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    Caz Clinic-Stanis Loredana MG V, GR 7

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    Dana Stăniş
    This document presents a case study of a 62-year-old Romanian woman who was hospitalized for pneumonia. She presented with productive cough, lack of appetite, fatigue, chills, chest pain, and fever of 38.8 degrees. Her medical history included hypertension and hepatitis B. On examination, she had diminished breathing on the left side with crackles heard bilaterally. Chest X-ray confirmed pneumonia. She was diagnosed with pneumococcal pneumonia based on sputum examination, chest X-ray findings, and lab results including leukocytosis and elevated fibrinogen. She was treated with intravenous and oral penicillin.

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    Caz Clinic-Stanis Loredana MG V, GR 7

    Uploaded by

    Dana Stăniş
    355 views18 pages
    This document presents a case study of a 62-year-old Romanian woman who was hospitalized for pneumonia. She presented with productive cough, lack of appetite, fatigue, chills, chest pain, and fever of 38.8 degrees. Her medical history included hypertension and hepatitis B. On examination, she had diminished breathing on the left side with crackles heard bilaterally. Chest X-ray confirmed pneumonia. She was diagnosed with pneumococcal pneumonia based on sputum examination, chest X-ray findings, and lab results including leukocytosis and elevated fibrinogen. She was treated with intravenous and oral penicillin.

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    Caz Clinic-Stanis Loredana MG v,Gr 7

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    This document presents a case study of a 62-year-old Romanian woman who was hospitalized for pneumonia. She presented with productive cough, lack of appetite, fatigue, chills, chest pain, and fever of 38.8 degrees. Her medical history included hypertension and hepatitis B. On examination, she had diminished breathing on the left side with crackles heard bilaterally. Chest X-ray confirmed pneumonia. She was diagnosed with pneumococcal pneumonia based on sputum examination, chest X-ray findings, and lab results including leukocytosis and elevated fibrinogen. She was treated with intravenous and oral penicillin.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    355 views18 pages

    Caz Clinic-Stanis Loredana MG V, GR 7

    Uploaded by

    Dana Stăniş
    This document presents a case study of a 62-year-old Romanian woman who was hospitalized for pneumonia. She presented with productive cough, lack of appetite, fatigue, chills, chest pain, and fever of 38.8 degrees. Her medical history included hypertension and hepatitis B. On examination, she had diminished breathing on the left side with crackles heard bilaterally. Chest X-ray confirmed pneumonia. She was diagnosed with pneumococcal pneumonia based on sputum examination, chest X-ray findings, and lab results including leukocytosis and elevated fibrinogen. She was treated with intravenous and oral penicillin.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 18

    Prezentare de caz

    Medicina Interna

    Pneumonie
    Pneumococica

    Stanis Loredana Alina


    MG V Grupa 7

    Date personale
    B.I 62 ani,Mediu rural Arad
    Internata de urgenta la Spitalul Clinic

    Judetean de Urgenta Arad in 20.04.2015


    Grupa sanguina: A II

    Motivele internarii
    Tuse productiva
    Inapetenta
    Astenie
    Frisoane
    Junghi toracic
    Febra 38,8 grade

    Antecedente heredo-colaterale

    Mama : Alzheimer
    Tata : operat de ulcer gastric

    Antecedente personale
    patologice si fiziologice
    Menarha : 14 ani
    Menopauza : 50 ani
    Sarcini : 3

    -Nasteri: 2
    -Avorturi: 1
    Purpura Henoch Schonlein in 2013
    Virus Hepatita B
    HTA

    Conditii de viata si
    munca
    Conditii de viata : bune
    Conditii de munca : bune
    Comportament :

    - 1 cafea/zi
    -nu consuma alcool
    - nu fumeaza

    Medicatie de fond
    Lagosa 150 mg
    Ramipril 5 mg

    ( adjuvant hepatoprotector)

    ( inhibitor ai enzimei de conversie)

    Istoricul bolii
    Pacienta in varsta de 62 ani,s-a internat pe

    sectia de Interne la Spitalul Judetean de


    Urgenta Arad in data de 20.04.2015 cu
    urmatoarele simptome : tuse
    productiva,inapetenta,astenie,frisoane
    ,junghi toracic,febra 38,8 grade pentru
    tratament si investigatii de specialitate.

    Examen Obiectiv

    Stare generala: buna


    Stare de constienta : constienta
    Facies:necaracteristic
    Talie: 1,56 m
    Greutate: 55 kg
    Tegumente: umede
    Fanere: normal colorate
    Tesut conjunctivo -adipos: normal reprezentat
    Sist.ganglionar :superficial nepalpabil
    Sist.osteo-articular: integru mobil
    Sist muscular : normoton-normotrof-normokinetic

    Aparatul respirator
    Torace : normal conformat
    Inspectie :diminuarea amplitudinii

    respiratorii de partea stanga


    Palpare : freamat pectoral prezent
    bilateral
    Ascultatie suflu tubar fiziologic
    - raluri crepitante bazal
    bilateral

    Aparatul
    cardiovascular
    Zgomote cardiace ritmice, fara sunete

    supradaugate
    Soc apexian prezent in spatiul V intercostal
    pe linia medioclaviculara stanga
    Puls periferic prezent
    TA : 130/70 mmHg
    Puls : 75 batai/min

    Aparatul digestiv
    Abdomen suplu, elastic, nedurerosos la

    palpare profunda si superficiala


    Tranzit intestinal prezent

    Sistem nervos, endocrin, organe


    de simt
    ROT : prezent bilateral
    Fara semne de iritatie meningiala

    Solicitarea analizelor
    Examen de sputa
    Radiografie pulmonara
    Hemoleucograma

    Diagnostic pozitiv
    Pneumonie Pneumococica
    ( pus pe urmatoarele criterii )

    Anamneza,examen obiectiv si urmatoarele analize :


    Examenul sputei : sputa pneumococica
    Examenul Radiologic : confirma diagnosticul clinic,
    indicnd opacitate triunghiulara, cu vrful n hil.
    Hemoleucograma : -leucocitoza (10.000-30.000)
    -neutrofilie
    -vsh crescut
    -fibrinogen crescut

    Diagnostic diferential
    Pneumonie Pneumococica se face cu :

    -Pneumonii infectioase nebacteriene : debut insidios


    tuse iritativa fara expectoratie,Rx necaracteristic
    -Infarct pulmonar : junghi,tuse,dispnee la 24-48 h ,febra
    -Abces pulmonar : febra tip septic
    -Astm bronsic: pacientul nu prezinta alergii, istoric familial
    de astm, testul de hipereactivitate bronsica
    -Bronsiectazie: nu prezinta sputa purulenta sau
    hemoptizii, pe Rx nu se observa dilatatie bronsica cu ingrosarea
    peretelui bronsic
    - TBC: Rx nu prezinta infiltrate pulmonare sau leziuni
    nodulare confirmare bacteriologica

    Tratament
    Igieno-dietetic:
    Repaus la pat,hidratare, evitarea stresului si

    frigului, ameliorarea nutritiei si reabilitare


    pulmonara, evitarea mediului poluant

    Etiologic
    -Penicilina G sau V 250mg-500mg la 6h
    - pn. necomplicate
    -Penicilina G 500.000 2 mil.UI iv. La 4-6h

    Multumesc!

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