Diagnosis: acute bilateral sinusitis.
Patient's complaints.
Complains of nasal congestion, not abundant mucopurulent discharge.
- Disease history.
She fell ill a month ago: a runny nose, cough, fever up to 37.5 were noted. The patient was prescribed the following treatment: warming up the nose, vasoconstrictor drops in the nose (pinasol). The effect was minor. The subfebrile temperature was maintained for a month. There was an abundant discharge from the nose of a mucopurulent nature, appeared headache in forehead, aggravated by stooping forward. To clarify the diagnosis and conduct
appropriate treatment by the local doctor, the patient was referred
in the ENT department of the Design Bureau.
5 Anamnesis of life, family history.
- allergic history.
Allergy to drugs (penicillin) and food products(sweet, citrus fruits, milk), as well as on animal hair.
- Past illnesses.
Chicken pox, lymphadenitis. Previously, acute respiratory infections were ill once a year, for the last two years - once a month. She has been suffering from neurodermatitis since the age of three.
Alcohol is consumed in moderation.
- Objective research.
The general condition is satisfactory. The position is active. Expression
faces are meaningful. Behavior is normal. The attitude towards the disease is adequate.
Consciousness is clear. Food is normal. The physique is correct.
The constitution is asthenic.
The skin is dry, natural color. In the area of the flexion surfaces of the elbows and knee joints papular-crustal rash is observed. Mucous
wet pink.
Peripheral lymph nodes are not enlarged, on palpation
painless.
The muscles are well developed, the tone is normal, on palpation
painless.
The cardiovascular system.
Pulsations and bulging of the cervical veins are not observed, "heart hump"
missing. The precordial region is painless on palpation.
The apex beat is located in the 5th intercostal space on the left side of the midclavicular
lines, unspilled, resistant, low, with an area of 2 square cm.
Limits of absolute stupidity:
- right: in the IV intercostal space along the right edge of the sternum
- left: in the 5th intercostal space along the left midclavicular line
- upper: on the 3rd rib along the left parasternal line.
Heart sounds are clear, rhythmic, there are no side murmurs. Pulse 80 per minute
rhythmic, synchronous, normal filling and tension, wall
arteries are elastic. HELL
- 110/70 mm Hg
Respiratory system.
The nose is straight, breathing through the nose is difficult, there is a scanty mucopurulent discharge. Larynx -
forms. In the act of breathing, both halves of the chest participate evenly and
equally. Type of chest breathing. Auxiliary muscles in the act
respiration is not involved. NPV - 20 per minute. rib cage on palpation
comparative percussion heard a clear pulmonary sound in all areas
chest. Upper and lower borders of the lungs with topographic
percussion are not changed. Breathing is vesicular, no wheezing.
Digestive organs.
Appetite is not reduced. The oral cavity is pink in color, without damage, shiny.
Tongue pink, wet. The teeth are saved. Gums, soft and hard
the sky is pink, moist, without raids, cracks, ulcers. Round belly,
not enlarged, participates in the act of breathing. Peristalsis of the stomach and intestines
it can be seen that there are no venous collaterals on the anterior abdominal wall. At
on superficial palpation, the abdomen is painless, soft, muscle tension
the anterior abdominal wall is not marked; tumors, hernias, divergences of straight lines
no abdominal muscles. On deep palpation, organs abdominal cavity
painless, soft consistency, not enlarged. Liver on the edge of the costal
arcs. Percussion borders of the liver are not changed. The spleen is not palpable. At
auscultation listened to peristalsis of the intestines and stomach. friction noise
peritoneum and vascular noise are absent.
urinary organs.
There is no swelling, redness in the projection area of the kidneys. Urination
free, painless, 6-7 times a day, straw-yellow urine color, without
pathological contaminants. Kidneys are not determined by palpation. Symptom
Pasternatsky is negative on both sides.
- Investigation of ENT organs.
Nose and paranasal sinuses.
The shape of the external nose is correct, deformities of the bones and cartilage of the walls
visually and palpation is not detected. Palpation of the anterior wall of the frontal sinuses
at the exit site of the first and second branches of the trigeminal nerve is painless. There is moderate pain in the anterior wall of the maxillary sinuses.
With anterior rhinoscopy, the entrance to the nose is free, the nasal septum is not
displaced, located in the midline.
The mucosa is hyperemic, moderately edematous.
the nasal passages are free, the shells are not changed. Breathing is difficult, there is scanty mucopurulent
detachable, the sense of smell is not broken.
Oral cavity.
The oral mucosa is pink, moist, clean. Orifices of excretory ducts
salivary glands are clearly visible. Teeth are sanitized.
The tongue is clean, pink, moist, the papillae are moderately expressed.
Oropharynx.
The palatine arches are contoured. moist, clean, pink. The tonsils are not enlarged. The back wall of the pharynx is moist, pink. The lymphoid tissue is
changed. The pharyngeal reflex is preserved.
Nasopharynx.
The vault of the nasopharynx is free. The pharyngeal tonsils are not changed. Mucous
pink, wet Opener in the middle line. Choanas are free. nasal
shells are not hypertrophied. The mouth of the auditory tubes is good
differentiated, free. Pipe tonsils and side rollers are not
increased.
hypopharynx.
Mucous pink, moist, clean. The lingual tonsil
hypertrophied. Vallecules are free. Piriform sinuses are free.
The epiglottis is movable, the passage to the larynx is free.
Regional lymph nodes (submandibular, deep cervical,
prelaryngeal, pretracheal) are not enlarged. Larynx correct form,
passively mobile, mucous pink, moist and clean. During laryngoscopy, the mucous membrane of the epiglottis, the area of the arytenoid cartilages, interarytenoid space and vestibular folds is pink, moist with a smooth surface, the vocal folds are gray, not changed, symmetrically mobile during phonation, they close completely. Subglottic space is free.
Right ear.
Left ear.
The auricle is of the correct shape. The contours of the mastoid process are not
changed. Palpation auricle, mastoid process and tragus
painless. The external auditory canal is wide. Contains a moderate amount of sulfur. There is no pathological content. The tympanic membrane is gray with a pearly hue. The short process and handle of the malleus, light cone, anterior and posterior folds are well contoured.
Hearing Passport.
right ear
left ear
AD + 30 15 s=64 s=2048 6m >6m
W CA CM Ji Js v V
AS + 30 15 c=64 c=2048 6m >6m
Conclusion: sound perception and sound conduction is not disturbed.
Vestibular Passport.
AD — — — — 20 60ml
St M Nуs Nуp Nуr Nуcal
AS — — — — 20 60ml
Conclusion: Vestibular functions are not disturbed.
- Additional research methods.
a) X-ray of the paranasal sinuses: intense homogeneous darkening of both maxillary sinuses compared to the orbits.
- Clinical diagnosis.
Acute bilateral sinusitis.
- Justification of the diagnosis.
The diagnosis was made on the basis of:
- complaints at admission: nasal congestion, profuse mucopurulent discharge, headaches in the forehead, aggravated by bending forward.
- Anamnestic data: the symptoms of a respiratory disease were not completely stopped by the ongoing treatment - there was an abundant mucopurulent discharge and constant subfebrile condition, later a headache appeared.
3) X-ray of the paranasal sinuses: intense homogeneous darkening of both maxillary sinuses compared to the orbits.
- Treatment plan.
Treatment is conservative. Aimed at improving the outflow of secretions from the maxillary sinus by expanding the anastomosis connecting the sinus with the nasal cavity.
- common mode
- table number 15
- vasoconstrictor nasal drops (naphthyzinum, sanorin, galazolin) 5 drops in each nostril 3 times a day
- hyposensitizing agents (pipolphen, suprastin, tavegil 1 t. 3 times a day
- sulfanilamide preparations (sulfadimezin 1t. 3 times a day)
- physiotherapeutic effect (UHF, UFO)
Head Chair : Obydennikov G. T.
Teacher : Taranova S. V.
Disease history
Diagnosis : Acute, purulent bilateral sinusitis
Performed :
group 403 student
Pozharskaya I. N.
Vladivostok 2006
Passport part:
Age: 14 years old
Education: student of school No. 23 in Vladivostok
Home address: Vladivostok, st. Svetlanskaya, 165, apt. 16
Receipt date: 28.10.2006.
COMPLAINTS ON ADMISSION:
Complaints: constant, intense, throbbing pain in the area of the projection of the maxillary sinus, in the area of the projection of the cells of the ethmoid labyrinth, aggravated when entering cold air, bilateral nasal congestion, mucopurulent discharge from the nasal passages, headache, general weakness, an increase in body temperature up to 37.5 ° C.
ANAMNESIS MORBI
The patient often suffers from colds with a frequency of about three times a year. He notes complaints of discharge from the nose of a mucopurulent nature. In this situation, against the background of frequent hypothermia, weakened immunity, acute, purulent sinusitis developed. The onset of the disease is associated with hypothermia. The state of health worsened: pains in the area of the maxillary sinus became constant, intense, pulsating, began to intensify when going outside, pains in the area of the projection of the cells of the ethmoid labyrinth joined, weakness, weakness appeared, the discharge became mucopurulent. In this regard, they turned to the Children's Clinical Hospital and on November 28, at the height of pain, the patient was examined by an otorhinolaryngologist, the diagnosis was made: "Acute, purulent bilateral sinusitis", and further examination and puncture of the maxillary sinus with subsequent treatment were prescribed.
ANAMNESIS VITAE
Brief biographical information. Born in Vladivostok, Primorsky Territory on August 28, 1994. The first child in the family. Breastfed up to 10 months. Developed normally. In mental and physical development does not lag behind peers. Studying in the 6th grade. School performance is good. Attends English courses.
Epidemiological history: not weighed down
Allergic history: not weighed down
Family history and heredity: not weighed down
Bad habits: Not
Weather sensitivity and seasonality: frequent colds in the autumn-winter period
INQUIRY BY SYSTEMS:
General state: There is a general weakness, increased fatigue, a feeling of weakness, head areas in the temporal region. Weight loss or development of fullness is not observed. There is no thirst, there is no dryness and itching of the skin. Furunculosis, no rash. Temperature rise to 37.5.
Trembling of the extremities, convulsions, gait disturbances are not observed. Skin sensitivity is not broken.
Respiratory system:
Cardiovascular system: There are no pains in the region of the heart, palpitations, sensations of interruptions in the region of the heart. There is no sensation of pulsation. There are no edema. The feeling of heaviness in the left hypochondrium denies. Intermittent claudication (pain in the calf muscles when walking) is absent.
The digestive system: There are no complaints. There is no smell from the mouth, no dyspeptic phenomena are observed. Pain and burning in the tongue denies. There is no dry mouth. Salivation is not noted. Appetite is good; there is no perversion of appetite. There is no aversion to food, there is no fear of eating. Swallowing and passage of food through the esophagus is free. The abdomen is rounded, symmetrical and participates in the act of breathing. The subcutaneous venous network is not expressed. There are no hernias and discrepancies of the rectus muscles.
There are no pains in the abdomen. Heartburn, belching, nausea, vomiting are absent.
urinary system. There are no complaints. There are no pains in the lumbar region. There are no edema. Urination is free. There is a predominance of daytime diuresis. The color of urine is straw yellow. Urine without impurities. There is no involuntary urination. The lumbar region is not changed. The kidneys lying down and standing are not palpable. The bladder is not palpable.
Musculoskeletal system. There are no complaints. Pain in bones, muscles, joints denies. There is no swelling or deformity of the joints. Reddening of the skin in the area of the joints, no increase in local temperature is noted. There is a curvature of the spine (scaliosis). There are no restrictions on movement in the joints. Pain and difficulty in movement in the spine are absent. On palpation, the joints are painless.
Endocrine system. There are no complaints. There are no growth or body defects. Weight disorders (obesity or wasting) are not observed. Violations of primary and secondary sexual characteristics are not observed. There are no violations of the hairline (excessive development, its appearance in places unusual for this sex, hair loss).
Sense organs. There are no changes in hearing, touch or taste. The sense of smell is broken. On the part of the visual analyzer, bilateral myopia is observed.
STATUS PREASENT
General examination of the patient. The general condition is satisfactory. Consciousness is clear. The position is active.
Facial expression is calm. The gait is free. The physique is correct. The constitutional type is normosthenic. Height - 162 cm, weight - 46 kg.
The patient's nutrition is satisfactory. The fatty layer is poorly expressed.
Depigmentation is absent, skin turgor is preserved. Humidity is normal. No dry skin, no flaking, no rash.
Groups of lymph nodes - occipital, ulnar, inguinal, popliteal - are painless on palpation, mobile, densely elastic in consistency, not soldered to the surrounding tissue and to each other.
The degree of development of the muscular system is normal, there is no trembling or tremor of individual muscles. Spastic paralysis of the extremities, flaccid paralysis, no paresis.
The bones of the skull, chest, pelvis and limbs are not deformed.
Joints: the configuration is normal, there is no swelling. Skin hyperemia and local temperature increase in the joint area were not detected. The volume of active and passive movements is free. There is no pain on touch or movement. Crunch, fluctuation, contractures, ankylosis are absent.
Special inspection.
Head oval, normal size. The structure of the brain and facial parts of the skull is proportional. Superciliary arches are expressed moderately.
Hair. Hair type - female. Hair loss is not observed.
Eyes. The width of the palpebral fissure, the condition of the conjunctiva, the reaction of the pupils to light are normal.
Nose undeformed in shape, bilateral swelling is noted.
Lips. The color corresponds to the norm, there are no cracks in the corners of the mouth.
Neck correct form, without visible pulsation of the carotid arteries, symmetrical.
Thyroid not enlarged, painless on palpation.
Chest examination. Static inspection: chest normosthenic shape, symmetrical, pathological curvature of the spine, shoulder blades slightly behind the chest.
Dynamic Inspection: there is no lag of one of the halves of the chest in the act of breathing. Breathing abdominal type, normal depth, rhythmic, RR = 17
Palpation. The chest is painless, elastic, the intercostal spaces are not dilated. Voice trembling on the symmetrical halves of the chest is felt with equal force.
Comparative and topographic percussion lungs within the physiological norm.
Auscultation of the lungs. On the anterior surface of the chest, vesicular breathing is heard, in the interscapular region at the level of 3-4 thoracic vertebrae - bronchial breathing. Adverse breath sounds are not heard.
Circulatory organs.
Inspection areas of the heart: No complaints. Cardiac hump, cardiac impulse are not visually determined.
Palpation. The apex beat is determined in the 5th intercostal space to the left, 1 cm medially from the mid-clavicular line. There is no cardiac impulse, the symptom of "cat's purr" in the places of the projection of the heart valves on the chest is not determined.
Percussion. The borders of the heart are within the normal range.
Auscultation. 2 tones and 2 pauses are heard. The tones are clear and rhythmic. No heart murmurs are heard.
Digestive organs.
Oral examination. The mucous membrane of the oral cavity is pink, moderately moist. Carious teeth - 1 (seven). Gums without pathology. The tongue, without plaque, is moist, there are no cracks and ulcers, there is no swelling. The tonsils are not enlarged.
Examination of the abdomen. Configuration: flattened. There is no swelling. The stomach does not participate in the act of breathing. The peristalsis of the stomach and intestines is not visible. There are no dilated saphenous veins.
Superficial approximate palpation of the abdomen according to Obraztsov-Strazhesko. The abdomen is soft and painless. The symptom of "muscular protection" is absent. There is no symptom of peritoneal irritation (Shchotkin-Blumberg symptom). The state of “weak spots” (umbilical ring, white line, inguinal rings) is normal. There is no fluctuation symptom. Divergence of the rectus abdominis muscles is not observed.
Deep sliding topographic methodical palpation of the intestines and stomach according to Obraztsov-Strazhesko and Vasilenko within the physiological norm.
Abdominal percussion characterized by determining the presence of fluid and gas in the abdominal cavity. Tympanitis is not pronounced, therefore, there is no accumulation of gas. There is no ascites. Mendel's sign was not detected.
Auscultation of the abdomen. There is no noise of friction of the peritoneum. Intestinal peristalsis is normal.
Study of the liver. Bulging, expansion of skin veins, spider veins are not observed.
Percussion of the liver. Percutere: borders of the liver are normal.
Palpation of the liver. The edge of the liver is sharp, even, soft, easily tucked up and insensitive. The size of the liver according to Kurlov: the first size is 10cm; the second size is 9.5; the third size is 8 cm.
Study of the gallbladder. The gallbladder is not palpable. There is no protrusion in the area of the gallbladder projection in the right hypochondrium. There is no pain on superficial palpation in this area.
Study of the spleen. When examining the hypochondrium in the area of the projection of the spleen on the left lateral surface of the chest and the left hypochondrium, no bulging is noted.
Percussion of the spleen. The length along the 10th rib is 6 cm. The diameter (perpendicular to the length) is 4 cm. The readings are normal.
Palpation of the spleen. Not palpable.
Examination of the pancreas.
Percussion of the pancreas. Determined: head - the middle of the right costal arch and the navel; body - xiphoid process and navel; tail - the middle of the left costal arch and the navel.
Palpation of the pancreas. Not palpable.
Urinary organs. There is no displacement of the kidneys. The lumbar region with tapping on the right and left (Pasternatsky's symptom) is painless. On palpation, the bladder is painless.
Study of the neuropsychic sphere. Consciousness is clear. Intelligence is normal. Memory is good. Sleep is normal. Speech is normal. The coordination of movements is not disturbed. The gait is free. No convulsions, no paralysis. Reflexes - the reaction of the pupils to light, pharyngeal, corneal - are normal. Rigidity of the occipital muscles is not noted.
Endocrine system. The thyroid gland is normal in size and consistency. There is no hyperthyroidism. Eye symptoms (exophthalmos, Graefe, Möbius, Stelvag) are absent. There is no skin pigmentation.
Provisional diagnosis: Acute, purulent bilateral sinusitis.
Examination plan:
- Additional research methods.
- complaints at admission: nasal congestion, profuse mucopurulent discharge, headaches in the forehead, aggravated by bending forward.
- Anamnestic data: the symptoms of a respiratory disease were not completely stopped by the ongoing treatment - there was an abundant mucopurulent discharge and constant subfebrile condition, later a headache appeared.
- common mode
- table number 15
- vasoconstrictor nasal drops (naphthyzinum, sanorin, galazolin) 5 drops in each nostril 3 times a day
- hyposensitizing agents (pipolphen, suprastin, tavegil 1 t. 3 times a day
- sulfanilamide preparations (sulfadimezin 1t. 3 times a day)
- physiotherapeutic effect (UHF, UFO)
- Polyp of the maxillary sinus. The polyp usually has an irregular shape on the x-ray. The polyp usually penetrates through the Hiatus sinus maxillaris into the nasal cavity (middle nasal passage). When puncturing the maxillary sinus with a polyp, blood is usually obtained. The polyp on the roentgenogram gives a characteristic grape-shaped dimming.
- Right-sided sinusitis. With sinusitis, there is also nasal congestion, irradiation of pain, purulent discharge from the nose. On the radiograph, sinusitis is visualized as blackouts with an upper horizontal level in the lower and middle thirds.
General blood analysis.
4. History of the disease.
In the ENT department of the Design Bureau.
She was born on March 17, 1985. She grew and developed according to her age.
6. Allergological history.
7. Past diseases.
9. Objective research.
Pink wet.
Painless.
Painless.
Pulsations and bulging of the cervical veins are not observed, "heart hump"
Limits of absolute stupidity:
The artery is elastic. HELL
There are no deformations, the character of the voice is normal. The cylindrical chest is painless, elastic. The voice trembling is the same on both sides. When
Urinary organs.
10. Study of ENT organs.
Nose and paranasal sinuses.
Enlarged.
Case history of sinusitis
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Russian Ministry of Health
Ivanovo State Medical Academy
Head Department: Lopatin S.B.
Lecturer: Kotilenkov M.K.
Curator: 4th year student of the 5th group
1. Passport part.
Place of residence: Ivanovo region, Podvyaznovo village
Place of study school 2
2. Date of receipt.
3. Complaints of the patient.
4. History of the disease.
She fell ill a month ago: a runny nose, cough, fever up to 37.5 were noted. The patient was prescribed the following treatment: warming up the nose, vasoconstrictor drops in the nose (pinasol). The effect was minor. The subfebrile temperature was maintained for a month. There was a copious discharge from the nose of a mucopurulent nature, a headache appeared in the forehead, aggravated by bending forward. To clarify the diagnosis and conduct
appropriate treatment by the local doctor, the patient was referred
in the ENT department of the Design Bureau.
5 Anamnesis of life, family history.
6. Allergological history.
Allergy to medicinal substances (penicillin) and food products (sweet, citrus fruits, milk), as well as to animal hair.
7. Past diseases.
Chicken pox, lymphadenitis. Previously, acute respiratory infections were ill once a year, for the last two years - once a month. She has been suffering from neurodermatitis since the age of three.
Alcohol is consumed in moderation.
9. Objective research.
The general condition is satisfactory. The position is active. Expression
faces are meaningful. Behavior is normal. The attitude towards the disease is adequate.
Consciousness is clear. Food is normal. The physique is correct.
The skin is dry, natural color. In the area of the flexor surfaces of the elbow and knee joints, a papular-cortical rash is observed. Mucous
Peripheral lymph nodes are not enlarged, on palpation
The muscles are well developed, the tone is normal, on palpation
The cardiovascular system.
Pulsations and bulging of the cervical veins are not observed, "heart hump"
missing. The precordial region is painless on palpation.
The apex beat is located in the 5th intercostal space on the left side of the midclavicular
lines, unspilled, resistant, low, with an area of 2 square cm.
Limits of absolute stupidity:
Right: in the IV intercostal space along the right edge of the sternum
Left: in the 5th intercostal space along the left midclavicular line
Upper: on the 3rd rib along the left parasternal line.
Heart sounds are clear, rhythmic, there are no side murmurs. Pulse 80 per minute
rhythmic, synchronous, normal filling and tension, wall
arteries are elastic. HELL
The nose is straight, breathing through the nose is difficult, there is a scanty mucopurulent discharge. Larynx -
forms. In the act of breathing, both halves of the chest participate evenly and
equally. Type of chest breathing. Auxiliary muscles in the act
respiration is not involved. NPV - 20 per min. chest on palpation
comparative percussion heard a clear pulmonary sound in all areas
chest. Upper and lower borders of the lungs with topographic
percussion are not changed. Breathing is vesicular, no wheezing.
Appetite is not reduced. The oral cavity is pink in color, without damage, shiny.
Tongue pink, wet. The teeth are saved. Gums, soft and hard
the sky is pink, moist, without raids, cracks, ulcers. Round belly,
not enlarged, participates in the act of breathing. Peristalsis of the stomach and intestines
it can be seen that there are no venous collaterals on the anterior abdominal wall. At
on superficial palpation, the abdomen is painless, soft, muscle tension
the anterior abdominal wall is not marked; tumors, hernias, divergences of straight lines
no abdominal muscles. Deep palpation of the abdominal organs
painless, soft consistency, not enlarged. Liver on the edge of the costal
arcs. Percussion borders of the liver are not changed. The spleen is not palpable. At
auscultation listened to peristalsis of the intestines and stomach. friction noise
peritoneum and vascular noise are absent.
There is no swelling, redness in the projection area of the kidneys. Urination
free, painless, 6-7 times a day, straw-yellow urine color, without
pathological contaminants. Kidneys are not determined by palpation. Symptom
Pasternatsky is negative on both sides.
10. Study of ENT organs.
Nose and paranasal sinuses.
The shape of the external nose is correct, deformities of the bones and cartilage of the walls
visually and palpation is not detected. Palpation of the anterior wall of the frontal sinuses
at the exit site of the first and second branches of the trigeminal nerve is painless. There is moderate pain in the anterior wall of the maxillary sinuses.
With anterior rhinoscopy, the entrance to the nose is free, the nasal septum is not
displaced, located in the midline.
The mucosa is hyperemic, moderately edematous.
the nasal passages are free, the shells are not changed. Breathing is difficult, there is scanty mucopurulent
detachable, the sense of smell is not broken.
The oral mucosa is pink, moist, clean. Orifices of excretory ducts
salivary glands are clearly visible. Teeth are sanitized.
The tongue is clean, pink, moist, the papillae are moderately expressed.
The palatine arches are contoured. moist, clean, pink. The tonsils are not enlarged. The back wall of the pharynx is moist, pink. The lymphoid tissue is
changed. The pharyngeal reflex is preserved.
The vault of the nasopharynx is free. The pharyngeal tonsils are not changed. Mucous
pink, wet Opener in the middle line. Choanas are free. nasal
shells are not hypertrophied. The mouth of the auditory tubes is good
differentiated, free. Pipe tonsils and side rollers are not
Mucous pink, moist, clean. The lingual tonsil
hypertrophied. Vallecules are free. Piriform sinuses are free.
The epiglottis is movable, the passage to the larynx is free.
Regional lymph nodes (submandibular, deep cervical,
prelaryngeal, pretracheal) are not enlarged. Larynx of the correct form,
passively mobile, mucous pink, moist and clean. During laryngoscopy, the mucous membrane of the epiglottis, the area of the arytenoid cartilages, interarytenoid space and vestibular folds is pink, moist with a smooth surface, the vocal folds are gray, not changed, symmetrically mobile during phonation, they close completely. Subglottic space is free.
The auricle is of the correct shape. The contours of the mastoid process are not
changed. Palpation of the auricle, mastoid process and tragus
painless. The external auditory canal is wide. Contains a moderate amount of sulfur. There is no pathological content. The tympanic membrane is gray with a pearly hue. The short process and handle of the malleus, light cone, anterior and posterior folds are well contoured.
The auricle is of the correct shape. The contours of the mastoid process are not
changed. Palpation of the auricle, mastoid process and tragus
painless. The external auditory canal is wide. Contains a moderate amount of sulfur. There is no pathological content. The tympanic membrane is gray with a pearly hue. The short process and handle of the malleus, light cone, anterior and posterior folds are well contoured.
AD +s=64s=2048 6m >6m
W CA CM Ji Js v V
AS +c=64 c=2048 6m >6m
St M Nуs Nуp Nуr Nуcal
11. Additional research methods.
12. Clinical diagnosis.
13. Substantiation of the diagnosis.
14. Treatment plan.
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ENT medical history. Diagnosis: acute bilateral sinusitis.
Diagnosis: acute bilateral sinusitis.
Complains of nasal congestion, not abundant mucopurulent discharge.
She fell ill a month ago: a runny nose, cough, fever up to 37.5 were noted. The patient was prescribed the following treatment: warming up the nose, vasoconstrictor drops in the nose (pinasol). The effect was minor. The subfebrile temperature was maintained for a month. There was a copious discharge from the nose of a mucopurulent nature, a headache appeared in the forehead, aggravated by bending forward. To clarify the diagnosis and conduct
appropriate treatment by the local doctor, the patient was referred
in the ENT department of the Design Bureau.
5 Anamnesis of life, family history.
Allergy to medicinal substances (penicillin) and food products (sweet, citrus fruits, milk), as well as to animal hair.
Chicken pox, lymphadenitis. Previously, acute respiratory infections were ill once a year, for the last two years - once a month. She has been suffering from neurodermatitis since the age of three.
Alcohol is consumed in moderation.
The general condition is satisfactory. The position is active. Expression
faces are meaningful. Behavior is normal. The attitude towards the disease is adequate.
Consciousness is clear. Food is normal. The physique is correct.
The skin is dry, natural color. In the area of the flexor surfaces of the elbow and knee joints, a papular-cortical rash is observed. Mucous
Peripheral lymph nodes are not enlarged, on palpation
The muscles are well developed, the tone is normal, on palpation
The cardiovascular system.
Pulsations and bulging of the cervical veins are not observed, "heart hump"
missing. The precordial region is painless on palpation.
The apex beat is located in the 5th intercostal space on the left side of the midclavicular
lines, unspilled, resistant, low, with an area of 2 square cm.
Limits of absolute stupidity:
Right: in the IV intercostal space along the right edge of the sternum
Left: in the 5th intercostal space along the left midclavicular line
Upper: on the 3rd rib along the left parasternal line.
Heart sounds are clear, rhythmic, there are no side murmurs. Pulse 80 per minute
rhythmic, synchronous, normal filling and tension, wall
arteries are elastic. HELL
The nose is straight, breathing through the nose is difficult, there is a scanty mucopurulent discharge. Larynx -
forms. In the act of breathing, both halves of the chest participate evenly and
equally. Type of chest breathing. Auxiliary muscles in the act
respiration is not involved. NPV - 20 per min. chest on palpation
comparative percussion heard a clear pulmonary sound in all areas
chest. Upper and lower borders of the lungs with topographic
percussion are not changed. Breathing is vesicular, no wheezing.
Appetite is not reduced. The oral cavity is pink in color, without damage, shiny.
Tongue pink, wet. The teeth are saved. Gums, soft and hard
the sky is pink, moist, without raids, cracks, ulcers. Round belly,
not enlarged, participates in the act of breathing. Peristalsis of the stomach and intestines
it can be seen that there are no venous collaterals on the anterior abdominal wall. At
on superficial palpation, the abdomen is painless, soft, muscle tension
the anterior abdominal wall is not marked; tumors, hernias, divergences of straight lines
no abdominal muscles. Deep palpation of the abdominal organs
painless, soft consistency, not enlarged. Liver on the edge of the costal
arcs. Percussion borders of the liver are not changed. The spleen is not palpable. At
auscultation listened to peristalsis of the intestines and stomach. friction noise
peritoneum and vascular noise are absent.
There is no swelling, redness in the projection area of the kidneys. Urination
free, painless, 6-7 times a day, straw-yellow urine color, without
pathological contaminants. Kidneys are not determined by palpation. Symptom
Pasternatsky is negative on both sides.
Nose and paranasal sinuses.
The shape of the external nose is correct, deformities of the bones and cartilage of the walls
visually and palpation is not detected. Palpation of the anterior wall of the frontal sinuses
at the exit site of the first and second branches of the trigeminal nerve is painless. There is moderate pain in the anterior wall of the maxillary sinuses.
With anterior rhinoscopy, the entrance to the nose is free, the nasal septum is not
displaced, located in the midline.
The mucosa is hyperemic, moderately edematous.
the nasal passages are free, the shells are not changed. Breathing is difficult, there is scanty mucopurulent
detachable, the sense of smell is not broken.
The oral mucosa is pink, moist, clean. Orifices of excretory ducts
salivary glands are clearly visible. Teeth are sanitized.
The tongue is clean, pink, moist, the papillae are moderately expressed.
The palatine arches are contoured. moist, clean, pink. The tonsils are not enlarged. The back wall of the pharynx is moist, pink. The lymphoid tissue is
changed. The pharyngeal reflex is preserved.
The vault of the nasopharynx is free. The pharyngeal tonsils are not changed. Mucous
pink, wet Opener in the middle line. Choanas are free. nasal
shells are not hypertrophied. The mouth of the auditory tubes is good
differentiated, free. Pipe tonsils and side rollers are not
Mucous pink, moist, clean. The lingual tonsil
hypertrophied. Vallecules are free. Piriform sinuses are free.
The epiglottis is movable, the passage to the larynx is free.
Regional lymph nodes (submandibular, deep cervical,
prelaryngeal, pretracheal) are not enlarged. Larynx of the correct form,
passively mobile, mucous pink, moist and clean. During laryngoscopy, the mucous membrane of the epiglottis, the area of the arytenoid cartilages, interarytenoid space and vestibular folds is pink, moist with a smooth surface, the vocal folds are gray, not changed, symmetrically mobile during phonation, they close completely. Subglottic space is free.
The auricle is of the correct shape. The contours of the mastoid process are not
changed. Palpation of the auricle, mastoid process and tragus
painless. The external auditory canal is wide. Contains a moderate amount of sulfur. There is no pathological content. The tympanic membrane is gray with a pearly hue. The short process and handle of the malleus, light cone, anterior and posterior folds are well contoured.
The auricle is of the correct shape. The contours of the mastoid process are not
changed. Palpation of the auricle, mastoid process and tragus
painless. The external auditory canal is wide. Contains a moderate amount of sulfur. There is no pathological content. The tympanic membrane is gray with a pearly hue. The short process and handle of the malleus, light cone, anterior and posterior folds are well contoured.
AD +s=64s=2048 6m >6m
W CA CM Ji Js v V
AS +c=64 c=2048 6m >6m
Conclusion: sound perception and sound conduction is not disturbed.
St M Nуs Nуp Nуr Nуcal
Conclusion: Vestibular functions are not disturbed.
a) X-ray of the paranasal sinuses: intense homogeneous darkening of both maxillary sinuses compared to the orbits.
Acute bilateral sinusitis.
The diagnosis was made on the basis of:
3) X-ray of the paranasal sinuses: intense homogeneous darkening of both maxillary sinuses compared to the orbits.
Treatment is conservative. Aimed at improving the outflow of secretions from the maxillary sinus by expanding the anastomosis connecting the sinus with the nasal cavity.
SBEI HPE "Bashkir State Medical University"
Ministry of Health Russian Federation
DISEASE HISTORY
Patient: M. C. Ya. (40 years old)
Main diagnosis: right-sided cystic maxillary sinusitis
Curator, student E.K. Buvaeva
Medical Faculty
Group 411B
I. Passport part:
Full name: M.Ch.Ya.
Age: 40 years old.
Gender Female
Date of receipt: 02.09.2015
Place of work, profession: Dyurtyuli, Central District Hospital. Medical technologist.
Place of residence: Dyurtyuli
The main diagnosis: right-sided cystic maxillary sinusitis.
Concomitant diseases: Atopic bronchial asthma, allergic rhinitis, SVD.
There are no complications.
II. Complaints of the patient upon admission to the medical institution:
At the time of pain in right half head (especially in the orbit), congestion, cough, general malaise, weakness, heaviness when talking.
Complaints, at the time of curation:
The patient experiences moderate pain in the right half of the head, notes the peculiarity of pain in the parietal region and orbit. Nasal congestion, dry cough, weakness, fever.
III. Anamnes morbi:
The patient has been experiencing pain in the right side of the head for a year, especially in the region of the orbit, the crown, the neck also hurt and blood pressure increased. Pain began in November 2014. In December, the patient went to a neurologist, she was diagnosed with autonomic dysfunction syndrome, intracranial hypertension. On January 26, 2015, an MRI was performed. In June 2015, the patient began to experience nasal congestion, runny nose, decreased sense of smell, and the same pain. At the end of July, according to the patient, she caught a cold, she had a cough, runny nose, temperature 39C. The therapist at the hospital at the place of residence prescribed antibiotic therapy. Within three months the patient took vasoconstrictor drops in the nose. On August 10, 2015, the patient went to the hospital and was scheduled for a planned operation. 09/02/15 entered the ENT Department of the RCH. G.G. Kuvatova.
IV. Anamnes vitae:
She was born on 06/29/1975 in the Republic of Belarus. She grew and developed according to her age. He has two educations: secondary special and higher. Works since 18 years old. Social conditions are good.
Past illnesses: ARVI (sick about 1 time per year), rubella, chicken pox, gastritis. A cholecystectomy was performed. Hereditary history is not burdened.
V. Allergological history: Allergic rhinitis, pollen sensitization with broncho-obstructive syndrome. According to the patient allergic reactions does not have.
VI. Objective research:
General condition is satisfactory
Consciousness is clear
Position active
Facial expression is calm
Free gait
Posture straight
Correctly oriented in space and time
The physique is correct, the constitution is normosthenic. Height 165, weight 67 kg.
The skin is of normal color, there are no pathological rashes, there are no excessive sweating, there are no visible tumors, there are no edema. The subcutaneous fat layer is moderately developed.
Hair growth by female type. Nail plates are normal.
Sclera yellowish.
The thyroid gland is not enlarged.
Lymph nodes are palpable submandibular.
Body temperature 37.2 C. BP 110/70 mmHg, heart rate 79 beats per minute.
VII. Study of organ systems
)Respiratory system: The nose is straight, breathing through the nose is difficult, there is a discharge. There is no bleeding. The larynx is not deformed, there is no swelling. The voice is quiet. The chest is normosthenic. The supra- and subclavian fossae are moderately concave, the width of the intercostal spaces is 1.2 cm, the direction of the ribs is moderately oblique. The epigastric angle is straight, the scapulae and clavicle protrude moderately. The chest is symmetrical. The movements of the chest during breathing are uniform, the intercostal spaces do not sink or protrude. The number of respiratory movements is 21 per minute. Breathing is deep, rhythmic, no shortness of breath, no wheezing. The type of breathing is mixed. )The cardiovascular system: In the region of the heart, the chest is not deformed, pulsations are not visible. There is no visible pulsation, epigastric pulsation. A localized apex beat is palpated in the 5th intercostal space 1 cm medially from the left mid-clavicular line, with an area of 2 square cm, of moderate strength. heart sounds are muffled, the rhythm is correct. Heart rate 78 per minute. No noises were detected either in the standing position, or sitting, or lying on the left side. When examining the vessels of visible pulsation and pathological changes not visible. There is no visible pulsation of the arteries of the jugular fossa and epigastric region. Arterial pulse is the same on both radial arteries, 78 per minute, rhythmic, satisfactory filling and tension. Arterial pressure on the brachial artery: 110/70 mm Hg. on both hands. )The digestive system: Appetite saved. Heartburn, belching, nausea, flatulence - absent. The chair is normal. The tongue is bright pink, moist, lined with a white coating, the papillary layer is pronounced. Teeth: no carious changes were found, no dentures. The gums are pink, dense, without signs of bleeding. The abdomen is normal, no swelling, no pain. The gallbladder has been removed. Intestine, liver, pancreas - without features. )Urinary organs: Pain in the lumbar region is absent, urination is not disturbed. Pasternatsky's symptom is negative on both sides. Kidneys are not determined by palpation. VIII. Examination of ENT organs. 1)
Nose and paranasal sinuses:Nose of the correct form. The skin of the nose is flesh-colored, normal moisture. There is a slight swelling of the skin in the area of the projection of the right maxillary sinus. Palpation of the nose is painful. Soreness is detected on palpation of the maxillary sinus region. Breathing is difficult, more weakened on the right side. Sense of smell is slightly reduced. Anterior rhinoscopy: The vestibule of the nose is free, there is hair on the skin. The mucous membrane of the turbinates on the right is hyperemic, on the left it is pale pink. The lumens of the middle and lower nasal passages are narrowed on the right and left, the surface of the mucous membrane on the nasal conchas is covered with mucous discharge, accumulations of the discharge at the bottom of the nasal cavity are also noted. The nasal septum is in the midline, has no significant curvature. Pharynx: The mucous membrane of the oral cavity is of normal color, there are no pathological changes. The teeth are sanitized, the tongue is clean and moist. The mucous membrane of the oropharynx is pink, without pathological changes. Oropharynx:The mucous membrane of the soft palate, palatine arches is pink, moist, clean. The palatine tonsils do not protrude beyond the arches, there are no adhesions with the arches, the lacunae are without pathological changes. The arches are pink in color, pathological changes are not determined. Nasopharynx (posterior rhinoscopy):The fornix and choanae are free. There is no runoff of pus along the posterior wall of the pharynx. The pharyngeal tonsil is pink, not enlarged. The posterior ends of the turbinates are not enlarged, the mucous membrane is hyperemic, edematous. Laryngopharynx: The mucous membrane of the laryngopharynx (valleculae, pyriform sinuses) is smooth, pink. The lingual tonsil is pale pink in color, of normal size. Larynx: AD: The skin of the auricle is pale pink in color, the relief is not changed, pressure on the tragus is painless. During external examination, the skin of the mastoid process is pale pink in color, there is no swelling, palpation is painless. At otoscopy: the external auditory meatus is normal, no infiltration of the walls is observed, there is no pathological discharge. There is a slight accumulation of sulfur. The tympanic membrane is not changed, gray. The following identification elements are visible on the surface of the tympanic membrane: the navel, the light cone, the handle of the malleus, the short process of the malleus, the anterior and posterior folds. Perforations and scars were not found.: The skin of the auricle is pale pink in color, the relief is not changed, pressure on the tragus is painless. During external examination, the skin of the mastoid process is pale pink in color, there is no swelling, palpation is painless. At otoscopy: the external auditory meatus is normal, no infiltration of the walls is observed, there is no pathological discharge. There is a slight accumulation of sulfur. The tympanic membrane is not changed, gray. The following identification elements are visible on the surface of the tympanic membrane: the navel, the light cone, the handle of the malleus, the short process of the malleus, the anterior and posterior folds. No perforations or scars were found. Hearing Passport. ADPARAMETERSASAbs.ear noiseAbs.6 meterswhisper speech6 meters--colloquial speech--VKSVK45 s15 s45 s15 s45 sS 2048(air) 45 s + Rinne experience + Federici experience + Weber experience + Gellet experience + Schwabach experience + Vestibular Passport. Dizziness, vomiting, loss of balance - periodically. Spontaneous nystagmus - no. Finger test is normal. Finger test is normal. There are no violations of coordination in the Romberg position. Straight gait is not changed. Flank gait is not disturbed. Dysdiadochokinesis was not detected. Fistula test (not performed). IX. Preliminary diagnosis: Maxillary hemisinusitis. x. Laboratory methods research: General analysis blood: IndicatorsResultNormLeukocytes 5.24.0-9.0Erythrocytes 3.853.9-5.0 Hemoglobin 121 g/l 110-160 g/l Platelets 220 150-400 Lymphocytes 29% 19-37% Stab neutrophils 4% 1-4% Segmented neutrophils 4%-72% Monocytes5% 3-11% ESR12 mm/hour Up to 15 mm/hour General urine analysis: Color - straw yellow transparent Specific gravity 1018 Leukocytes 1-0-2 B / x blood: Total protein - 82.6 Glucose - 3.94 Urea - 5.2 Cholesterol - 4.2 Bilirubin total - 13.2 Rheumatoid factor - neg. C-reactive. Protein - neg. Coagulogram: Fibrinogen - 2.8 Prothrombin time -13 Thrombosed index - 90 X-ray examination: On the radiograph in the nasolabial projection, a homogeneous spherical darkening of the right maxillary sinus is determined. No pathological changes were found in the left maxillary, frontal, sphenoid sinuses, as well as in the cells of the ethmoid labyrinth. Conclusion MRI: MR picture of the cyst of the right maxillary sinus, left-sided hemisinusitis. Minor external hydrocephalus. X. Clinical diagnosis and its rationale: Main disease:right-sided cystic maxillary sinusitis Concomitant disease:Atopic bronchial asthma, allergic rhinitis, SVD. The diagnosis was made on the basis History of the disease: complaints of the patient (permanent copious discharge from the nose of a mucous nature, constant congestion of both halves of the nose, pain in the right side of the head, eye sockets, crown of the head). From the history of the disease. Data from an objective study: anterior rhinoscopy. Additional study data: radiography of the nose and paranasal sinuses in the nasolabial projection, MRI data. XI. differential diagnosis. XII. Treatment: )Surgery: Operation No. 847 performed Name of the patient: Murtazina Ch.Ya. Surgeon: Yanborisov T.M. Operating sister: Syundyukova A. Operation: right-sided endoscopic maxillary sinusectomy Duration: 40 min. Operation progress: Sol injections were made. Novocaini 2.0% - 5.0 ml see the addition of Sol. Adrenalini 0.1% at "projection points": the place of attachment of the middle turbinate, the anterior end of the middle turbinate, the nasal septum; Removed the uncinate process, polyps of the middle nasal passage, sphenoethmoid space. Under the control of the endoscope, the pathological contents from the right maxillary sinus are carefully removed using Blaxley forceps, the sinus is washed. The fistula of the frontal sinus, the maxillary sinus are freely probed. Tamponade with a homeostatic sponge. He underwent the operation satisfactorily. The material was sent for hyst. Study. )Medical treatment: Rep.: Dr. Diazolini 0.1 N 10. S. 1 tablet 2 times a day ..: Sol. Naphthizini 0.1% 10 ml. S. Drops in the nose (3 drops 3 times a day in each nasal passage). Rp.: "Cefotaxim" 1.0.t.d.N. 10 S. Dissolve the contents of the vial in 5 ml of saline, inject intramuscularly 3 times a day. Lubrication of the nasal mucosa with a 10% solution of silver nitrate. The general condition is satisfactory, the consciousness is clear, the position is active. The patient complains of pain near the orbit, in the right half of the head, nasal congestion, cough and general malaise. BP 110/70, temperature 37.2 C. Respiratory rate 21, heart rate 78. Nose mucosa on the right side is hyperemic, on the left it is pale pink, there is a discharge. Larynx-vocal folds gray, symmetrically closed. The pharyngeal arches are slightly hyperemic. The general condition is satisfactory, the consciousness is clear, the position is active. Complaints of runny nose, headaches. BP 120/70, temperature 37.0 C. Respiratory rate 21, heart rate 80. Nose mucosa on the right side is hyperemic, on the left it is pale pink, there is a discharge. Larynx-vocal folds gray, symmetrically closed. Zev - palatine arches are slightly hyperemic. The general condition is satisfactory, the consciousness is clear, the position is active. There are no complaints. BP 120/70, Temperature 36.8 C. Respiratory rate 18, heart rate 80. Nose - pink mucosa, there is discharge. Larynx-vocal folds gray, symmetrically closed. Zev - no change. XIV. Prevention: Prevention will be non-specific. Immunostimulatory therapy. XV. Forecast: For life - favorable. Good for recovery. For labor activity - favorable. sick analysis diagnosis therapy List of used literature 1.http://lookmedbook.ru/ Ovchinnikov Yu. M., Lopatin A. S., Gamov V. P. Diseases of the nose, pharynx, larynx and ear. (2008). Otorhinolaryngology: textbook Palchun V.T., Magomedov M.M., Luchikhin L.A., 2011. Surgical stomatology: textbook (Afanasiev V.V. and others); under total ed. V. V. Afanasiev. - M. : GEOTAR-Media, 2010
PMGMU them. I. M. Sechenova
Department of Ear, Nose and Throat Diseases.
Disease history
Completed by: MPF student, 6th year, 2nd group
Lecturer: Candidate of Medical Sciences, Associate Professor Klimova L.A.
Moscow 2011.
Full Name: O.A.
Age: 46 years old
Place of work, profession: teacher
Place of residence: Moscow city
Complaints on admission: difficulty in nasal breathing on the right, purulent discharge from the nose, pain in the area of the projection of the maxillary sinus on the right, which occurs in the afternoon, snoring.
Disease history:
Since childhood, she noted difficulty in nasal breathing, for which at the age of 18 (1983) she underwent surgery to eliminate the curvature of the nasal septum, after which she noted an improvement in nasal breathing.
From the age of 23 (1988) annually (1-3 times a year) she applied to the hospital for the treatment of acute sinusitis that occurred against the background of SARS, where punctures of the maxillary sinuses, antibiotic therapy, and physiotherapy were performed. In the interictal period, she used nose drops with a vasoconstrictive effect: galazolin, naphthyzinum; after the use of which there was a short-term improvement in nasal breathing and the feeling of nasal congestion disappeared.
The last exacerbation of the process in June 2011, antibiotic therapy was carried out on an outpatient basis.
In September 2011 At the appointment with the dentist, when analyzing the X-ray of the upper jaw, a darkening of the right maxillary sinus was detected, and therefore she turned to the ENT department of the 1st University Clinical Hospital and was hospitalized for additional examination and treatment.
Anamnesis of life:
Born in Moscow. Physically and intellectually developed normally, did not lag behind peers. Higher education.
There are no occupational hazards.
Bad habits are denied.
Past diseases: at 7 years old - chickenpox
Allergic reactions to cat and dog hair, vegetable and animal fluff, chemical agents, building dust, manifested by sneezing, dry cough with an asthmatic component.
Heredity is not burdened.
Statuspraesens
At the time of examination: the general condition is satisfactory, the body temperature is 36.7 ° C, there were no complaints indicating the pathology of the organs of the circulatory, respiratory, and digestive systems.
ENT status.
Nose and paranasal sinuses.
On examination: the external nose of the correct form, swelling and changes in the skin in the area of the nose is not observed. Palpation and effleurage in the area of the external nose and paranasal sinuses revealed no pain.
With anterior rhinoscopy: the nasal septum is not changed, the mucous membrane of the turbinates is hyperemic, edematous in the region of the inferior turbinate, on the right in the middle nasal passage there is an accumulation of purulent discharge. The lumen of the nasal passage on the right is significantly narrowed.
Nasal breathing is weakened, more difficult through the right nasal passage than through the left. The sense of smell, according to the patient, is preserved.
Pharynx.
At pharyngoscopy: the mucous membrane of the oral cavity is pale pink, without rashes. Teeth are sanitized. The tongue is clean and moist. The palatine tonsil on the left does not protrude beyond the arches, on the right it is sharply enlarged (hypertrophy of the II degree), pale pink in color, there are no adhesions with the arches, there are no lacunae without pathological changes, there is no pathological discharge when pressing on the anterior arch. The arches are pale pink in color, pathological changes are not determined. The mucous membrane of the posterior wall of the pharynx is pink, shiny, moist. Lymphoid granules are not visible.
Regional lymph nodes are not palpable.
With posterior rhinoscopy: the vault is free, the mouths of the auditory tubes are differentiated. The posterior ends of the turbinates are not enlarged, the pharyngeal tonsil is not changed.
With hypopharyngoscopy: the mucous membrane of the valecules, the epiglottis of a pale pink color, is not infiltrated. Piriform sinuses are free.
Larynx.
Breathing is free. Nasal voice is not defined.
External examination: normal shape, palpation of the cartilage of the larynx is mobile, crepitus is felt.
With indirect laryngoscopy: the mucous membrane of the epiglottis, aryepiglottic and vestibular folds is pale pink, not infiltrated. The edges of the vocal folds are whitish in color, their movements are symmetrical. During phonation, they close completely. The subglottic space, the visible part of the trachea are not changed
Ears.
AS:
The skin of the auricle is pale pink in color, the relief is not changed, pressure on the tragus is painless.
During external examination, the skin of the mastoid process is pale pink in color, there is no swelling, palpation is painless.
At otoscopy: the external auditory meatus is wide, there is no infiltration of the walls. There is a slight accumulation of sulfur. The tympanic membrane is not changed, grayish-white with a pearly tinge. The following identification elements are visible on the surface of the tympanic membrane: the navel, the light cone, the handle of the malleus, the short process of the malleus, the anterior and posterior folds. No perforations or scars were found. The auditory tube is passable.
Hearing Passport.
PARAMETERS
noise in the ear
whispered speech
Speaking
Rinne experience
Weber experience
= AD
Jelle experience
Sound conductivity
C128 air
C128 bone
Conclusion: Violations of sound perception and sound conduction were not revealed.
Vestibulometry:
Dizziness, vomiting, loss of balance - no.
Spontaneous nystagmus - no.
Spontaneous detachment of hands - not detected
Finger test is normal.
Finger test is normal.
Stable in the Romberg position
Straight gait is not changed.
Flank gait is not disturbed.
Adiadochokinesis was not detected.
Conclusion: there are no vestibular disorders, the excitability of the vestibular apparatus is normal, symmetrical.
Clinical diagnosis: chronic right-sided purulent sinusitis.
Substantiation of the diagnosis:
The diagnosis of chronic right-sided purulent sinusitis can be made based on:
characteristic complaints of the patient about the undulating course of the disease, characterized by alternating periods of remission and exacerbation of the process, difficulty in nasal breathing, especially on the right, the presence of purulent discharge from the nose, pain in the projection of the right maxillary sinus that occurs in the afternoon due to insufficient outflow of purulent secretion through the fistula located at the upper wall of the sinus;
anterior rhinoscopy data: hyperemia and edema of the mucous membrane in the region of the lower nasal concha on the right, accumulation of purulent discharge in the middle nasal passage, narrowing of the lumen of the nasal passage on the right.
differential diagnosis.
Must be done with:
Chronic polypous sinusitis, in which, with anterior rhinoscopy, polyps (benign formations with a smooth surface of a bluish-gray color) are determined in the middle nasal passage. On the radiograph of the paranasal sinuses, spotting of the maxillary sinuses is determined.
Frontitis in which patients complain of a headache in the forehead, a feeling of heaviness in the projection of the frontal sinuses (increasing in the morning). With anterior rhinoscopy, purulent or mucous nature of the discharge in the middle nasal passage is determined. On the radiograph, a homogeneous darkening of one or both sinuses is determined.
Ethmoiditis in which patients are concerned about nasal congestion, purulent or mucous discharge, a feeling of heaviness at the root of the nose, headache in the forehead. With anterior rhinoscopy, swelling of the mucous membrane in the region of the middle nasal passage, accumulation of purulent secretion is determined. The radiograph shows the darkening of the cells of the ethmoid labyrinth.
Sphenoiditis in which patients are concerned about pain in the occipital region, sensation. That the head is in a tight helmet, sleep disturbance, dizziness and unsteadiness when walking, weakness, memory loss. On examination, ophthalmoplegia, ptosis, exophthalmos, and lacrimation can be detected. With posterior rhinoscopy, the detection of pus draining along the posterior wall of the nasopharynx, in the absence of changes in the anterior rhinoscopy.
Treatment plan.
The patient is shown endoscopic surgery on the right maxillary sinus.
The goal of endoscopic surgery is to expand the opening of the sinus to restore ventilation and drainage of the affected sinus through the physiological pathway.
In the postoperative period, the use of Fluimucil-antibiotic IT by introducing into the paranasal sinuses 1-2 ml of solution 1 time per day for 7 days, and 0.1% Naphthyzine solution intranasally 3 drops 3 times a day for 5 days.
Rp.: Fluimucili - Antibiotici IT 0.5
D.t. d. No. 7 in fl.
S. Dissolve the contents of the vial in 4 ml. water for injection. Enter into the right maxillary sinus 2 ml 1 time per day.
Rp.: Sol. Naphthyzini 0.1% 10ml