CRIMEA STATE MEDICAL UNIVERSITY

NAMED AFTER S.I. GEORGIEVSRY

Department of Oncology

Head of Department : Prof. Sorkin Vitaley Markovich

Teacher : Prof Jamal

Case History
Patient : Bugay Nikolai Rigoreivich
Age : 59 years old
Admitted: 02/03/2009

CLINICAL DIAGNOSIS:

Main disease : Cancer of Right Lung

Stage III A T2 N2 M0(Post Operative)
Accompanying disease : none
Complication : none

Student: VinodKumar Gunushakran

Course: 5th
Group: 540
I. PASSPORT DATA
Patient Name : Bugay Nikolai Rigoreivich
Age : 59
Sex : Male
Marital Status : Married
Address : Simferopol, Crimea.
Occupation : Construction Worker
Admitted : 2nd March 2009

II. INQUIRY
COMPLAINTS

Patient complaints of nausea and loss of appetite and weakness due to chemotherapy and
radiotherapy.

ANAMNESIS MORBI

The patient had the 1st symptom in September 2008 First, patient felt pain in the chest
and scapular. This pain became sharper by time. Patient also had progressive cough with
blood and also dyspnea. Patient’s condition became worse and he admitted to the hospital
on the 04/09/2008.Patient was diagnosed with lung cancer stage III a T2N2M0.Patient
had surgery to remove part of lung on the 16th September 2008.Patient currently admitted
for adjuvant therapy :chemotherapy and radiotherapy.

ANAMNESIS VITAE

Patient was born on 7/08/1950 and is the only child to the family. He smokes. He
smokes an average of 20 cigarettes a day for the past 30 years. Patient also told
that he drinks occasionally. He does not take narcotics, not allergic to any substance,
no trauma, no other infectious disease like tuberculosis, venereal disease and hepatitis, no
hemotransfusion. His parents were healthy. They did not have any illness or genetic
disorders. He does not have any allergies or allergic reactions to medicines. He is
also not allergic to any certain type of food.

III. DATA OF THE PHYSICAL EXAMINATION

GENERAL EXAMINATION

General condition of the patient is satisfactory. Consciousness is clear, posture is active

and patient is cheerful. Patient’s body structure is normosthenic. The facial expression is
healthy. Skin is normal, clean, elastic and normal hydration. Lips are pink, visible
mucous membrane are pinkish, moist. Subcutaneous fat is developed well.
There were no edema in the lower extremity of the patient.

Temperature of body - 36.5 ºC

Height - 170 cm
Weight - 62 kg

Respiratory System

Patient complains about shortness of breath during physical exertion. But the breathing
becomes normal upon resting.

The patient breathes through his nose. The patient has abdominal type of respiration.
Breathing is rhythmic. His respiration rate is 16 times per minute. The patient has a
normosthenic and regular chest. The epigastric angle is nearly 90 º. The chest is
symmetric, supraclavicular fossae are slightly pronounced. Ribs are moderately inclined
when viewed from the side, scapular are closely fit to the chest and are at the same level.
The chest is the same height as the abdominal part of the trunk.

Rigidity of the chest increases bilaterally because of the age of the patient. The chest is
painless during palpation.

Comparative percussion revealed that there is a dull sound at a upper lobe of right lung.
Topographical percussion was done to determine the lung border.
Lower border of the lung:

Lines Right Left

Parasternal V rib -
Midclavicular VI rib -
Anterior axillary VII rib VII rib
Middle axillary VIII rib VIII rib
Posterior axillary IX rib IX rib
Scapular X rib X rib
Paraspinal XI spinous process XI spinous process

Mobility of lower border of the lung:

Lines Right Left

Midclavicular 5 cm -
Middle axillary 7 cm 7 cm
Scapular 5 cm 5 cm
During auscultation of the chest, vesicular breathing is heard over symmetrical points of
the lung. The vesicular breathing was decreased at the upper lobe of right lung.
Adventitious sounds like rales and crepitation are absent.
Cardiovascular System

Apex beat is palpated at the 5th intercostal space, 1cm medially from the left mid-
clavicular line. The apex beat is low, restricted and medium in strength. “Cat’s purr”
symptom is negative.

Percussion was used to determine the borders of the heart. The borders are normal.
Borders of relative cardiac dullness: the right border is 1cm from the right edge of the
sternum, upper border is at the 3rd intercostal space and the left border is 1cm medially
from the left midclavicular line. Borders of absolute cardiac dullness : the right border is
along the left edge of the sternum, the upper border is at the level of 4th rib and the left
border is 2 cm medially from the left midclavicular line.

On auscultation of the heart two sounds are heard at all 5 points. The sounds are
rhythmic. The 1st sound is louder than the 2nd at the heart apex and tricuspid valve. The
2nd sound is louder than the 1st at the heart base. Heart sound in the right pulmonary trunk
is more intensified than aorta. Both 1st and 2nd sound has the same intensity at the Botkin-
Erb point. No murmurs were observed.

The patient has regular pulse. Pulse is equal on both the arms. Pulse rate is 100 beats per
minute. The pulse symmetric, rhythmical or regular (pulsus regularis) and it has
satisfactory tension and filling. The nail bed formed an even margin suggesting that the
circulation is good.

Blood pressure of the patient is a bit higher than normal 125/80 with 125 being the
systolic pressure and 80 being the diastolic pressure. The blood pressure of the patient
was measured on both left and right arms. The blood pressure measurement was equal on
both left and right arms. The pulse pressure is 45 mmHg.

Digestive System

The patient does not have any difficulty in swallowing or passing food through the
esophagus. There are no incidences of hypersalivation as well.

The mouth is in a generally clean condition, without any unpleasant smells. The size of
the patient’s tongue is usual. The tongue is also moist and coated with a thin white layer.
The tongue is in a generally normal state. Mucous membrane of the mouth is pale colour.

The shape of the abdomen is normal and symmetrical. Tympanic sound is heard over all
parts of bowel in the abdomen. Dull sound can be heard over the part where located liver
and spleen.
Skin of the abdomen is soft and painless. Hernias and superficial tumours are not
palpable. Sklyarov’s, Mendel’s and Shchetkin-Blumberg’s symptoms are negative.

The sigmoid colon can be palpated in the left iliac region. It is cylindrical in form, soft
and painless during deep palpation.

By using deep palpation, the caecum can be palpated in the right iliac region. The caecum
is palpated as a smooth, soft cylinder and there is no pain. Other parts of the intestine are
not palpable.

Sign of liver enlargement is absent and it was palpated as soft, elastic and painless. On
the right midclavicular line, the upper border is located at level 6 th rib and lower border is
located at the edge of costal arch.

Gall bladder is not palpable. Symptoms of pressing and tapping of gall bladder are
negative and all tenderness points of gall bladder are negative. (Kera’s symptom,
Murphy’s symptom, Ortner’s symptom, Lepene’s symptom and Vasilenko’s symptom
are negative.)

Pancreas is not palpable. Kacha’s point and choledochopancreatic point are negative.

During auscultation of the abdomen, rumbling sound is heard over in all parts of large
intestines.

Urinary System

There is no pain in the loins, sacrum and the supra-pubic area. The patient has normal
urination. There is no pain during urination. Colour of the urine is normal, light yellow
color.

Edema, hyperemia and swelling of the loin are absent.

The kidneys are not palpable. When checked, Pasternatsky symptom is negative for both
sides of the lumbar region. The urinary bladder is not palpable.

Palpation of the ureter, kidney and the urinary bladder is painless.

IV. INITIAL DIAGNOSIS

Main diseases: Cancer Of RightLung(Post Operative)
V. ADDITIONAL INVESTIGATIONS
1. Blood Test
2. Urinalysis
3. Chest X/ray
4. Coagulogram

1. General Analysis of Blood

Haemoglobin : 134 g/l

Erythrocytes : 4.1 x 1012 /l
Colour index : 0.9
Leucocytes : 5.5 x 109 /l
Neutrophil – stab : 3 %
– segmented : 58 %
Lymphocytes : 34%
Monocytes : 4%
Eosinophil : 1 %
ESR : 5 mm/h

Conclusion: The result of the blood analysis is normal.

2. General Analysis of Urine

Colour : light yellow

Transparency : transparent
Protein : negative
Specific gravity : 1.009
Glucose : negative

Microscopy of urine sediment

Leukocytes 3-4 in field of vision

Erythrocytes 1-2 in field of vision

Conclusion: The result of the urinalysis is normal.

3. Chest xray
Before Surgey:
The picture of the anterior - posterior chest x/ray gives the image of a cloudy
infiltration at the middle area, outer zone of the right lung. The border of the
infiltration is uneven and irregular
After Surgery:
 The x-ray is normal

4.Coagulogram

Prothrombine index : 61%

Time of recalcification : 110’’
Fibrinogen A : 5.7
Fibrinogen B : negative
Fibrin : 26 mg

Conclusion: The result of coagulogram is normal

VI. DIFFERENTIAL DIAGNOSIS

Bronchitis. Pneumonia. Cancer of lung.

DEFINITION Inflammation of large airways Infection of small Malignant tumor of the
(bronchi) air sacs of lung lung.
(alveoli) and
tissues around
them.
ETIOLOGY Infection or exposure to irritants. Infection. a) smoking
a)Mycoplasma pneumonia a)streptococcus b) exposure to
b)Chlamydia pneumonia pneumonia radiation,
c)Streptococcus pneumonia b)Staphyloccus asbestos, arsenic,
d)hemophylus influenza aureus. chromates, nickel.
e)smokers c)klebsiella c) Air pollution
f)exposure to strong acids, pneumonia d) Have other lung
ammonia,chlorine, hydrogen d)immuno- diseases such as
sulfate. compromised tuberculosis and
e)smokers fibrosis.
SYMPTOMS & a)running nose a)moist cough a)Moist cough
SIGNS b)sore throat b)chest pain b)hemoptysis
c)fatigue c)chills c)chest pain
d)chilliness d)fever d)fever
e)fever e)shortness of e)droopy eyelids
f)moist cough breath. f)shortness of breath
e)back n muscle ache. g)loss of appetite
h)loss of weight
i)fatigue
g)cyanotic face and neck
COMPLICATION No metastasis No metastasis Metastase to other parts
of body.
VII. FINAL DIAGNOSIS

Main disease: Cancer of Right Lung

Stage III A T2 N2 M0(Post Operative)
Accompanying disease: none
Complication: none

VIII. TREATMENT

PLAN OF TREATMENT

1. Chemotherapy
2. Radiotherapy

IX. PROGNOSIS
Social recommendation:
 Patient should not smoke and drink alcohol. He also should not take any
high cholesterol food. Patient should advice to take diet high in oily fish,
fruit, vegetables, fibers and low saturated fats.
Labor recommendation:
 Patient’s activities should be limited, he should not involve in any strenuous
activity. Patient may return however he may not participate in physical
loaded work.

Medical recommendation:
 Patient can take the pain killer to decrease pain.
 Parient should follow doctor advice and take medication regulary
 Patient should visit hospital for futher examination and medication
according doctors advise.