National O.O. Bohomolets Medical UniversityDepartment of Propaedeutic of Pediatric Head of department: Prof. Teacher: Melina Case report of Name of Pt: Velichka Dema 17 y.o Diagnosis: Duodenal Ulcer Complication: Chronic Cholecystitis and Chronic Pancreatitis Student: Group 36 5th year Med 1Date of examination:23/09/08
A) Identifying information • Surname: Velichka Dema • Age. Date of birth: 17 y.o 1990 • Nationality: Ukraine • Address: Kiev, hostel. • Admission date n time: 19/09/08 evening • Diagnosis: Duodenal UlcerB) Chief complain: - Pt complained about a gnawing pain at upper abdomen near epigastric region.Each pain last for 2 to 3 minutes and attack few times per day. Pain arises 4 hours after meal. Pt lies down to reduce the pain. Pt takes 1 tab. of enterosorbent per day. - No complain of vomiting, headache or nausea. Normal body t۫C) Anamnesis of Morbi: - Pt suffered from the illness since 15/09/08. Pt was hospitalized and Still under medication (enterosorbent). Pt doesn’t feel better after medication. 1. Respiratory system - No specific complain. 2. G.I system- short and mild pain at upper abdomen near epigastric region which occurs 4 hours after meal. 3. Genitourinary system-no back pain. Normal color of urine (light yellow). 4. Nervous system and psychic state- No specific complain. 5. Sense organs-good vision, sense of smell is good, no taste disturbance. 6. Mucoskeleton system- No specific complain. 7. Cardiovascular system-No specific complainD) Anamnesis Vitae - Living far from parents and stays in the hostel in Kiev. No family problems. - Secondary school student. - positive family history of gastritis.( grandpa from father’s side and grandma from mother’s side) - No allergic and no other diseases. - Normal dietary. Hostel food.3 times per day (mostly cereals) and tea. Meat and vegetables are not very often. - sports : sometime a) Obstetric anamnesis:- • Pregnancy I • Delivery I • Neonatal period:- - Weight: 3100g - Length: 52cm • Physical development according to percentile method: - Body length: middle (25-75 centile) - Body weight: middle (25-75 centile)
Child is weight is harmonically for his length. b) Physical and neuro-psychological development of the child: • Current weight: 53.5kg’s (25 -75 centile) • Current height: 160.5 cm (25-75 centile) Child is weight is harmonically for his height. c) Breast-feeding: - Only artificial feeding by Malish bottle feeding. e) Vaccination: - According to the table. 3-5 years School 12 13 Vaccine 2 months 3 months 4 months (Pre- Leaving months months School) (13-18yrs) Diphtheria, Tetanus,Pertussis,Inactivated Polio DtaP/IPV/Hib DTaP/IPV/Hib DTaP/IPV/Hib Hib DTaP/IPV . Td/IPVVaccine, (taken) (taken) (taken) (taken) (taken)Haemophilusinfluenzae (Hib)Pneumococcal PCV PCV PCV . . . .conjugate vaccine (taken) (taken) (taken) Men C Men C MenCMeningitis C . . . . (taken) (taken) (taken)Measles, Mumps, MMR MMR . . . . .Rubella (taken) (taken) E) Physical examination: 1. General condition of child • Mood: good • Position on the bed: active • Consciousness: clear • Sleep: good and at the correct time. • Appetite: Normal appetite but pain occurs 4 hours after meal. • Body constitutional: Normostenic a. Respiratory system - No specific complain. b. G.I system- abdomen pain at upper abdomen near epigastric region. c. Genitourinary system-no back pain. Normal color of urine (light yellow). d. Nervous system and psychic state- No specific complain. e. Sense organs-good vision, sense of smell is good, no taste disturbance. f. Mucoskeleton system- No specific complain. g. Cardiovascular system-No specific complain
Physical development: • Height: 160.5 cm (25-75 centile) • Weight: 53.5 kg’s (25-75 centile) • Head circumference: 53.8 cm (25-75 centile) • Chest circumference: 82.5 cm (25-75 centile) • Body mass index: harmonious because the weight is proportional with the height. 2. Skin • Skin colour: normal skin color (pink) • Humidity: satisfactory • Elascity: satisfactory • Rash: absent • Tugor: satisfactory • Edema: absent • Swelling: absent 3. Mucous membrane • Color: pink colour without any hemorrhage. • Tongue: satisfactory. No specific sign of abnormality. • Eyes: satisfactory. No specific sign of abnormality 4. Subcutaneous layer -Moderate. • Turgor: satisfactory. • Distribution: uniformly • Thickness: satisfactory (2cm) • Edema: absent5. Muscular system • Hypertonus/ hypotonus: adduction and abduction movements satisfactory and without any abnormalities • Gower’s symptom : negative • Atrophy: absent • Paralysis and paresis: absent, satisfactory of muscle tonus, absent of Muscular twitching, no arbitrary and also controllable movements of face, trunk and limb muscle. • Rickets symptom: absent Skull: Absent of caput quadratum, absent of Olympic forehead, absent of caput natiforme, no flat back of the head, no crniotabes, no tower skull, no macrocephaly Thorax: normostenic chest form and without deformation. Absent of pigeon chest, funnel chest and Harrison fissure Extremities: without deformation. Absent of strings of pearls, satisfactory thickness of wrist and ankles. No O-shaped form, no X-shaped form Teeth: 30 permanent teeth which is satisfactory according to her age and
without any eruption and deformation • Muscle’s force and muscles tones: satisfactory. - Muscles development is satisfactory according to age. 6. Bone system • Teeth: 30 permanent teeth, satisfactory according to her age group. • Size of head: 53.8 cm (25-75 centile) satisfactory according to percentile Table.Without any deformation • Size of thorax: 82.5 cm (25-75 centile).satisfactory according to percentile table. Normostenic • Edema: absent • Rickets symptom: negative. Skull: Absent of caput quadratum, absent of Olympic forehead, absent of caput natiforme, no flat back of the head, no crniotabes, no tower skull, no macrocephaly Thorax: normostenic chest form and without deformation. Absent of pigeon chest, funnel chest and Harrison fissure Extremities: without deformation. Absent of strings of pearls, statisfactory thickness of wrist and ankles. No O-shaped form, no X-shaped form Teeth: 30 permanent teeth which is satisfactory according to her age and without any eruption and deformation • Scoliosis: absent7. Joints • Pain: No pain. • Limitation of movement: No limitation of joint movement. satisfactory • Color: normal skin color, no hyperemia or pallor. • Size: normal size, according to her body built and size. They are not enlarged. • Temperature: The temperatures around his joints are of normal body temperature. • Edema: absent Tendon: Wrist: positive and symmetrical at the dextra and sinister. Painless Knee: positive and symmetrical dextra and sinister. Painless Elbow: positive and symmetrical dextra and sinister. Painless Ankle: positive and symmetrical dextra and sinister. Painless 8. Lymphatic system No abnormalities in any localization of lymph nodes. Palpation: • Neck: Submandibular: slightly palpable (0.5cm), painless, elastic, movable, not conglomerated, normal skin temperature, skin is not changed above them Inframandibular: slightly palpable (0.5cm), painless, elastic, movable, not conglomerated, normal skin temperature, skin is not changed above them. • Axillary: slightly palpable (0.5cm), painless, elastic, movable, not conglomerated,
normal skin temperature, skin is not changed above them • Inguinal: slightly palpable (0.5cm), painless, elastic, movable, not conglomerated, normal skin temperature, skin is not changed above them. • Occipital: not palpable, painless, • Supraclavicular: not palpable, painless • Infraclavicular: not palpable, painless • Cubital: not palpable, painless • Popliteal: not palpable, painless 9. Respiratory system • Chest circumference: 82.5 cm (25-75 centile).satisfactory according to percentile table. • Size of chest: Normostenic. Cone shape form of thorax, the transversal size is more than the anterior- posterior size, angle of thorax is equal to 90 degree • Rate of breathin: normopnea. 22 per minute • Rhythm: rhythmic respiration • Type of breathin: thoraxic and symmetrical • Passage of breathing: free nasal • Vocal tremor: symmetrical in both sides. It’s identical from both sides but on the apex of the lungs it is louder in comparison with the lower lobe. • Examination of fauces: satisfactory, normal colours of mucous (no inflammation), no swelling of the palatine tonsils, any hemorrhage spots and rash Palpation: No abnormality. • Pain; absent • Edema: absent • Protrusion of intercostals intervals: absent • Resistance of thorax: satisfactory. • Pleural rub: absent of the noise by deep palpation Topographical percussion: • Upper border from anterior side: 3cm above the clavicles • Upper border from posterior side: C7 • Kronig’s area: 4 cm • Inferior border: right midclavicular- right: VI rib Middle axillary line; right; VIII rib; left; VIII rib Scapular line; right; X rib; left; X rib • Excursion of the lungs: 3cm Comparative percussion: symmetrical and resonance sound. Auscultation sound: symmetrical and without any additional sound. Vesicular sound near alveoli and bronchial sound at the throat and trachea. Cough: absent Bronchophony; satisfactory10. Circulatory system
Palpation of apex: weak pulsation. Horizontal line: V intercostal space Vertical line: 0.5cm to the middle from the left midclavicular line Area of apex: 1x1cm Magnitude of apex beat: moderate height Force of apex beat: moderate force Cardiac thrust: invisible Cardiac hump: absent Pulse rate: 68 per minute Pulse rhythm: regular Tension of pulse: Moderate Filling of pulse: satisfactory Size of pulse: normal size Borders of relative heart dullness: Right border: between right parasternal and right sternal line. Closer to the latter, further called “right sternal line” Upper border: III rib Left border: on the left midclavicular line Transversal heart distance: 11cm. Border of absolute heart dullness: Right border: left sternal line Upper border: IV intercostal interval Left border: left parasternal line Transversal heart distance: 5 cm Auscultation: 1st point: S1 louder than S2 (mitral valve) 2nd point: S2 louder than S1 (aortic valve) 3rd point: S2 louder than S1 (pulmonary valve) 4th point: S1 louder than S2 (tricuspid valve) 5th point: S1 louder than S2 (Botkin Erb’s point) - No additional sound been heard. No murmur. Blood pressure: 120/75 mmhg11. GI system Inspection:- • Mouth: normal colour mouth (natural light pink) • Mucous membrane: satisfactory colour. • Tongue: light pink colour, damp, clean • Fauces: normal colour and moisture of tonsils and posterior pharyngeal walls • Teeth: permanent • Stomach: normal form. Round and symmetrical, size is lower than thorax level, Bad participation of stomach muscles due to pain. Palpation:-
• Sigmoid colon: smooth surface, 2cm, soft, mobile, absent of grumbling , painless • Cecum: inactive, 3 cm smooth surface and rather dense but painful • Shchotkin – Blumberg symptom: negative/painless • Rovsing symptom: negative • Ascending colon: 2cm of thickness, mobile, painful and grumbling. • Transverse colon: umbilicus level, mobile upwards and downwards, soft, without grumbling, 2cm of thickness but painful. • Descending colon: 2cm of thickness, mobility, painful and grumbling • Mendel’s symptom: negative • Liver: soft, smooth surface, sharp margin, tenderness but painful. Gall bladder (GB):- • Kehr’s symptom: positive/pain present during inhalation • Lepine’s symptoms: positive • Mussy’s symptom: positive • Ortner’s symptom: positive • Murphy’s symptom: positive. pain present during inhalation • Boas symptom: negative. Painless Pancreas:- • Chauffard’s zone: present • Grott’s method: palpable. • Desjardin point: pain • Mayo- Robson’s point: pain • Spleen: impalpable. Percussion:- • Stomach: tympanic resonance sound. Slight abdomen pain (acute) especially near right hypochondrium and epigastic region. • Liver: dullness sound. (Kurlov’s method): - Margin I: 10 Margin II: 7 cm Margin III: 7 cm • Spleen: dullness sound at the 10th ribs Fluctuation: no liquid in abdominal cavity Auscultation of stomach:- - Grumbling sounds are present - Lower border of stomach: 2-3cm above umbilicus Stool: Without complain. Once a day without pain. Brown colour and no odor12. Genitourinary
Edema: absent Palpation of bladder: painless. Pasternatsky symptom:-negative and no pain Obraztsov-Strazhesko: –negative, kidney is not palpable and no pain Shelagurov’s method: – negative and no pain Israel’s method: – negative and no pain Botkin’s method: - negative, kidney is not palpable and no pain Hnatyuk’s method: - negative and no pain Percussion: decrease in resonance because of empty bladder. Urine: light yellow colour and satisfactory diuresis. No nocturia 13. Nervous system - All 12 cranial nerves are normal without any disorder. More sympathetic effect than Parasympathetic. N. OLFACTORIUS : No disorder. (Patient can identify different smell) N. OPTICUS : No disorder. (Both eyes coordinate symmetrically) N. OCULOMOTORIUS : No disorder. (Eyes blinks) N. TROCHLEAR : No disorder. (Eyes blinks) N. TRIGEMINUS : No disorder. Tactile of skin is symmetrical in both sides of the cheeks. N. ABDUCENS : No disorder. Movement of m. orbitalis superior and m.orbitalis inferior. N. FACIALIS : No disorder. Symmetrical in both sides of face. N. VESTIBULARCOCHLEAR : No disorder. Balanced. N. GLOSSOPHARYNGEAL : No disorder. (No problem with swallowing, speech is clear.) N. VAGUS : No disorder. (Skin on the abdomen appears tactile and during Demography, red lines appears. Symmetry at both sides) N. ACCESORIUS : No disorder. Symmetrical in both sides. N. HYPOGLOSSAL : No disorder. MENINGEAL SYNDROME:- No headache, no vomiting, no nausea and normal sensitivity. MENINGEAL SIGN • RIGIDITY OCCIPITALIS : Negative. No pain. • BABINSKOGO REFLEX : Negative. • KERNIG’S REFLEX : Negative. • BRUDZINKI REFLEX :- a) UPPER REFLEX : Negative. b) MIDDLE REFLEX : Negative. c) LOWER REFLEX : Negative. Permanent reflexes;
• Swallowing – no disorder • Tendon reflexes on limbs – no disorder • Conjunctival reflexes – eye blinks without delay (no disorder) • Corneal reflexes – eye blinks without delay (no disorder) • Mc Carthy’s – Negative (no disorder)ENCEPHALITIC SYNDROME: - - Negative and without disorder • Temperature: absent • Tumor: absent • Consciousness: clear • Epilectic seizures: absent • Muscle: without jerks. • Breathing: no violation • Cardiac: no violation • Movement: good and no abnormalities • Speech: good and no abnormalitiesMOVEMENT VIOLATION SYNDROME: - Negative and no disorder. • Central (spastic): negative • Peripheral (atonic, flaccid): negative • Hyperkinesias: negativeIMPAIRMENT OF CONSCIOUSNESS SYNDROME:- Clear consciousness and no disorderCONVULSION SYNDROME:- Negative and no disorder • Tonic: negative • Clonic: negative • Tonic-clonic: negativeSIMPLEX REFLEX • SKIN REFLEX: Positive. Muscle movements is symmetrical at dextra and sinister • MUCOUS : Tongue n swallowing reflex is normal. Symmetrical at dextra and sinister • EYE : Eye blinked. Symmetrical at dextra and sinisterTENDON:Wrist: positive and symmetrical at dextra and sinister. PainlessKnee: positive and symmetrical at dextra and sinister. PainlessElbow: positive and symmetrical at dextra and sinister. PainlessAnkle: positive and symmetrical at dextra and sinister. Painless
14. Endocrine system Palpation of thyroid gland: • Pain – painless • Surface-smooth, • Consistency – soft • Mobility – mobile(during swallowing movements) • Pulsation – absent - No abnormality/no disorder.F) Preliminary DiagnosisAccording to complaints:- Pt has short abdominal pain after eating oily food. The pain is sharp at the right side quadrant and epigastric region.According to anamnesis:- This is the 1st attack of illness where the child was ill for a weak and was under some medication to reduce the pain but no improvement. The pain occur at upper abdomen near epigastric region. The pain occur for 2 – 3 minutes 4 hours after meal. The pain reduce after meal.According to physical examination:-Pt has shown positive symptoms for pathology of the GB : Kehr’s symptoms, Mussy’s symptoms, Murphy’s symptoms, Ortner’s symptoms and Lepine’s symptom. Also positive sign for pathology of pancreas and stomach.- We can say that the child have gastrointestinal pathology especially stomach, gall bladder and pancreas..- The pt needs some additional examination to confirm this diagnosis.G) Additional examination - Ultra sound (US) - Fibrogastroduodenoscopy (FGDS) - Duodenal probing - Blood analysis - Biochemical analysis: ALT, AST, bilirubin, protein, amylase - Helicobacteria pylori testH) Result of the additional examination 1. FGDS - present of ulcer at duodenum. pH 5.5 2. US - Gallbladder is enlarged, choleduct without any pathology changes but the walls are thin and pancreas also enlarged.
3. Blood and biochemical analysis RBC 4.4 x 1013 g/L Hb 142 g/L WBC 6.8 ×109 g/L Basophil 0% Eosinophil 1% Band 5% Segment 48% Lymphocyte 38% Monocyte 8% ESR 6 mm/H ALT 16 U/L AST 31 U/L Bilirubin 18.8mmol/L Glucose 4.5 mmol/L Cholesterol 3.6 mmol/L Protein 81 g/L Amylase 96.64. Stool examination. Form Formed Consistence Solid Color Brown Smell Natural / usual Mucus Absent Pus Absent Blood Absent Connective tissue - Muscular fibers + Neutral fat ++ Fatty acids +++ Remains of fatty food ++ Non digested cellulose - Digested cellulose + Starch + WBC - RBC - Epithelium - Protozoas - Helminthes -
5. Urine analysis Color Straw yellow Transparency Transparent pH 5 Specific gravity 1.018 Protein - Epithelium - WBC - RBC - Cylinders - Salts + Slime -6. ECG - sinus rhythmical.7. Urease test - absence of H.pyloriI) Consultation - Consultation with gastroenterologist.J) Differential diagnosis Cholelithiasis Pt feels positive pain symptoms in the regions associated with GB, therefore cholethiasis could be suspected. In urinalysis, there is no bilirubin found in the urine. Pt does not have any yellowish discolouration on his skin or sclera. All his other biochemical blood profile results are normal except for a high level of amylase enzyme. Therefore, cholelithiasis can be ruled out. Functional abdominal pain Pt experiences dull pain/ache in the epigastric/periumbilical region which is a characteristic of functional abdominal pain. However, pt says he doesn’t undergo any stress and seems to be calm. Pt also has pain that occurs only 4 hours after each meal, thus ruling out functional abdominal pain. Gastrointestinal allergy. Pt could be suspected to have gastrointestinal allergy as he experiences abdominal pains after meals. However, pt has this pain symptom after each meal regardless of whatever he eats, thus there’s no specific food that could be considered as an allergic factor causing this pain. Parasitic infections. Parasitic infections can cause pain in the abdominal pain. This pain can be dull or intense. However, this pain is independent of food intake and occurs intensively at night. Pt has pain only 4 hours after each meal. Urease test showed absence of Helicobacter pylori bacteria and Lamblia therefore it can’t be parasitic infections.
K) Clinical diagnosis Main: Duodenal ulcer Complications: cholecytitis and pancreatitis Pt is having cholecystitis and pancreatitis. Pt has positive pain symptoms in Kehr’s point, Murphy’s, Ortner’s, Mussy’s, Boas’s and Lepine’s or Chauffard’s zone which is a typical indication of cholecystitis and pancreatitis. Pt’s white blood count which is usually an inflammation indicator is within the normal range. The US test has diagnosed morphological changes in the gallbladder and pancreas indication inflammation of these two organs. Instrumental test such as the FGDS has indicated signs of duodenal peptic ulcer. Pt’s liver function test has shown a high increase of amylase. A high level of amylase indicates pancreatitis. Therefore, pt is having duodenal ulcer with complications of chronic pancreatitis and cholecystitis. Accompanying diseases: NoL) Etiology and pathogenesis of disease - of gastritis (stress)M) Treatment of patient Diet -Pt is advised to follow a healthy diet comprising all main nutrients such as carbohydrate, protein, vitamins and fat in healthy proportions. He should reduce his fatty food intake. Medication Regime 1. Proton pump inhibitory : Omeprazole (20 mg PO qd) 2. Antihistamine, H2 blocker : Famotidine (Initial: 40 mg PO hs, Maintenance: 20 mg PO hs) 3. Antimicrobials : Amoxicillin (>20 kg: 50 mg/kg/d PO q8h)N) Epicris Pt was admitted to the hospital on 19.09.08 for complaints of pain 4 hours after each meal in the epigastric and periumbillical region since 15.09.08 . Pt has never had a history of any illness or hospitalization. Pt was preliminarily diagnosed with duodenal ulcer. However, upon further diagnostic investigations, pt was confirmed to have chronic cholecystitis and chronic pancreatitis as well. Pt is undergoing traditional treatment as mentioned above. Pt’s symptoms have improved.O) Prognosis -Pt has a good prognosis if he maintains good diet regime and lifestyle.