MEDICAL CASE REPORT
I. PATIENT’S ID
1. Name:Yarulina Fauziya
2. Age: - 68 yrs old
3. Occupation: - Pensioner
4. Home Address: - Gudavanceva Street, House 43, Flat No 16, Kazan.
5. Date of Admission: - 25 november 2008
II. MEDICAL HISTORY
1. CC: Unconstant Abdominal pain, located in the periumbilical area, pain
is colicky type, pain occurs after having a meal in 30 minutes, pain
is relieved by itself within 15 minutes, pain sometimes occur in
midnight which awake her.
Secondary Complaints: - weakness and headache sometimes.
2. HPI: - She got the diagnosis of Peptic Ulcer Disease in 2002, that is, 6
years ago and she was treated in hospital. She has suffered 4 times
exacerbation of ulcer in 6 years and this is her 5 hospitalization due to
She is taking Omeprazole, Almagel and Herbal drugs. She feels better
after taking these medicine.
History of recent admission: - Planned hospitalization for the operation of
Umbilical Hernia but on pre operative examination on Endoscopy revealed
ulcers in duodenum
3. PMH: •
Other medical problems: - She has gall bladder stone from last 3
years but without any symptoms.
She has no allergies.
No any major childhood illness.
All required immunization has been done. No hemotransfusion.
4. FH: - No any family history of having ulcerative disease in her family
Medications: - no other medications.
Habits: Tobacco smoking: No
Alcohol consumption: No
She did not take any narcotics.
III. Data of Physical Examination:0
General Condition of the patient is satisfactory. T : 36.8 C.
Patient’s position is active and level of consciousness is clear.
Facial expressions are satisfactory, no painful expression on face, no
cyanosis and do not show any disease process.
Constitutional type is hypersthenic. Height 169 cm. weight 75 kg. BMI:
26.25kg/m . No gait and bearing abnormalities.
Skin colour is physiologic.
Nails are faint white-pinkish in colour without any abnormalities and
without digital clubbing.
There is no edema on legs.
Lymph nodes are not visible on inspection and not palpable on palpation
without any tenderness.
Muscles: general development is satisfactory and absence of tenderness
on palpation. Muscle strength is strong and muscular tone is regular.
Bones: On examination of skull, chest, spine, extremities tenderness and
deformations are not revealed.
Joints: There is no deformation and no tenderness.
Respiratory system:Nasal breathing is not laboured. Nasal form is correct.
Chest shape is flat.
Chest is symmetrical without any deformities. Respiratory pattern is
abdominal. Respiration is regular with respiratory rate: 18 per minute.
Chest respiratory motions of both sides are even, symmetric and there is
no lag in motion. Additional respiratory muscles don’t participate in
Percussion of lungs:
On Comparative percussion resonant note is heard which is same on both
sides of back side of chest.
Lung Auscultation: Vesicular Breath Sounds is heard. No adventitious
breath sound is heard.
Precordium: Absence of any protrusion and deformities, no pulsation is
Apical impulse is not palpable.
Cardiac impulse and epigastric pulsation are absent.
Thrills are absent.
Cardiac Relative Dullness borders: right 1 cm lateral to right sternum edge
in 4 intercostal space.
Left: 1 cm lateral to Midclavicular line in 5 intercostal space.
Upper border: 3 rib.
Heart configuration is normal.
Heart Auscultation: - Rhythmic heart sounds S1 and S2 are heard.
Absence of any murmurs.
Heart rate is regular: - 80 per minute and it is regular.
Arterial pulse 80 per minute, regular, satisfactory filling, satisfactory strain
equal on both arms
B P 130/90mm Hg
Fetor oris: No smell from mouth.
Visible mucous of oral cavity has a pinkish tint.
Tonsils are not inflamed.
Gums are pinkish yellow in colour without any bleeding,
Tongue is pinkish in colour, moist velvety appearance with slight greyish
white fur. Tongue is coated.
Abdomen is flat. It is symmetrical, but we see the umbilicus 3cm coming
out we suggests for umbilical hernia.
Muscles of abdominal wall actively take part in respiration.
On auscultation of abdomen bowel sound i.e borborygmus is heard.
On percussion of abdomen tympanitic percussion note is heard.
On superficial palpation of the abdomen is tender in periumbilical area.
Shchetkin-Blumberg’s sign is negative.
Sigmoid colon is not palpable.
Using percussion, auscultopercussion, auscultoaffriction methods the
stomach lower border is defined at the level of about 5cm above
Gastric greater curvature and pylorus are not palpable.
Pancreas is not palpable.
Liver area: On observation there is absence of any protrusion or masses
or any other deformities.
Liver span after Kurlov: On right Midclavicular line 12 cm, on Midsternal
line 6 cm on left coastal arch 6 cm.
Liver palpation: Liver is not palpable.
Gallbladder is not palpable.
Spleen area: On observation there is absence of any protrusion or masses
or any other deformities. There is no area of tenderness.
Spleen on percussion over 10 rib horizontal length is 8 cm; vertical length
is 4cm between 9 and 11 ribs. Spleen is not palpable.
Kidneys On observation there is absence of any protrusion or masses or
any other deformities. There is no area of tenderness.
Kidneys are not palpable. Pasternatsky’s sign is negative.
Urinary bladder is not palpable.
IV. Provisional diagnosis
Umbilical Hernia, Duodenal ulcer disease, exacerbation.
V. Investigation Data.
a) Blood Analysis: - Hb – 132g/l, ESR – 22 mm/h. RBC 4.6,
Leukocytes -7.5 ×10
/l, neutrophils asegmented-2, segmented –
68, lymphocytes- 22, monocytes- 6, eosinophils-2, thrombocytes
275000, PTI 95%.
b) Urine analysis: - density 1010, epithelial cell 1, RBC I, Protein
c) Biochemical Blood Analysis: - urea 5.9, total proteins 82, total
bilirubin 11.6, Amylase 56, AlkP 74, Na 143, GGT 26, AST 19,
ALT 21, Creatinine 76, sugar 3,9.
d) ECG: - Sinus Rhythm, Little ST elevation in V5, Ventricular
Extrasystole, EA shift to left.
e) Endoscopic conclusion:- Duodenal ulcer, Erosive Gastritis, Reflux
VI. Clinical diagnosis
Umbilical Hernia, Duodenal ulcer disease, exacerbation period, without any
Diet no 1.
Omeprazole 20mg twice daily
Drotraverin 0.04g thrice daily
On retrieving remission period of ulcer, operative procedure of Umbilical