Case History Surgery

8/18/2019 Case History Surgery

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VOLGOGRAD STATE MEDICALUNIVERSITY

DEPARTMENT OF FACULTATIVE SURGERY

CLINICAL CASE HISTORY

Student : Abdul Muhaimin Aliff Faial

G!"u# : $$C"u!e : IVFa%ult& : Gene!al Medi%ineTea%he!: Sha!ah'ina L(

V"l)")!ad *+,$


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PASSPORT DATA

Surname, Name, Patronymi : -ula'Date o! "irt# : +,.+,.,/0$

A$e : 1+ &ea! "ldNationa%ity : RuianGen&er : MaleP%ae o! Re'i&ene : 2"t"3a4 Ul( 2"mmuniti%he'a&a"%oo& Grou( : O 5I G!"u#6R#e'u' !ator : 7"iti3eRe!erre& to #ere on : +8(+$(*+,$ 5Tueda&6

Initia% Dia$no'i') A%ute #an%!eatitiC%inia% Dia$no'i') 7an%!eati% C&t

Fina% Dia$no'i') 7an%!eati% C&t

COMPLAINT7atient %"m#lain "f f"!mati"n "n #ain in e#i)at!i% !e)i"n !adiatin) t" the ba%'( 7atiental" %"m#lain nauea( N" "the! %"m#lain #!e3ail(

ANAMNESIS MOR"I

7atient4 -ula' %"m#lain "f a%ute e#i)at!i% #ain and bein) h"#itali9ed at"#ital N" ;(7atient ha n" "the! %h!"ni% dieae #!i"! t" admii"n(

ANAMNESIS VITAE• Ma!!ied al!ead& and ha3e* %hild!en(

• N" famil& hit"!& "f a%ute "! %h!"ni% dieae(

• a3e bad habit. m"'in)4 al%"h"l "n "%%ai"n(

• N"t d!u) addi%ted(

• E#idemi% infe%ti"n . d"n


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STATUS PRAESENS

Con&ition ) Satifa%t"!&

Coniou'ne'' ) Clea! Po'ture ) A%ti3eCon'tituition ) N"!m"theni%A((etite ) N"!mal(S*in an& muou' mem+rane ) N"!mal %"l"!(Peri(#era% %ym(# no&e' ) N"t enla!)ed and n"t #al#able("one' ) N" an& defe%t "f 'ull and %het(oint' ) N"!mal m"3ement "f e=teni"n4 fle=i"n4 abdu%ti"n4 and

addu%ti"n(

PHYSICAL E-AMINATION.a/ RESPIRATORY SYSTEM

Form o! #e't ) N"!m"theni% %het(Re'(iratory mo0ement ) Vei%ula! !e#i!ati"n(Re'(iratory rate ) ,0 #e! minute(Re'(iratory &e(t# ) N"!mal b!eathin)(Re'(iratory r#yt#m ) N"!mal !h&thm(

Pa%(ation )

N" #ain i #al#ated at b"th ante!i"! and #"te!i"! th"!a%i% !e)i"n( N"!malelati%it&( V"%al f!emitu a!e identi%al "n &mmet!i%al #"int "n b"th ide "f the%het and ba%'(

Peru''ion )T&m#ani% "und a!e &mmet!i%al in b"th ide "f lun)( N"!mal lun) b"!de!(

Au'u%tation)

Vei%ula! b!eathin) i hea!d4 >ith"ut !ale and %!e#itati"n(

.+/ CARDIOVASCULAR SYSTEM

In'(etion )

ea!t !e)i"n i n"!mal( S'in i n"!mal %"l"! and n"t )!ea&( N" %a!dia% hum#ba%'(

Pa%(ation ) A#e= beat : 7al#able in 1th inte!%"tal #a%e4 *%m mediall&f!"m left mid.%la3i%ula! line >ith n"!mal >idth4 hei)ht4 !eitan%eand i9e(

Ca!dia% beat : N"t #al#able(E=t!a a#i%al #ulati"n : A"!ti% #ulati"n : N"t #al#able(

E#i)at!i% #ulati"n : N"t #al#able( 7ulati"n "f li3e! : N"t #al#able(

Cat


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#a%e(ea!t !ate : ?* beat@minute(-l""d #!eu!e : ,$+@?+ mm)(Rh&thm : Rh&thmi%

Peru''ion )

The !elati3e and ab"lute b"!de! h"> that #atient i >ithin n"!mal !an)e((

Au'u%tation )

Au%ultati"n "und at all au%ultati"n #"int a!e %lea! and n"!mal( N" mu!mu!( N"a!!h&thmia i hea!d(

./ URINARY SYSTEM

In'(etion )

Abent "f #!"t!ui"n and edema(

Pa%(ation)

2idne& : im#al#able 5n" #t"i "! enla!)ement "f 'idne&6U!ete! and u!ina!& bladde! : im#al#able

Peru''ion)

7ate!nat'&ith"ut #ain(

S#leen : N"t #al#able(

2idne& : N"t #al#able(

7ate!nat'ii Si)n . Abent

U!inati"n : N"!mal f!eel&4 >ith"ut #ain

Defe%ati"n : N"!mal( St""l n"!mal and !e)ula!(


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Statu' %oa%i'

The!e i n" %han)e at l"%al a!ea "f the #ain(

La+oratory Te't

.A/ Coa$u%o$ramme .123425364/

Reult N"!mal 3alue

7!"th!"mbin ,0(+ ,;.,8

7a!tial Th!"mb"blatin time *?(+ *;.$;

Fib!in")en *(1 *.;)@l

S"luble Fib!in M"n"me!&nhC"m#le= tet 56

. Till ;+)@l

."/ "%oo& Te't .123425364/

Indi%at"! N"!mal 3alue Reult

E!&th!"%&te M :;(1.1(+ = ,+,*F :$(1.;(1 = ,+,*

;(; = ,+,*

em")l"bin ,,8.,0+)@l ,*;

C"l"u! inde= +(8., +(8;

E"in"#hil $ +

7a!aite .

Leu%"%&te ;./ = ,+/ ;(? = ,+/

-a"#hil +.+(,

Neut!"#hil

.m&el"%&te .

.metam&el"%&te .

.band f"!m ; *

.e)mented f"!m 0$ ?*

L&m#h"%&te ,/.$?H *;

M"n"%&te $.,,H *

ESR 8 mm@h! 5N"!mal: M: *.,+mm@h!J F: *.,1mm@h!6

.C/ "io#emia% te't o! Serum .123425364/

T"tal -ili!ubin .,+(,Di!e%t -ili!ubin .+Indi!e%t -ili!ubin .,+(,


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ALT .*8 AST .$8U!ea .$(/C!eatine .1,Glu%"e .$(?

Albumin .$/(8 Am&lae .*8 Al'aline #h"#hatae .,0+

.D/ Urea te't

Kuantit& : ;+(+Rea%ti"n : a%idi%C"l"! : %lea! S#e%ifi% )!a3it& : ,+,*7!"tein : .

N" "f leu'"%&te#e! 3iual field : +.*N" "f f!eh R-C#e! 3iual field : .E#ithelium :7a3ement 5PQ6 : abent

C!&tal : abentC&linde! : abent

In'trumenta% Dia$no'i'

U%tra'oun& E7amination

Date ,+.+$.*+,*

O!)an Si9e C"nt"u! E%h")eni%it& Veel St!u%tu!e

Li3e! ,*?J ?+ mm Sm""th Medium V( #"!tae./mm

"m")en"u

Gall-ladde!

?1= *; mm Sm""th Thi%'ne "f all *mme!e%h")ene%it&

"m")en"u

-ile du%t d( %h"le%"hu 1(0 %m4 3iuali9ati"n len)th *+ mm

7an%!ea

** = 8 = tailbut n"t3iible

N"tm""th

Medium d(#an%!eati%u

S#leen ,+, = 1+ mm Sm""th Medium 3( lienali1mm

"m")en"u

U!ina!&bladde!

1+ %m$ Sm""th Thi%'ne "f >all *.$ mm "m")en"u

2idne&


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Ri)ht ,+/ = 1+ Sm""th Medium "m")en"u

7a!en%h&mal thi%'ne ,0.,?

Left ,+/ = 1+ Sm""th Medium "m")en"u

7a!en%h&mal thi%'ne ,0.,?

On Ult!a"und E=aminati"n4 3iible #an%!eati% %&t at head "f #an%!ea >ith i9e "f*1mm =,1mm = ,+mm(

Com(uter Tomo$ra(#y

On E=aminati"n4 3iible a %&t.li'e ma l"%ated at the head "f #an%!ea >ith i9e "f*1mm =,1mm = ,+mm(

Dia$no'i'

Diffe!ential Dia)n"i• A%ute inflammati"n

• 7e!f"!ati"n "f h"ll"> "!)an

• Obt!u%ti"n "f the alimenta!& t!a%t

• A%ute inte!nal bleedin)

• ea!t i%hemia

ith hel# "f ult!a"und and CT %an e=aminati"n4 the #atient i dia)n"ed >ith#an%!eati% %&t(

Final Dia)n"i: 7an%!eati% C&t

P%an o! Treatment

C"ne!3ati3e t!eatment:

,6 "#italied*6 Diet N"( 1$6 D!u) "mat"tatin 5"%t!e"tide de!i3ati3e "f "mat"tatin6 ,++ mi%!")!am$ time #e! da& f"! 1 da&

. Antibi"ti% if the!e i an& int"=i%ati"n i)n


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Diary

6683485364

Gene!al %"nditi"n "f #atient atifa%t"!&4 a##etite )""d4 lee# >ell4 %lea! %"n%i"une(Re#i!at"!& !ate: ,? #e! min4 n" %!e#itati"n4 3ei%ula! !e#i!ati"n(-7 : ,*+@8+ mm )7ule : 8+ beat@min

6983485364

Gene!al %"nditi"n "f #atient atifa%t"!&4 a##etite )""d4 lee# >ell4 %lea! %"n%i"une(Re#i!at"!& !ate: ,8 #e! min4 n" %!e#itati"n4 3ei%ula! !e#i!ati"n(-7 : ,*1@8+ mm )7ule : ?* beat@min

E(iri'i'

7atient4 -ula' A( -( 4 1+ &ea! "ld 5+,.+,.,/0$64 li3e in V"l)")!ad Cit&4 2"t"3a4Ul( 2"mmuniti%he'a&a (

e >a ent t" "#ital N(; "n +8(+$(*+,$4 b& %"m#lain "f a%ute e#i)at!i% #ain( Afte! "me e=aminati"n4 the d"%t"! #ut dia)n"e.

- 7an%!eati% %&t

i mana)ement: C"ne!3ati3e t!eatment

7atient ta'e diet %"nt!"l diet N(1: le fat.%"ntainin) diet( And %"ntinue ta'in) : S"mat"tatin

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Case History Surgery