UNEVERSITATEA DE STAT DE MEDICINA SI

FARMACIE“ NICOLAE TESTEMITANU “ DIN

REPUBLICA MOLDOVA

Department Of Pneumophtisiology

Medical Report

Patient's Name: Simin Andrei

Teacher: Presented to Dr. Osipov Tatiana

Name : Sirhan Mohammad

Group: M1549

Faculty: Medicine Nr.2

Chisinau 2018
 I. Inquiry - interview
1) GENERAL DATA:
Name: Simin Andrei
Gender: Male
Age: 35 years old
Date of birth: 27/12/1983
Date of admission: 11/03/2019
He don’t work now
Weight: 80kg
Height: 182cm

2) COMPLAINS:
 Epigastric pain
 Coughing
 Hemoptysis
 Headaches
 Slightly increase in temperature 37-37.5
 Thoracic pain
 Pain in foot during walking
 Visual disturbances in morning

3) History of the present disease:

 Onset of the disease: before 8 years and its get worse by
time (chronic).
 First symptoms: Hypertension, nicturia – frequent
nighttime urination, epigastric pain.
 by time these symptoms increase and get more severe.
 For hypertension he take captopril
 Dialyze for kidney failure.
4) Past patient history:
 Birth place – Chisinau
 Patient health in birth – normal physical and mental
development.
 Normal life conditions
 Stopped working
 Normal patient diet
 No physical activity
 No previous operations/trauma
 Parents and family members are healthy
 No food or drugs allergy
 Harmful habits: smoking and alcohol consumption.

II. Objective examination

1. General inspection:
 Mental status: patient is fully conscious.
 Posture of patient: Active.
 Constitution: Asthenic.
 Temperature: 37-38 C
 Body movement: the patient walks normally
 State of nutrition: normal 1.5cm
 Tegument: intact (normal color of the tegument).
 Edema: had.
 Abdominal mass / lesion: absent.
 Thorax: no scars or lesions.
 Skin: pale, elastic, cyanotic in the morning around eye.
 Peripheral edema is present in the morning in the face
especially around eyes and in legs.
 Lymph node are not palpate able
 Muscular system with normal development and normal
strength.
 Bones with no deformities or defects.
 Joints are normal
 No abnormalities in the extremities

2. Respiratory system
a. Complains:
 Dyspnea: present
 Cough: present
 Sputum: present
 Expectoration with blood: present
 Pain in the chest: present in different location
 Asphyxia: sometimes

b. Inspection:
 Normal configuration of the thorax symmetric
 Asthenic chest
 No spine deformities
 Abdominal breathing
 Normal breathing rhythm 20 times per min
 Involvement of thoracic muscles during breathing

c. Palpation:
 The chest is elastic
 Some pain by checking the painful points
 vocal fremitus decreased a little pit
 The vertebral column is straight, no deformities, no
kyphosis, no lordosis, and no scoliosis.
d. Percussion:
 Dull sound instead of resonance in some point of the
thorax

e. Auscultation:
 Bronchial in the trachea in neck
 Broncho vesicular breathing
 Crepitation + moist rales (crackles)
 Bronchophony increased

3. Cardiovascular system
a. Complains:
 Pain in the heart: no
 No dyspnea
 No cardiac asthma
 No palpitation
 Cough
 Hemoptysis
 Edema in face and legs

b. Inspection:
 The condition of the neck vessels: no pathological
pulsation of the carotid artery, no dilation of veins and
jugular veins, no positive pulse.
 Normal carotid pulsation
 No cardiac beat
 No epigastric pulsation was observed
 No cardiac humpback
 No edema
 No orthopnea
 The skin is pale
 No observed pulsation of the aorta
 Normal posture, not orthopnea.
 No caput medusa
 Visible pulsation on his left hand due to the presence of
fistula and catheter for dialysis of the blood brachial artery

c. Palpation:
 Heart apex: was felt in the left 5th intercostal space 1,5cm
toward the sternum from the left midclavicular line.
Width=1,5-2cm height=moderate strength= moderate
resistance=moderate
 Pulse 84 per min
 No systolic and diastolic thrill was felt (cats purr)
 No strong abdominal aorta pulsation was felt
 No strong pulsation of the RV was felt
 No strong pulsation of the portal vein was felt
 Brachial artery

d. Percussion:
 During percussion we revealed that the heart is slightly
enlarged due to hypertension and it deposited slightly to
the left.
 Other border of the heart is normal except left one
 Normal vascular bundle length

e. Auscultation:
 Regular rate and rhythm
 regular S1 and S2 in the auscultation points
  mitral valve at 5th intercostal space to the left of
midclavicular line - normal
 aorta 2nd intercostal space in midclavicular line to the right
of sternum which is slightly increased
 pulmonary trunk 2nd intercostal space in midclavicular line
to the left of sternum - increased
 tricuspid valve at the lower part of xiphoid process –
normal
 Murmurs: no systolic murmur , best heard above the
heart apex ( 5th left intercostal space ) and it radiate to the
axilla.

4. Gastrointestinal system
a. Complaints:
 Pain in abdomen: epigastric pain
 Dyspeptic manifestation: no belch, heartburn, sickness,
or vomiting
 Appetite: no change
 Swallowing: no swelling
 Thirst : there is no dryness in the mouth
 Weight: increase when water is accumulated without
dialysis
 Bleeding : no esophageal or gastrointestinal bleeding , no
blood observed in the stool or with the vomited content
 b. Inspection:
Examination of the oral cavity:

 Oral cavity: no smell , rose mucous membranes, no ulcers

were observed
 Tongue : slightly white , normal not enlarged or atrophied
nipples, moist , no ulcers
 Gum : paleness
 Teeth: the patient didn't pass some dental therapies.
Examination of abdominal cavity:
The patient has a soft abdomen, it is participating normally in
the respiration, symmetric, no development of venous collaterals
(caput medusa), no visual peristalsis of the stomach and
intestine. No painful point by coughing.

c. Auscultation:
The intestinal peristalsis were auscultator one every 8-10
second, clear sound.

d. Percussion:
By percussion was relived tympanic sound, there is signs of the
presence of liquid in some region due to decreased tympanic
sound and no fecal gas in the abdomen.

e. Palpation:
Superficial palpation: there is pain in epigastric region, the
abdominal muscles are not tensed, no infiltration or tumor-
shaped formation, no divergence of abdominal muscles.
Negative Blumberg symptoms. No hernias.
Deep palpation: by sequenced palpation (Obraztsov-Strajesco)
of : sigmoid , cecum , terminal position of ileum , ascending and
descending colon, large curvature of the stomach , pylorus were
observed that the borders of the intestine are well felt , smooth
not hard , no dislocation , no pain and no additional masses .pain
only in epigastric region.

f. Succession:
No splash murmurs in the stomach and intestine

Liver and Gallbladder:

Some disease of liver but the patient didn’t know the type of
disease.
Palpation of the area of Gallbladder:
Can’t fell its enlargement, but the patient fells pain by palpating
this area
Spleen:
The spleen wasn’t accessible for palpation. Normal
Pancreas:
With palpation, there is no enlargement or pain in it.

5. Endocrine system
a. Complaints:
There is nothing of these signs: thirst , polyuria , skin
itching , accelerated appetite , loss of weight , excessive
eating , perspiration , shiver , muscle fatigue .
b. Inspection:
No observed weight loss, the patient well developed, no
acromegaly, normal face shape ( not moon shape ), no
 exophthalmia , no enlarged thyroid gland , no cicatrices
from stretching the skin.
Normal distribution of the hair on the patient's body.
c. Palpation:
The thyroid gland is soft, not enlarged, without any
nodules

6. Nerve-Psychic condition & sense

organs
Consciousness: clear
Mood: stable
Sleeping: good, 5-7 hours per day.
Headaches: present
By the examination of the sense organs hearing, vision, smell,
speech, feeling (skin) -- normal sensation was obtained.

7. Urinary System:
a. Complaints:
- Edemas: edemas under the eye or in the face and legs
- Pain: moderate pain in the lumbar area.
- Urination: Dysuria

b. Inspection:
No swelling or hyperemia in the lumbar area
Also no edemas on the lumbar area and other places sometimes
in abdomen.

c. Palpation:
The right kidney can be palpated. In case of enlarged kidney
hypertrophied, kidney was palpated slight pain; also there is
slightly pain by palpating the area over the pubis.

d. Percussion :
Positive symptom of pasternanacki's (Giordano) at right
side (pain).

8. Laboratory tests

a. General blood analyze

 Hematologic:
 02/11/2018:
 RBC -2.38*10^3/uL decreased
 WBC – 9.36 *10^6/uL increased
 HB – 6.8 g/dL decreased
 Ht – 24.21% decreased
 MCV – 101.7 increased
 MCH – 28.56 pg normal
 MCHC – 28.07 g/l decreased
 Neutrophils – 77% increased
 Lymphocyte – 11.6% decreased
 Monocyte – 7.97% normal
 Eosinophils – 1.95% normal
 Basophils -1.5% increased
 ESR – 32mm/h increased
 Morphology:
 Hypochromic++
 Poikilocytosis +
 Biochemic:
 Uree – 30.1µmol/l very high
 Creatinine – 776.8 µmol/l very high
 ALT +AST – normal
 Amylase – normal;
 Glucose – normal
 Total protein – normal
 Potassium – 6.4 µmol/l increased
 Sodium – normal
 Immunologic:
 Total PSA – 0.75 ng/ml normal
 MRS – negative
 Blood group – O Rh +
 HIV - negativ
 Fibrinogen – 4g/l normal
 Urine test:
 Urination 24hours – 800-1000 ml
 RBC – present
 Red cell cast – present
 WBC – present
 Protein – present increased in 24 h
 Sputum test:
 Red
 Seropurulent
 Viscous
 Small epithelium
 Unique macrophage
 Leucocyte 3-5 c/v
 Erythrocyte >150c/v
 Neutrophils 100%
 9. Instrumental investigations
*) Chest - Xray: left segment 6 bronchopulmonary opacity
1 cm , near this opacity small nodular opacities , different
size and intensity with unclear borders , induration of the
helium.
*) Pulmonary CT: In left lung S6S8S9 , multiple nodular
opacities , Infiltration zone from 0.4 – 2.7 cm with zone of
destruction.
Mantoux test: positive 16 induration after 72 hours

AFB –
MBT +
(bacteria is resistance to isoniazid , rifampicin .
streptomycin)

according to the results of clinical and paraclinical

investigations it can be established the diagnosis :
Pulmonary infiltrtive Tuberculosis, Round type, left lung ,
progressive phase (iniltration, dissemiantion) , AFB
negative, new case.

10. Diagnosis:

Treatment : Pharmacological treatment:

• The treatment deal in that case is to deal with Multi drug
resistance mycobacterium Tb, which can’t be treated with the
first line anti tuberculosis drug .
• Initial phase:
6 months at the hospital :
Kanamycin
Levofloxacin
Parazynamide
Cyckoserin
Ethinamide
Contiuation phase:
Levofloxacin
Parazynamide
Cyckoserin
Ethinamide
follow up by chest x-ray and smear microscopy

My conclusion:
According to the result I think the best way to treat the patient is
to reduce the fluid retention to avoid appearing of edemas of
face and legs that is by providing the patient to do every day at
least one dialysis and blood transfusion of 250 ml per day
because of the blood loss from cough and from urine so that will
reduce most of the symptoms which appear.
In the end he should stay under vision and to give him enough
attention to prevent him from getting worse and worse until the
end of treatment ,after that during his normal life he should be
long time under attention of the hospital to avoid any future
reoccurrence or evolution of the diseases.