Rubzzzz's Surgery Hx Gastric Peptic Ulcer 5th year
National O.O. Bohomolets Medical UniversityDepartment of Surgery Head of department Prof. Teacher: Case report of Sergev NicholaiClinical Diagnosis : Gastric Peptic UlcerAccompanying Disease : Initial Pancreatitis and Renal CalculiComplication : No Student: Group 36 5th year Med 1Date of examination:30/01/09
A) Identifying information • Surname: Sergev Nicholai • Age .Date of birth: 41 y.o • Nationality: Ukraine • Occupation: Currently not working. • Address: Kiev • Status: Divorced • Admission date n time: 19/01/09 evening • Diagnosis: PancreatitisB) Chief complaint: - Pt was admitted due to strong pain before eating (hunger pain) at epigastric region (9/10 according to pain scale). This pain had continued about 2 weeks (5/10 according to pain scale). The pain become worst aggregated by movements and it continue for the whole day. The pain also increases after oil intakes. - Pt also had fever 38.9 degree for one week. - Pt also complained about vomiting about 2 times per day in the evening. Pt also feels dizzy when the pain becomes strong. Pain scale is 9/10 where he will scream. - To reduce the pain feeling, pt put pillow on the stomach. - Pt is on medication: Ranitidine and Drotaverin.C) Anamnesis of Morbi: - The pain started suddenly in September 2008. The pain comes and goes (irregularly). This was continued for a week (5/10 according to pain scale). - Pt has good appetite. He takes only milk and bread (carbohydrates) after the pain started. - The pain increases due to oil intakes.D) Anamnesis Vitae - Pt had respiratory dz when he was young. - Pt had spleenectomy in 2002. - Pt’s diet regime is once per day in small portion. He takes a lot of hot drink such as tea and coffee. - No allergy. - Pt smokes 5 cigarettes per day. - Pt used to drink alcohol (1 ml per day) but he reduced d amount in summer 08. - No drug intakes. - Unstable pressure.E) Physical examination: 1. General condition of pt. • Mood: active • Position on the bed: active
• Consciousness: clear • Sleep: good and at the correct time. • Appetite: Normal appetite. • Body constitutional: Normostenic a. Respiratory system - No specific complain. b. G.I system- epigastric pain before eating and it increase with oil and carbohydrate intakes. 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 complain2. Skin • Skin colour: normal skin color (pink) • Humidity: satisfactory • Elascity: satisfactory • Rash: absent • Tugor: satisfactory • Edema: absent • Swelling: absent3. Lymphatic system - No additional lymph nodes can be palpated.4. Respiratory system • Size of chest: Normostenic. • Rate of breathing: Normopnea. 23 per minute • Rhythm: rhythmic respiration • Type of breathing: thoracic and symmetrical • Passage of breathing: free nasal • Vocal tremor: symmetrical in both sides. • Palpation; no pain,the thickness of the skin fold under the scapular is of normal • thickness. • Percussion sound is normal • Auscultation sounds is normal.5. Cardiovascular system • Blood pressure; 115/70 • Pulse: 80 • The heart beat is sinus,regular
6. 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, good participation of stomach muscle 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: negative • Lepine’s symptoms: negative • Mussy’s symptom: negative • Ortner’s symptom: negative • Murphy’s symptom: negative • Boas symptom: negative. 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 odor 7. Bone system • Size of thorax: Normostenic • Edema: absent • Scoliosis: absent 8. Joints • Pain: pain at extremities. • Limitation of movement: No abnormalities • Color: Pale • Size: normal size, according to his body built and size. They are not enlarged. • Temperature: The temperatures around his joints are of normal body temperature. • Edema: absent. 9.Urinary system • Normal amount of urine • No pain during urination • Absent of blood in urine. • Pasternatsky’s sign is negative • No edema on face or extremities 10. Nervous system - All 12 cranial nerves are normal without any disorder. More sympathetic effect than Parasympathetic. - Absent of meningeal signF) Preliminary Diagnosis - Duodenal ulcer.G) Additional examination - Ultra sound guided Bx. - Endoscopy. - Blood analysis. - Biochemical analysis: ALT, AST, bilirubin, protein, amylase
4. Ultrasound guided Bx.- pancreas is dense. Stone about 0.8cm was found at (R) kidney.- 5cm ulcer was found at the lesser curvature of stomach and Bx was taken for histologicalanalysis.5. Endoscopy- 5cm ulcer was found at the lesser curvature of stomach with significant inflammation filledwith fibrin.J) Differential diagnosis • Stomach ulcer • Functional abdominal pain • Parasitic infectionStomach ulcerPt experiences strong epigastic pain before eating with is characteristic in duodenal ulcer but insome cases can be occur in stomach ulcer. The pain is due to dietary intakes which is common inany peptic ulcer. US and endoscopy test showed ulcer at lesser curvature of stomach and thusruling out duodenal ulcer.Functional abdominal painPt experiences dull pain in the epigastric region which is a characteristic of functional abdominalpain. However, pt says he doesn’t undergo any stress and seems to be calm. Pt also has pain thatoccurs only before meal and due to oily intakes, thus ruling out functional abdominal pain.Parasitic infectionsParasitic 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 onlybefore meal. Urine test showed absence Lamblia therefore it can’t be parasitic infectionsK) Clinical diagnosisMain: Duodenal ulcerComplications: Pancreatitis and kidney stoneAccompanying diseases: NoPt is having pancreatitis and right kidney stone. Pt has positive pain symptoms in Chauffard’szone which is a typical indication of pancreatitis. Pt’s white blood count which is usually aninflammation indicator is within the normal range. The US test has diagnosed increased indensity of pancreas indication inflammation of pancreas. Instrumental test such as the endoscopyhas indicated signs of stomach ulcer where 5cm of ulcer was found at the lesser curvature andalso 0.8cm of right kidney stone. A high level of amylase indicates pancreatitis. Therefore, pt ishaving stomach ulcer with accompanied disease of pancreatitis and kidney stone.
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 : Ranitidine. Famotidine (Initial: 40 mg PO hs, Maintenance: 20 mg PO hs) 3. Antimicrobial : Metronidazole 400mg + Clarithromycin 500mg (both are given twice daily) N) Prognosis (for work and life) -Patient has a good prognosis for work and life if he continues to maintain a healthy lifestyle and undergo his treatment regime properly.