KHARKIV NATIONAL MEDICAL UNIVERSITY OTORHINOLARYNGOLOGY DEPARTMENT Head of the Otorhinolaryngology Department A. Lypur, MD, associate professor Teacher _________________________________ _________________________________ STUDENT’S CASE HISTOR Patient____________________________________________, _______-year-old Work place_______________________________________________________ _________________________________________________________________ Clinical diagnosis:__________________________________________________ Main diagnosis: ____________________________________________________ __________________________________________________________________ Complications______________________________________________________ __________________________________________________________________ Additional diagnosis: __________________________________________________________________ Student ______________course ______________faculty ___________________group First, second name _________________________ Kharkiv Complaints __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Medical history: considers himself ill during the __________ when the above complaints have arisen. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Life history: Virus Hepatitis_____, Tuberculosis____, Diabetes mellitus _____ Venereal disease _____ Allergic history without features. Intolerance ________________ There was no blood transfusion and its components. History of life without features. Living, working and living conditions are satisfactory. Transferred diseases, operations ____________________________________________________________________ ____________________________________________________________________ Heredity is not burdensome. Habits: smoking, addiction to alcohol. Objectively: the patient's overall condition is satisfactory, moderate, severe. Proper constitution, elevated, good, satisfactory nutrition. Skin and visible mucous membranes of normal color, hyperemic, pale, cyanotic, icteric. No rash, erythematous, papular, bullous on _________________. Peripheral lymph nodes are not enlarged, enlargement of angular and maxillary, inguinal lymph nodes. Musculoskeletal system without visible pathology. Lungs auscultation: vesicular breathing, weakened, hard breathing, no wheezing, scattered, dry, wet, (left, right). Pulse ___ beats per minute, satisfactory qualities, heart tones pure, muffled, rhythmic, arrhythmic, noises are not heard, blood pressure __ / __ mm Hg The abdomen is soft, painless, abdominal organs without visible pathology, tapping in the lumbar region is painless on both sides. Neurological status: no features. Physiological departure is normal. ENT status: The outer nose is not deformed. Palpation and percussion of projection points of the nasal sinuses are painful, painless. The mucous membrane of the nose: pink, hyperemic, pale, moist, dry, swollen, deviation of the nasal septum. Nasal breathing free, complicated, persistent hypertrophy of the inferior nasal turbinates. In the nasal passages (left, right) mucous, mucous-purulent discharge. With posterior rhinoscopy without pathology, the posterior ends of the inferior nasal turbinates are enlarged, hypertrophy of the nasopharyngeal tonsil __ stage. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ The mucous membrane of the pharynx is pink, hyperemic, pale, moist, dry. Hypertrophy of lymphoid tissue in the form of granules on the back wall of the pharynx, hypertrophy of the posterior pillar, hypertrophy of the palatine tonsils ____ stage. Palatine tonsils with scar change, soldered with pillars._________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ The larynx mucosa: pink, hyperemic, pale, moist, dry, swollen. Vocal folds are evenly mobile during phonation and breathing, mobility restrictions (left, right), edema, infiltration (left, right) of the vocal fold, vestibular vocal folds (left, right), epiglottis. Voice function is not compromised (decreasing, lost).________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Right ear (AD): The external auditory meatus is wide, narrowed by infiltration, swelling of the skin, clean, covered with mucous-purulent secretions, cholesteatomic masses. Tympanic membrane is pearl-gray color, hyperemic, moving, retracted, extended. Perforation is marginal, central, total, subtotal in __________________________________________________________ quadrant, Distinctive points are visualizating well, not visible. Mucous membrane of tympanic cavity is pink, hyperemic, pale, wet, dry, swollen, granulation, polyp ____________________________________________________________________ The patency of the auditory tubes ___ stage. Hearing: whispering ____ m. speaking____ m. Left ear (AS): The external auditory meatus is wide, narrowed by infiltration, swelling of the skin, clean, covered with mucous-purulent secretions, cholesteatomic masses. Tympanic membrane is pearl-gray color, hyperemic, moving, retracted, extended. Perforation is marginal, central, total, subtotal in __________________________________________________________ quadrant, Distinctive points are visualizating well, not visible. Mucous membrane of tympanic cavity is pink, hyperemic, pale, wet, dry, swollen, granulation, polyp ____________________________________________________________________ The patency of the auditory tubes ___ stage. Hearing: whispering ____ m. speaking____ m. PRELIMINARY DIAGNOSIS (justify preliminary diagnosis using complaints, history, review) _________________________________________________________________ _________________________________________________________________ _ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Scheme of examination (make a scheme of examination using laboratory and instrumental methods) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _________________________________________________________________ RESULTS OF ADDITIONAL RESEARCH METHODS Blood test Urinary test Date___________________________ Date______________________ RBC 10* /л___________ Hb g/l_______________________ WBC 10*9/л_____________ PLT 10*9/л____________ GRAN: ______________% LYM_________________% MON__________________% EOS_________________% _______________ Conclusion ___________________ ___________________________ ___________________________ count _______________ color__________________ transparency _____________ consistence______________ PH____________________ protein__________________ RBC_____________ WBC______________ bacteries________________ mucus ___________________ Conclusion ____________________ _____________________________ _____________________________ 12 Biochemical tests of the liver Blood group, Rh factor Data___________________________ Data________________________________ Total bilirubin__________ _______________________________ Connected _____________ _______________________________ Free ______________ RW-test ALT/AST______________________ Data___________________________ Alkaline phosphatase ____________ _______________________________ Timol _____________ _______________________________ B - lipoproteins _____________ _______________________________ Conclusion___________________ ECG ___________________________ Data_______________________________ ___________________________ ______________________________ ___________________________ ______________________________ ___________________________ ______________________________ Other methods ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Hearing Right ear (AD) Wispering Speaking С128(П=90сек.) С128(П=50сек.) С2048(П=40сек) Rinne Veber Federiche Left ear (AS) Wispering Speaking С128(П=90сек.) С128(П=50сек.) С2048(П=40сек) Rinne Veber Federiche Appellation (-о-о-о-) – air conduction, (-х-х-х-) – bone conduction. Conclusion_____________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ____________________________________________________________________ Tympanometry: type А, type В, type С Conclusion_____________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Vestibular system Right side Tests Left side Subjective feelings Spontaneous nystagmus Finger-nose test Finger-finger test Vodak-Fisher test Stability in the Romberg pose Straight walk Flang walk Adiadokhokinez Press test Conclusion_____________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ____________________________________________________________________ ______________________________________________________________________ DIFFERENTIAL DIAGNOSIS __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 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__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ FINAL СLINICAL DIAGNOSIS (Diagnosis clinika) (to substantiate the final diagnosis taking into account all complaints, histories, objective study data, using ancillary research methods, make a diagnosis based on modern clinical classification of the disease (major, complication of major, concomitant) ____________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 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__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ COMPLICATIONS (list all possible complications of the disease) ____________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Etiology and pathogenesis of the disease __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 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__________________________________________________________________ Prognosis (regarding recovery, life, work capacityі) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ DISEASE JOURNAL Data The condition of the patient Treatment Literature _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Teacher's note_____________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ ____ Mark_____ SIGNATURE OF TEACHER:_________________
