Волгоградский Государственный Медицинский Университет

Каф. Факультетской Xирургии

Преподаватель:
Л.В.Шарашкина

АКАДЕМИЧЕСКАЯ ИСТОРИЯ БОЛЕЗНИ

Ф.И.О. больного : Runaev Dimitriy Vasilevich

Отделение : Surgical Department

Диагноз : Acute pancreatitis

КУРАТОР :
Студент IV-ого Курса
51-ая Группа
Аб Халим Мухаммад
Ирсйад Бин
 Year 2017

I) PASSPORT DATA

Surname, Name, Patronymic : Runaev Dimitriy Vasilevich

Age : 34 years

Nationality : Russian

Date of Admission : 23 March 2017

Occupation & Place of work : Mechanic / OOO "HBK"

Home address : Volgograd

Directed by : КССМП Volgograd via ambulance

Diagnosis of directing : Acute pancreatitis

Establishment

Diagnosis of clinical final : Pancreonecrosis

II) MAIN COMPLAINTS

Main complaint of the patient is pain in the epigastric and umbilical region. Pain
develops after having fatty food with a cup of coffee. Patient feels nausea and multiple vomiting.
The patient also complains of strong feeling of thirst and dry mouth.

III) ANAMNESIS MORBI

According to the patient, he had pain after having his lunch which consist of kotleta and
mashed potato. He took activated charcoal to reduce pain but it has no effect. Around 4 years
ago, he had the same kind of situation with pain. He was then admitted to Hospital No. 7 with
diagnosis of pancreatitis. In connection with the increasing of pain, the patient was transferred
from КССМП Volgograd to Hospital No. 7.

IV) ANAMNESIS VITAE

He is the first child of 2 siblings. His infancy was normal and he was born in the
maternity house on 1983. He was born into normal family and had no disease then. He had a
natural nutrition(maternal milk).

His childhood was also normal. He started his school years normally at the
age of 7 years old. He also had all necessary vaccination (e.g. against TBC). He finished his
higher education.

He was once diagnosed with chronic pancreatitis and had undergo diagnostic laparoscopy
in 2013. He also had fracture of humeral bone long ago.

He is not married and still living with his mother and sister. The family state of health
was normal. They have no history of his current disease. His living condition and housing
condition was also normal but his working condition is stressful.

He had a regular nutrition without any starvation. He is not allergic to chemical

substances and food.

He mentioned has some harmful habits such as smoking for 15 years but doesn’t drink
alcohol. He smoke approximately 1 pack per day.
V) STATUS PRAESANS

General inspection

Patient had normal consciousness (present and clear), posture was active.

Habitus

Constitution : normostenic
Height : 193 cm
Weight : 78 kg

Head : normal
Countenance and shape of face : normal, movement of facial muscle symmetrical.
Eyes and eyelids : normal
Nose : normal and symmetrical
Mouth : normal; teeth: normal; tongue: normal (clear)
Skin : normal with no eruptions.
Hair : normal
Nails : normal
Lymphatic system : lymph nodes were not palpated.
Muscular system : normal development with normal functions.
Bones of skull, chest spine, : normal development without any defects.
extrimities
Joints : normal

Current temperature : 37.2°C (normal)

RESPIRATORY SYSTEM

INSPECTION:
Nose : normal
Larynx : normal

PALPATION:
Thorax : normal chest
Epigastric angle : 90°,
Supraclavicular fossa : prominent

Respiration type : vesicular

Respiration depth : superficial rhythmical.
Dyspnoe : absent
Vocal fremitus : all same comparing the right and left side.
PERCUSSION:
Comparative percussion : all same comparing the right and left side

UPPER BORDERS:
Interior from clavicle : 3cm
Posterior : on the level of spine of 7th cervical vertebra
Kreonigarea : 5cm

LOWER BORDERS:

Borders Right Left

Parasternal line 5thintercostals space -
Midclavicular line 6th rib -
Anterior axillary line 7th rib 7th rib
Midaxillary line 8th rib 8th rib
Posterior axillary line 9th rib 9th rib
Scapular line 10th rib 10th rib
Paraspinal line Spinous process of 11th Spinous process of 11th
Thoracic vertebra Thoracic vertebra

Motility of lower border of lung:

Lines Left Right

Midclavicular line 6cm -
Midaxillary line 6cm 6cm
Scapular line 4cm 4cm

AUSCULTATION:
Comparative auscultation : same comparing the right and left side.
Respiratory hums : normal vesicular
Adventitious sound : absent
CARDIOVASCULAR SYSTEM

Heart rate : 68 beats/min

Blood pressure : 120/80

PALPATION:
Pulsation of radial artery : pulse simultaneous on both side of hand.
Vessel wall assessment : normal as thin elastic tube.

Apex beat : in 6thintercostals space on the left midclavicular line

Size : diffuse (2.5cm)
Height of : high
apex beat
Strength : increased (forced apex beat)
Resistance : increased.

Heart base beat : normal (pulsation in absent)

Extra-apical pulsation : No pulsation in jugular, epigastrium, and liver.

PERCUSSION:

Borders Relative Dullness Absolute Dullness

Upper border 3rdintercostals space 4thintercostals space

at left parasternal line
Left border 6thintercostals space 2 cm medial of relative dullness
coincide with apex beat (on
midclavicular line)
Right border 4thintercostals space Along left edge of sternum
right border of sternum

Vascular Bundle : 5 cm

Heart shape : Aortic configuration (due to left ventricle hypertrophy).

AUSCULTATION:
Main sounds :

Point Findings
1st Normal (intensity of 1st sound was higher)
Synchronize with pulse of carotid artery
2nd Normal (intensity of 2nd sound was higher)
3rd Normal (intensity of 2nd sound was higher)
4th Normal (intensity of 1st sound was higher)
5th (ButkinErbs) 1st sound slightly higher than 2nd sound

Pathological sounds : none

DIGESTIVE SYSTEM

INSPECTION:
Inspection of mouth : tongue appears to have white coating
Teeth : normal
Gums : normal
Palate : normal
Tonsils : normal.
Inspection of abdomen : symmetrical form with bloating
Skin color : normal
Muscle symmetry : normal
Surface : normal

PALPATION:

Surface palpation

Tender skin and muscle

Preliumstrain : normal
Abdominal skin and subcutaneous tissue condition : pain in epigastric and umbilical region
Muscle separation : normal with no hernial protrusions

Deep palpation (Obraztsov- Strazhenko method):

Ceacum, ascending colon and stomach : palpable, normal resistance with pain
Ascending colon : palpable, normal resistance with pain
Sigmoid colon : palpable
Liver : normal
Spleen : impalpable

Zakharyin’s symptom : Negative

Vasilenko’s symptom : Negative

Obraztzov’s Murphy symptom : Negative

Orthner’s symptom : Negative

Shchetkin-Blumberg’s symptom : Positive

De-Mussy-Geogievsky symptom : Negative

Myo-Robson symptom : Positive

Rozdolskyy symptom : Positive

Korte symptom : Positive

Voskrenskyy symptom : Positive

Pancreas : not palpable

PERCUSSION:

Liver: according to Kurlov’sborder :midclavicularliene : 9cm

Linea alba : 8cm
Left rib edge : 8cm
Fluctuation sign : absent – no fluid in abdominal cavity
Traube’s space : normal condition, size and localization
Vasilenko symptoms : absent
Spleen: length : 4cm; diameter : 2cm

AUSCULATATION:

Peristalsis sound : present

Peritoneum murmur : absent

URINARY SYSTEM

INSPECTION:

Absent protrusion, edema and contour of the lumbar area is normal

PALPATION:

Kidney : impalpable due to pain

Ureter and urinary bladder : impalpable

PERCUSSION:

Pasternatsky’ssymptom : absent
Absent any edema

ENDOCRINE SYSTEM

INSPECTION:

Absent no growth disorders ( nonanism and gigantism). Dimension and length of body part is
proportionate.
Skin : normal without any hyperpigmentation, thinning or thickening, humidity, turgor
and vitiligo, scratching, striae or cholesterol deposition.
Nails : normal and not brittle.
Hair : normal pattern of growth according to male pattern. No falling of hairs.

Eyes : absent any ocular symptom; no exopthalmus or enophthalmus.

PALPATION:

Thyroid gland : Absent any enlargement of ithmus and its lobes. Palpation done without
any painfulness. Isthmus length is 2cm and its height is 1cm.

NERVOUS SYSTEM

INSPECTION

Patient behavior : adequate with normal orientation to time and place.

Mood: normal
Motor function assessment : normal motor function
Body is symmetry. No mimic muscle of face function derangements. Position of tongue is
normal (put out directly).
Speech normal.

Locomotion if upper and lower extremities are normal. Posture of Romberg is nonresistance.
Reflex function: pupils identical. Vision, audition and smell sensations are good.
Tactile sensitivity, numbness in legs.

HEMOPOIETIC SYSTEM

INSPECTION:

Coloration of skin is normal with no hemorrhagic eruptions.

Tongue is not changed, papillae are normal.
Tonsils, gums and mucosa are normal.
Abdomen is symmetry. Absent any augmentation in upper part or left and right hypochondrium.
State of bone and joint were normal.

PALPATION:

Submandibular lymph nodes are slightly enlarged without any painfulness, not connected with
around tissues
Other lymph nodes size and condition were normal.
PERCUSSION:

Liver and spleen size were normal.

Liver : according to Kurlov’s border : midclavicularliene : 9cm

Linea alba : 8cm
Left rib edge : 8cm
Spleen : length : 4cm; diameter : 2cm
Percussion of breastbone and tubular bones were done without pain.

LABORATORY INVESTIGATIONS

Total blood test

WBC: 5.9*10^9/L
Lymph#: 2.3*10^9/L
Mid#: 0.5*10^9/L
Gran#: 3.1*10^9/L
Lymph%: 39.2 %
Mid%: 8.5%
Gran%: 52.3%
HGB: 142g/L
RBC: 4.57*10^12/L
HCT: 41.1%
MCV: 90.0 fL
MCH: 31.0 pg
RDW-CV: 13.2%
RDW-SD: 44.3 fL
PLT: 242*10^9/L
MPV: 9.1 fL
PDW: 16.1
PCT: 0.220%
Glucose level:

1100: 19.8
1600: 16.5
2000: 12.6
2200: 10.0
0600: 8.9

Liver function test

Bilirubin: 10.28 micmol/L

Thymol test: 0.4
ALT: 22.0
AST: 28.0
Cholesterine: 6.4
Creatinine: 69.2
TG: 2.3

Gases and electrolytes:

Potassium: 4.68 mmol/L

Sodium: 141.6 mmol/L
Calcium iodide: 1.4 mmol/L
HbA1c: 9.6

Total urine test

Appearance: Yellow
Protein: 0.024g/L
Acetone: negative
RBC: 0-1
WBC: 1-2
Epithelial cells: Occasional

DIARY
24.03.2017
Condition is satisfactory. Patient complained of pain in epigastrium and
sometimes the whole area of abdomen. No vomiting or nausea.
Heart rate: 67 beats/min
Arterial blood pressure: 130/80 mmHg
Temp.: 36.6℃

25.03.2017
Patient was admitted to the reanimation for laparoscopic operation.
No information about patient during this day.

27.03.2017
Condition is satisfactory. Patient complained of pain in epigastric region and
pain because of postoperation. A drainage was inserted in patient's abdominal
cavity. No vomiting or nausea.
Heart rate: 74 beats/min
Arterial blood pressure: 125/80 mmHg
Temp.: 37.7℃

28.03.2017
Condition is satisfactory. Patient complained of pain in epigastrium but
already lessen. The tube has been removed. No vomiting or nausea.
Heart rate: 70 beats/min
Arterial blood pressure: 120/80 mmHg
Temp.: 37.5℃

29.03.2017
Condition is satisfactory. Patient complained of mild pain in epigastrium. No
vomiting or nausea.
Heart rate: 69 beats/min
Arterial blood pressure: 130/80 mmHg
Temp.: 37.2℃

30.03.2017
Condition is satisfactory. Patient have no complain, only slightest feel of pain
in epigastric region.
No vomiting or nausea.
Heart rate: 75 beats/min
Arterial blood pressure: 120/80 mmHg
Temp.: 36.8℃

ETIOPATHOGENESIS OF PANCREATITIS
1. Bad habits. Smoking has toxic effect on pancreas
2. Bad diet and which lead to disfunction of pancreas
3. No prove on genetic involvement.

TREATMENT

1. Antibacterial treatment
2. Antithrombosis drug
3. Disintoxication therapy
4. Endoscopic retrograde cholangiopancreography (ERCP)
5. Surgery of pancreas

DIFFERENTIAL DIAGNOSIS

Acute cholecystitis
- pain right subcostal region after taking fatty food-radiate to right shoulder, scapula
- vomiting with bile-not relieve pain
- Ortner’s +ve – tap perpendicular to right lowest rib, feel pain

Gastroduodenal ulcer
- epigastric pain (gastric-increase pain around 3h after taking meals, duodenal-relieved)
- nausea, vomiting-pain relieved
- heart burn

Acute adnexitis
- pain in lower abdomen radiating to lumbar area, perineum
- increase body temperature
- vaginal discharge

Renal colic
- lumbar pain, radiation to scrotum, pelvis, upper thigh
- dysuria
- Pasternatsky symptom +ve – punch at back, cause hematuria

Acute appendicitis
- dull pain in the right iliac region
- vomiting 1-2 times, not relieve pain
- constipation
- increase body temperature
- decrease appetite
- Kocher’s symptom
- pain in epigastric, then to right iliac region
- Voskrenskyy’s symptom
- strech T-shirt, move finger from epigastric to right iliac region, pt feel pain
 - Sitkovsky’s symptom
- pain arises in right iliac region when changing patient’s position from supine to left
lateral position

EPICRISIS

Patient, Runaev Dimitriy Vasilevich, 34 years old being hospitalized on 23rd March 2017
due to complaint of thirst, dry mouth, pain in the epigastric and umbilical region. Patient was
diagnosed with acute pancreatitis and was treated with with antibacterial treatment.
Blood glucose level test was done regularly to make sure the glucose level is within
norms. Urine test shows glucosuria with slight improvement after the insulin therapy. Patient’s
conditions is better after the treatment and level of glucose is normalized.
Patient is recommended to follow his diet regime to make sure that his weight and
glucose level are normal. Since patient shows no acute or chronic complication, we suggest that
patient pay more attention on diet regime and physical exercises.

FINAL DIAGNOSIS

Acute Pancreatitis.