Anda di halaman 1dari 12

Patients full name : Yaroslava stipanovka lucenko Age : 25 yrs Date of birth : 01/01/1986 Weight : 45 kg Sex : Female Address

: Nationality : Ukrainian Marital status : Single Occupation : Teacher (teaches music in kindergarten) Date of admission : 07th April 2011 Complaints : Pain in left epigastric region of the abdomen, that can last from a min to an hour(1min-1hr). pain is felt mostly in the day time and rarely at night. Pain is presented before meals(hunger pain). Weakness, headache, belching and bitter taste in mouth. Anamnesis Morbi Started about age 22 but has been periodic in character, biut patient never treated the disease. Exacerbation period occurs every spring and autumn each year. She was firstly diagnosed of peptic ulcer disease of duodenum in 2011 in polyclinic 5. The attack is less often now since she is under treatrment after she was diagnosed. Anamnesis Vitae She lives with her parents in a comfortable well ventilated apartment in sumy.Her parents have no history of peptic ulcer disease and no genetic illness in the family. She and her parents have no history of any disease such as tuberculosis, HIV infection, diabetes mellitus e.t.c .No allergies. No smoking and no drinking. Summary Patient complains of recurrent pain in epigastric region which is accompanied by belching and weakness. Onset of the disease was in 2008 and patient never under went any form form of treatment. Patient has no genetic illness and any family trace of the disease. Patient doesnt smoke or drink and no allergies, Physical examination General status of patient is satisfactory. The consciousness is clear. Her mental state is adequate. Patients posture is active. Body structure constitution is normosthenic. She is of regular body build. Her weight is 45 kg. Her height is 166 cm. Patients skin has normal skin color, texture and tugor. No visible sign of hyperpigmentation, eruptions or lesions. Joints are of regular shape, painless during palpation and movements. The patient looks slim.

Temperature of the body

: 36.6centigrade

Skin and mucous membrane Colour of skin is corporal, lip-nose triangle is pink, cyanoses are absent. Rashes are absent, surface of skin is smooth. Elasticity of skin is preserved. Temperature of skin is normal. Sensitivity of skin to heat, tactile, vibration and pain is preserved. The nail bed is pink, and free end are white. The nails are neatly cut. The hair is brown and long, evenly distributed and elasticity is preserved. The mucous membrane of the mouth is pinkish red in colour, its moist and no presence of lesions. The gum is pink without any lesion and no bleeding. The subcutaneous fat is distributed evenly and the skin tugor is kept. The Lymphatic system Peripheral lymph node i.e. submandibular, axillaries, and inguinal lymph node are enlarged. Muscular system Muscles are well developed, muscular tone is preserved. The range of motions are preserved. No pain on palpation of muscles. Bone system Chest is normosthenic. Epigastric angle is 90o. spine is without scoliosis and kyphosis. The extrimeties are symmetrical without deformities. Bones are without pathologies. The joints are not swollen without pains, temperature is normal, range of motion is preserved and the skin over them are normal. Respiratory system She breathes normally. Voice sound is normal. Form of chest is normosthenic, the epigastric angle is 90 degrees . The chest is symmetric. Respiration is abdominal type. Breathing is rhythmic. Respiratory rate is 18per minute. Vocal fremitus is equal and symmetric on both sides. On comparative percussion of lungs clear lung sound can be heard. Traubes space gives tympanic sound. Lower border of the lung : at the 5th intercostal space. Upper level of the apices on both sides anteriorly is 3-cm above clavicle and posteriorly it is at the level of the spinal process of the 7th cervical vertebra. Mobility of the lower edge of the lung on midclavicular line on both sides is 4 cm and on scapular line is 5 cm. On auscultation vesicular breathing was heard. Line Parasternal Midclavicular Right lung V VI Left lung -

Anterior axillary Middle axillary Posterior axillary scapular paraspinal

VII VII VIII VIII IX IX X X Spinous process of XI Spinous process of XI thoracic vertebra thoracic vetebra

Cardiovascular system Visible arteries pulsation is absent. Venous pulse is negative. Cardiac hump back and visible pulsation in the heart region are absent. Apex beat is palpated in the V-th intercostal space, 1 cm inside from the left mid- clavicular line. It is diffuse, strong and high. Cats murmur was not determined. Epigastric pulsation in breathing is not palpable. Borders of relative cardiac dullness: Right - 1cm laterally from the right edge of the sternum Upper - 3rd rib on the left parasternal line Left - 2 cm medially from left mid clavicular line Borders of absolute cardiac dullness: Right - along left edge of sternum Upper - lower edge of 4th rib Left - 1 cm medially from border of relative cardiac dullness The right and the left borders of vascular dullness are found along the edges of the sternum. On auscultation of the heart two sounds are heard in all 5 points. The sounds are rhythmic. The 1st sound is louder than the 2nd one at the heart apex and the tricuspid valve. The 2nd sound is louder than 1st one on the heart bases. Cardiac rate is 80 beats per minute. Pulse is equal on the both arms. Its rate is 70 per minute. Pulse is rhythmic, fast and diameter is of about 1,5 cm. Temporal and carotid arteries are well palpated, pulsation on the both sides is equal. Arterial pressure: Systolic - 110 mm Hg Diastolic - 60 mm Hg So, pulse pressure - 50 mm Hg

Digestive system The tongue is of usual size, moderately moist and smooth. Mucous of the mouth is light pink color and clean. Tonsils are not enlarged. Abdomen is of a regular form and symmetric. Abdominal wall participates in breathing. Tympanic sound is heard over all parts of the abdominal during percussion. In superficial palpation abdomen is tense and painful. Hernias and superficial tumour are absent. On auscultation of the abdomen peristalsis of the intestine of the moderate sound and frequency is heard. Vessel murmurs are absent. Greater curvature of the stomach is determined as soft smooth ridge 3 cm above the navel, its painless, displaces on 1.5-2 cm, produces slight rumbling sound. Other part of the stomach is not palpable. Visible enlargement of the liver is absent. Upper border of absolute hepatic dullness is on the level of 6th rib, lower is just down the edge of the costal arch. Gall bladder is not palpable. The symptom of pressing and concussion of the gall bladder is negative. Tenderness in the points of gall bladder is absent. Pancreas is not palpable. Tenderness in the points of conforming to the head, to the body and to the tail of pancreas and in point of phrenic nerve is not determined.

Urogenital system Visible pathology of the lumbar region is absent. Kidneys are not palpable. Palpation of the kidneys region is painless. Palpation along the course of ureters is painless. Pasternatzkovs symptom is negative on both sides. The urinary bladder is not palpable. Endocrine system Changes of the eyes (exopthalmus or enopthalmus) are not determined. There is no thyroid gland inflammation. Neurological Examination Consciousness is kept. Full mental development. Reaction to environment is adequate, patient knows who she is and where she is. Pain and tactile sensitivity is kept.

. Initial diagnosis Based on my investigations, by physical examinations and by complaints of the patient, my initial diagnosis will be peptic ulcer. Plan of investigation Clinical blood analysis Thrombosis, prothrombosis index Biochemical blood analysis Analysis of sugar in blood Urine analysis Stool test Endoscopy Rapid urease test Ultrasound ECG Physiotherapy and lasotherapy

Laboratory and Instrumental Methods

1.General analysis of blood: Hemoglobin 131 g/L Erythrocytes 3.6 X 10/L12 Leucocytes 4.0 X 109/ L ESR 14 Eosinophills 4% Stab cells 2 Segmented cells 55% Lymphocytes 30% Monocytes 9% Thrombocysi 208.8 x 109/L s Conclusion: Patient has normal blood indexes and does not show any pathology. 2. Coagulogram

Prothrombin index

75 mg %

Conclusion: Values are in the normal range. 3. Biochemical blood analysis Albumin Globulins A-globulin B-globulin G-globulin Total bilirubin Conjugated bilirubin Unconjugated bilirubin Creatinine A/G Protein Uric acid ALT AST ALP GGT LDH 57% 43% 14% 10% 19% 20.5 5.1 15.4 6.7 1.3 73 5.9 7 13 80 13 255

4. Analysis of sugar in blood Sugar in blood 5

5) Urine analysis: Reaction : Acidic Quantity : 30 Colour : yellow Transparency : transparent Protein: 0.017g/l Leucocytes: 3-4 in fov Erythrocytes: 3-4 in fov Cylinders : 0-1 Oxalate : small amount Mucus: moderate Conclusion: Nephritic and Nephrotic sign is absent.

6. Stool test Colour : brown Consistency: moderate Helminthes : absent Conclusion : stool is normal. 7. Gastroscopy Reddening and ulceration is seen. Ulcer of the duodenum, deformity of the bulb and gastroduoodenitis (diameter of ulcer 0.4cm). Swelling of mucous layer of duodenum . Redddness of mucous membrane of esophagus. Swelling and redness of mucous of stomach Rapid urease test Positive. Main diagnosis Peptic ulcer disease of duodenum Differential diagnosis:

Gastric ulcer gastroduodenitis gastritis gastroesophagesl reflux disease gastric cancer pancreatitis

Treatment 1st line of treatment is used which contains 1 proton pump inhibitor(PPI) and 2 antibiotics for 14 days. For eradication of H. pylori. Rp. : Omeprazoli 0,02g D.t.d.N.10 in caps. S. take orally 1 capsule once daily Rp. : Amoxicillini 1,0g D.t.d. N. 10 in tab. S. take orally 1 tablets 3 times daily

Rp. : Tab. clarithromycini 0,5g D.t.d. N 10 S. take orally 1 tablet 2 times daily

Epicrisis
Patients full name Yaroslava stipanovka lucenko Age : 25 yrs Date of birth : 01/01/1986 Weight : 45 kg Sex : Female Address : Nationality : Ukrainian Marital status : Single Occupation : Teacher (teaches music in kindergarten) Date of admission : 07th April 2011

1.General analysis of blood: Hemoglobin 131 g/L Erythrocytes 3.6 X 10/L12 Leucocytes 4.0 X 109/ L ESR 14 Eosinophills 4% Stab cells 2 Segmented cells 55% Lymphocytes 30% Monocytes 9% Thrombocysis 208.8 Conclusion: Patient has normal blood indexes and does not show any pathology. 2. Coagulogram Prothrombin 75 index mg %

Conclusion: Values are in the normal range. 3. Biochemical blood analysis Albumin Globulins A-globulin B-globulin G-globulin Total bilirubin Conjugated bilirubin Unconjugated bilirubin Creatinine A/G Protein Uric acid ALT AST ALP GGT LDH 57% 43% 14% 10% 19% 20.5 5.1 15.4 6.7 1.3 73 5.9 7 13 80 13 255

4. Analysis of sugar in blood Sugar in blood 5

5) Urine analysis: Reaction : Acidic Quantity : 30 Colour : yellow Transparency : transparent Protein: 0.017g/l Leucocytes: 3-4 in fov Erythrocytes: 3-4 in fov Cylinders : 0-1 Oxalate : small amount Mucus: moderate Conclusion: Nephritic and Nephrotic sign is absent. 6. Stool test

Colour : brown Consistency: moderate Helminthes : absent Conclusion : stool is normal. 7. Gastroscopy Reddening and ulceration is seen. Ulcer of the duodenum, deformity of the bulb and gastroduoodenitis (diameter of ulcer 0.4cm). Swelling of mucous layer of duodenum . Redddness of mucous membrane of esophagus. Swelling and redness of mucous of stomach Rapid urease test Positive.

Final clinical diagnosis: Peptic ulcer disease of the duodenum

Recommendation Cigarette smoking, aspirin and NSAIDs should be avoided. Alcohol in gtbgmoderation is not harmful and no special dietary advice is required.

Sumy State University Medical Institute


Department of therapy
Lecturer : NINEL ALEXANDROVICH

CASE REPORT
Full name of patient:
Clinical diagnosis

Yaposlave stipanovka lecenko

Main Disease :

peptic ulcer of duodenum

Student name: Iwunwa sandra Course: Fourth Group no

.: 714