Выписка из истории болезни №073/021

Выписка из истории болезни №073/0215
Больная Энген Бэлла, 24.11.1974 г. рожд., гражданка Норвегии, находилась с 21.02.2015 по 26.02.2015 на стационарном лечении в клинике «МЕДИ лтд» по адресу Кыргызстан, г. Бишкек, ул. Суеркулова, 5/3.
КЛИНИЧЕСКИЙ ДИАГНОЗ:
Тупая травма грудной клетки. Закрытый перелом VI-VII ребер слева. Гемоторакс справа. Травматический шок I степени.
ЖАЛОБЫ ПРИ ПОСТУПЛЕНИИ: на сильные боли в области грудной клетки слева с чувством нехватки воздуха, чувство сухости во рту, общую слабость.
АНАМНЕЗ ЗАБОЛЕВАНИЯ: 21.02.2015 получила травму, катаясь на лыжах на горнолыжном курорте Тюя-Ашу. Самостоятельно, в сопровождении друзей, была доставлена в клинику МЕДИ для обследования и лечения.
ОБЪЕКТИВНО: Состояние больной средней тяжести. Кожные покровы и видимые слизистые бледные. Дыхание самостоятельное, ритмичное, жесткое, затрудненное, хрипов нет, ЧД-23 в минуту. Сатурация 90%. Тоны сердца ритмичные, в момент поступления АД-120/90 мм рт ст, ЧСС-98 в минуту. Язык влажный, чистый. Живот мягкий, пальпаторно безболезненный, перистальтика прослушивается. Симптомы раздражения брюшины отрицательные. Симптом поколачивания по 12 ребру отрицательный. Стул и диурез самостоятельный.
ЛОКАЛЬНЫЙ СТАТУС: При осмотре отмечается подкожные гематомы области грудной клетки слева. Пальпаторно отмечается болезненность в области проекции 5-8-го ребер слева по передней подмышечной, среднеключичной и заднеподмышечной линиям. Глубокий вдох ограничен болью, сохранен. Дыхание проводится с обеих сторон, ослаблено в правом нижнем отделе. Положение вынужденное.
НЕВРОЛОГИЧЕСКИЙ СТАТУС: сознание ясное, ориентирована в пространстве, во времени. Грубой очаговой и менингеальной симптоматики нет. Функции тазовых органов контролирует.
ОБСЛЕДОВАНИЯ:
МРТ грудного отдела позвоночника от 21.02.2015: Остеохондроз грудного отдела позвоночника. Множественные грыжи Шморля. Избыточный кифоз.
Рентгенография органов грудной клетки от 21.02.2015 На рентгенограмме органов грудной клетки легочные поля прозрачны. Корни структурны. Синусы свободны. Сердечная тень обычной конфигурации. Выявляется перелом со смещением 4-5 ребер слева по среднелопаточной линии. /протокол прилагается/.
УЗИ внутренних органов от 21.02.2015: Заключение: гемоторакс справа. /протокол прилагается/.
Клинический анализ крови от 21.02.2015: Гемоглобин – 117,0г/л, Ht-35%, эритроциты–4,0х1012/л, ЦП 0,88, тромбоциты – 308,0х109/л, лейкоциты – 10,7х109/л: п-1, с-73, э--, л-22, м-3, СОЭ 4 мм/ч.
Биохимические анализы крови от 21.02.2015: Глюкоза натощак 7,6 ммоль/л, общий белок 72,1 г/л, общий билирубин 14,6 мкмоль/л, прямой 0, не прямой 14,6, тимоловая проба 3,5ед, АСТ 13,0 Ед/л, АЛТ 9,0 Ед/л, мочевина 3,3 ммоль/л, креатинин 59,7 мкмоль/л.
ССК от 21.02.2015: фибриноген 2,4 г/л, ПИ 83%.
ЛЕЧЕНИЕ:
Медикаментозное:
Витамин С 5% 10,0 +NaCl 09%-400,0 в/в капельно
Рефортан 6% 500,0 в/в капельно
Промедол 2% 1,0 в/м №2 Трамадол 5% 2,0 в/м №1
Этамзилат натрия 12,5% 4,0 в/в струйно
Рибоксин 10,0 +NaCl 09%-400,0 в/в капельно
Нимесил 1 пакет на 100,0 воды 2 раза в день
Индометациновая мазь 3 раза в день

Рекомендовано: Эвакуация пациента возможна с 23.02.2015 регулярным рейсом самолета.
Лечащие врачи: _____________ Сушков Е.А./ травматолог-ортопед/
_____________ Логачева Е.Г. /зав. отделением реанимации/
Главный врач: ______________ Тимухин А.В. /нейрохирург/

Результаты (английский) 1:

Extract from case history no. 073/0215Sick Engen Bella, 24.11.1974 master, citizen of Norway, from 21.02.2015 to 26.02.2015 for hospital treatment in the clinic "MEDI Ltd. in Kyrgyzstan, Bishkek, UL. Suerkulova, 5/3.CLINICAL DIAGNOSIS: Blunt trauma to the chest. Closed fracture of VI-VII of the ribs on the left side. Right-sided hemothorax. Traumatic shock I degree.COMPLAINTS on ADMISSION: the severe pain in the chest on the left with a sense of lack of air, a feeling of dry mouth, weakness.MEDICAL HISTORY: 21.02.2015 got injured while skiing in the ski resort of Tuya-Ashu. Alone, with friends, was taken to the hospital for examination and treatment of COPPER. OBJECTIVELY: the State of the patient is moderate. The skin and visible mucous pale. Breathing independently, the smooth, rigid, difficulty, wheezing no CD 23 per minute. 90% saturation. Heart rhythmic, at the time the ad-120/90 mm Hg, HEART RATE is 98 per minute. Tongue wet, clean. The abdomen is soft, painless by palpation, peristalsis is bugged. Symptoms of irritation of the peritoneum in the negative. Symptom hummering of 12 edge negative. Stools and diuresis independent.LOCAL status: when inspecting the subcutaneous haematoma chest on the left. By palpation indicated pain in the area of the projection of 5-8-th edges left on the anterior axillary, sredneklûčičnoj and zadnepodmyšečnoj lines. Deep breath limited pain persisted. The breath is held on both sides, weakened in the lower division. The situation forced.NEUROLOGICAL STATUS: consciousness clear targets in space, over time. Rough, and meningeal symptoms No. Pelvic organs function controls.SURVEY:MRI of spinal column of 21.02.2015: Osteochondrosis of the thoracic spine. Multiple hernia Shmorl. Excessive kyphosis.Chest x-ray from 21.02.2015 On the radiograph of the chest lung fields are clear. The roots of the busi. Sinuses are free. Cardiac shadow normal configuration. Detected a fracture with offset 4-5 ribs left on the srednelopatočnoj line. //is attached Protocol.Abdonimal from 21.02.2015: conclusion: hemothorax right. //is attached Protocol.Clinical analysis of blood from 21.02.2015: Hemoglobin-117, 0gr/Lt, Ht-35%, red blood cells-4, 0h1012/l, platelets, 0.88 CPU 308 h109/l, leukocytes-10, 7h109/l: p-1, p-73, e-a-l-22, m-3, FW 4 mm/h.Biochemical blood tests from 21.02.2015: Fasting Glucose 7.6 mmol/l, total protein 72.1 g/l, total bilirubin 14.6 µmol/l, straight 0, not direct 14.6, etc sample 3, half units, AST 13.0 u/l, ALT 9.0 u/l, 3.3 mmol/l urea, creatinine 59.7 µmol/l. SSK from 21.02.2015: Fibrinogen 2.4 g/l, P 83%. TREATMENT: Medication:Vitamin c 5% NaCl + 09% 10.0 -400.0 in/in the drip Refortan 6% 500.0/dripPromedol 2% 1.0/m no. 2 Tramadol 5% 2.0/m no. 1Etamsylate sodium 12.5% 4.0 in/in struinoRiboksin 10.0 + 09% NaCl -400.0 in/in the drip1 package Nimesil 100.0 water 2 times a day Indometacinovaâ ointment 3 times a day Recommended: evacuation of the patient is possible with 23.02.2015 scheduled flight of an aircraft.Doctors: _ Sushkov EA/orthopaedic surgeon/ _ Logacheva E.g./head. Department of intensive care/Chief Physician: _ Timuhin Av/neurosurgeon/

Результаты (английский) 2:

Extract from the case №073 / 0215
patient Engen Bella, was born 11.24.1974., a citizen of Norway, was on 02/26/2015 02/21/2015 with in-patient treatment in the clinic "COPPER LTD" at Kyrgyzstan, Bishkek, st . Suyerkulov, 5/3.
Clinical diagnosis:
Blunt chest trauma. Closed fracture VI-VII ribs on the left. Hemothorax right. Traumatic shock I degree.
Complaints on admission: severe pain in the chest on the left with a feeling of lack of air, the feeling of dryness in the mouth, general weakness.
anamnesis: 02.21.2015 was injured while skiing at a ski resort Tuya-Ashu. On their own, accompanied by friends, was taken to the hospital COPPER for examination and treatment.
OBJECTIVE: The patient's condition of moderate severity. Skin and visible mucous membranes are pale. Independent breathing, rhythmic, hard, difficult, no wheezing, BH-23 per minute. Saturation of 90%. Rhythmic heart sounds, at the moment the AD-120/90 mm ​​Hg, heart rate 98 per minute. Language moist, clean. The abdomen is soft, painless palpable, peristalsis bugged. Symptoms of peritoneal irritation negative. Symptom effleurage on edge 12 is negative. Stool and urine output independent.
LOCAL STATUS: Seen marked subcutaneous hematoma on the left chest. Palpation, tenderness in the projection of 5-8 th left ribs on the anterior axillary, and zadnepodmyshechnoy midclavicular lines. Deep breath limited pain saved. The breath is held on both sides, weakened in the lower right section. The situation forced.
Neurological status: a clear conscience, oriented in space and time. Rough focal and meningeal symptoms are not present. Control of the pelvic organs.
SURVEY:
MRI of the thoracic spine from 21.02.2015: osteochondrosis of the thoracic spine. Multiple hernias SHmorlja. Excessive kyphosis.
Chest X-ray of 21.02.2015 on chest radiograph lung fields are transparent. The roots are structural. Sinuses are free. Heart shadow conventional configuration. Detected displaced fracture of ribs 4-5 on the left srednelopatochnoy line. / Protocol attached /.
US of internal organs from 02.21.2015: Conclusion: hemothorax right. / Protocol attached /.
CBC on 21/02/2015: Hemoglobin - 117,0g / L, Ht-35%, erythrocyte-4,0h1012 / l, CPU 0.88, platelets - 308,0h109 / L, white blood cells - 10 , 7h109 / xn-1, C-73, e--, L-22, M-3, erythrocyte sedimentation rate of 4 mm / h.
Biochemical analyzes of blood from 21.02.2015: fasting glucose of 7.6 mmol / L, total protein 72.1 g / L, total bilirubin 14.6 mmol / l, 0 straight, not straight 14.6, thymol test 3,5ed, AST 13.0 U / L, ALT 9.0 U / L, urea 3, 3 mmol / l creatinine 59.7 mmol / l.
CCK from 21.02.2015: Fibrinogen 2.4 g / l, 83% PI.
TREATMENT:
Drug:
Vitamin C 5% 10,0 + NaCl 09% -400.0 / drip
Refortan 6% 500.0 / drip
Promedol 2% 1,0 / m №2 Tramadol 5% of 2.0 V / m №1
Etamsylate sodium 12.5% ​​4.0 / jet
Riboksin 10,0 + NaCl 09% -400.0 / drip
Nimesil 1 package at 100.0 water 2 times a day
indometacin ointment 3 times a day is recommended: Evacuation of patients with possible 02.23.2015 scheduled flight of the aircraft. Attending physicians: _____________ Sushkov EA / trauma orthopedic / _____________ Logacheva EG / Manager. resuscitation department / Chief Physician: ______________ Timuhin AV / Neurosurgeon /

Результаты (английский) 3:

Extract from the history of disease No.073/0215
Rumania Enghien power to attract that special someone, 11.24.1974. virgin Mary., a citizen Norway, visited 02.21.2015 on 02.26.2015 in the stationary treatment in the clinic "Copper" Ltd. , at Kyrgyzstan, Bishkek city. Суеркулова, 5/3.
Enter the diagnosis:
is blunt chest trauma. Closed fracture (VI-VII ribs on the left side. Гемоторакс on the right hand side. Traumatic shock I degree.
complaints when income:The pain in the chest on the left side with a sense of lack of air, the feeling of dryness in the mouth, a common weakness.
many systemic diseases: 02.21.2015 received injury, skiing at the ski resort Тюя-Adzhigardak.On its own, accompanied by friends, was delivered in a hospital copper for the survey and treatment.
OBJECTIVELY: Status sick mid-level. Penetrate the skin and visible mucous membranes are faded. Breathing self,I am talking about, rigid, difficult, bronchial reactivity no, RR-23 in one minute. Saturation 90 %. Heart cadenced tones, at the moment of arrival ABP-120/90 mm hg Hg, heart rate 98 per minute. The language is wet, clean. Abdomen soft, smooth movement by palpation,Peristaltic motion be heard. Symptoms irritation ventral negative. Symptom поколачивания on 12 rib negative. Chair and dekstrana displayed self.
local status:When inspecting the Subdermal hematoma the chest on the left side. There has been movement by palpation tenderness in the field of projection 5-8-th ribs on the left anterior axillary, midclavicular line and заднеподмышечнои lines.A deep breath is limited by pain, was saved. Respiration is carried out on both sides, weakened in the lower division. The situation forced.
НЕВРОЛОГИЧЕСКИЙ STATUS: conscience clear, action-oriented in space, in time.Primary очаговои and менингеальнои симптоматики do not. The pelvic organs monitors.
survey:
MRI spine from 02.21.2015 : Google Translate-spine.Multiple hernias Шморля. Excessive kyphosis or.
Radiography Chest from 02.21.2015 on film bodies chest pulmonary fields are transparent. Working Group is slated for the Roots. Sinuses - which contains are free.Cardiac shadow a typical configuration. Is Detected fracture with offset 4-5 ribs on the left side the midscapular line, straight line. /Protocol is attached/ .
ultrasound internal organs from 02.21.2015 : Conclusion: гемоторакс on the right hand side./Protocol is attached/ .
clinical analysis of the blood from 02.21.2015 : hemoglobin - 117.0 g/l, ht-35 %, transport-4.0 x1012/l, CPU 0.88 , platelets - 308.0 x109/l, haemorrages - 10.7 x109/l: p-1, P-73, e--, l-22, m-3, ESR 4 mm/h.
biochemical blood tests from 02.21.2015 :On an empty stomach the glucose 7.6 mmol/l, the total protein 72.1 g/l, Rhesus - once 14.6 мкмоль/l, straight 0, is not a straight line 14.6 , тимоловая sample 3.5 units, ATC 13.0 units/l, ALT 9.0 units/l, urea 3.3 mmol/l, creatinine 59.7 мкмоль/l.
SSC Panel dated 02.21.2015 : Fibrinogen 2.4 g/l, PI 83 %.
TREATMENT:
medically:
vitamin C 5% 10.0 - NACL 09 %-400,0 in/in капельно
Рефортан 6% 500.0 in/in капельно
Промедол 2% 1.0 in/m 2 Трамадол 5% 2.0 in/m No.1
Этамзилат sodium 12.5 % 4.0 in/in
Рибоксин page: 10.0 - NACL 09 %-400,0 in/in капельно
Нимесил 1 package at 100,0 Water 2 times a day
Индометациновая ointments 3 times a day lord recommended: patient evacuation is possible with 02.23.2015 regular flight.
doctors: _____________ Association E.a./ osteogenesis imperfecta/
_____________ Logachev E.g. /Prod.The resuscitation/
chief physician: ______________ Тимухин as well.in. /Staffed/