CASE HISTORY

Identifying information
Surname: Diana
Age. Date of birth: 16 y.o
Nationality: Ukraine
Address: Kiev
Admission date n time: 20/07/2022 10am
Diagnosis: Gastritis

Chief complains
Sharp abdominal pain (near epigastric region) and also radiated to right upper
quadrant of abdomen.
Each pain last for 15 to 20 minutes and attack few times per day. Pain arises
after eating

Anamnesis of Morbi
Patient suffered from the same illness before 13 yrs. Patient was hospitalized
and was under medication for two weeks (Noshpa, Furasalidum, Duspatalin).
Patient became better after medication. She was under supervision of
Gastroenterologist. - Second attack was on 28 November 2007. The pain
increased due to oily food so she stop fat intakes in dietary.
1. Respiratory system - No specific complain.
2. Gl system- sharp abdomen pain radiated to right hypochondrium and
epigastric region.
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 complain
Anamnesis Vitae
-The only child in the family. Living with parents. No family problems.
- Secondary school student.
-No allergic
a) Obstetric anamnesis:
o Pregnancy 1
o Delivery I
o Neonatal period: -
Weight: 3100g
Length: 52cm
o Physical development according to percentile method: -
Body length: middle (25-75 centile)
Body weight: middle (25-75 centile)
o Child is weight is harmonically for his length.

b) Physical and neuro-psychological development of the child:

o Current weight: 53.5kg's (25-75 centile)
o Current height: 160.5 cm (25-75 centile)
o Child is weight is harmonically for his height.
c) Breast-feeding: Only artificial feeding by Malish bottle feeding.
e) Vaccination: According to the table.

Physical examination
1. General condition of child
o Mood: excited and happy
o Position on the bed: active
o Appetite: Normal appetite. Without any oily food
o Body constitutional: Normostenic
a. Respiratory system - No specific complain.
b. G.I system- sharp abdomen pain radiated to right hypochondrium and
epigastric region.
c. Genitourinary system-no back pain. Normal color of unne (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.

Preliminary Diagnosis
According to complaints:
o Patient has short abdominal pain after eating oily food. The pain is
sharp at the right side quadrant and epigastric region.
According to anamnesis:
o The 1st attack of illness was in 1998 where the child was ill for a year
and was under some medication.
o The 2nd attack started a week ago and child has to take medicine to
relieve the pain. The pain occurs after eating especially oily food.
According to physical examination:
o Patient has shown positive symptoms for pathology of the gall
bladder: Kehr's symptoms. Mussy's symptoms, Murphy's symptoms,
Ortner's symptoms and Lepine's symptom.
o We can say that the child have gastrointestinal pathology especially
gall bladder. - The patient needs some additional examination to
confirm this diagnosis.

Additional examination
o Ultra sound
o Endoscopy and Intragastric pH
o Duodenal probing
o Blood analysis
o Biochemical analysis: ALT, AST, bilirubin, protein, amylase
o Helicobacteria pylori test
Result of the additional examination
1. Fibroesophagogastroduodenalscopy
-Hyperemia and edema of stomach mucosa., Plicas are enlarged.
Pylorus are normal.
2. Ultrasound.
-Gallbladder is enlarged, choleduct without any pathology changes
but the walls are thin
3. Blood analysis.
4. Stool examination.

5. Urine analysis.
Consultation
o Consultation with gastroenterologist.

Differential diagnosis
o Gastric ulcer
o Gastritis
o GERD
o Chronic cholescystitis
o Biliary colic
o Biliary Dyskinesia

Clinical diagnosis
o Main: Chronic Gastritis
o Complications: No
o Accompanying diseases: Biliary Dyskinesia

Etiology and pathogenesis of disease

o of gastritis (stress)

Treatment of patient
o Antacid ex: Maalox
o Proton pump inhibitor: Cimetidine - Acid blocker: Omeprazole