additional investigation of the patient (X-ray): showed marked
shadowing of the upper lobe of left lung; analysis of the sputum: rusty color,
mucopurulent character and present of leucocytes 30-40 in f.v., there are also present of
pneumococci; There is present of Dysproteinemia in biochemical research of blood, make
it possible to formulate the following final diagnosis:

MAIN DISEASE: Acute Lobar Pneumonia of Upper Left Lobe of Lung

COMPLICATION: ACCOMPANYING DISEASE: -

7. FUNDAMENTAL TREATMENT
A) Bed Regimen recommended
B) Diet No. 0 ( for postoperative treatment)
C) Prescriptions
1. Ceftriaxon (Antibiotic)
Rp.: Ceftriaxon 1.0
D.t.d.N 10
S. 1g to dissolve in 10 ml of water for injection IM 3 t/d
2. Lasarvan (expectorant drug)
Rp.: Tab. Lasarvan
D.S. 1 tab. 3 t/d
3. Ascorbic Acid (Water soluble vitamin)
Rp.: Dr. Ac. Ascorbinici 0.05
D.t.d.N 50
S. 1dr. PO 3t/d after meal.
4. Non- steroid Anabolic Drug Mildronate ( Antihypoxants)
Rp.: Sol. Mildronati 10% - 5.0 ml
Sol. Glucosi 5% 200ml
D.S to introduce IV 1 t/d