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DEPARTMENT OF

THE INFECTIOUS DISEASES AND EPIDEMIOLOGY

Head of infectious diseases department Reader: Ryabokon.E.V

CASE HISTORY
Patient Name : Sergay batife ClinicalDiagnosis: Acute Gastroenteritis Meddle stage Student : Hassoun Saad Group : 1 A Course : 5th year Teacher:

PASSPORT DATA
FULL NAME AGE SEX NATIONALITY MARITAL STATUS OCCUPATION HOME ADMISSION DATE :Sergay batife : 47 years : Male : Ukrainian : Married : Hard Labour zaporzhye : 30.11.2006

INQUIRY
COMPLAINTS: The patient complaints of severe pain in hypogastric diarrhea 5 time a day. also vomiting in the morning .. ANAMNESIS MORBI The pain started after he fell in the abdominal region before tow weeks from admitting to hospital .The pain started simple pain then became acute. Nausea and temperature. He was not using any treatment before admitting to hospital. ANAMNESIS VITAE The patient has never been admitted to hospital previously for any illness. He has never undergone any operation and has no known allergy for drugs. He has never undergone blood transfusion. He takes alcohol drinks moderately in the occasions and he is was smoking when he had old 15 but right now he is not smoking. EPIDEMIC ANAMNESIS:

The general state of patient is in normal style. Patient is clear and conscious while interview. He is not having delirium or hallucination. His appearance corresponds to his age. His body structure is normal. His body constitution is normostenic .His gait is normal. Weight of patient 75kg. Height of patient is 175cm.he has wife and he is leaving with his wife in his family home his working as mechanical .condition of his work is normal .the transport using to work by bus. Using bath every day .was not he in business trip. the condition nourishment is normal .using milk products .hi is clear up to contact with another at home and with people .he did not make any medical manipulation for 6 months transfusions, operations and extractions teeth .

IMMUNOLOGICAL ANAMNESIS:
The diseases were not suffering in past. and the patient he did not get any antibiotic and another chemical preparations.

EXAMINATION OF BODY PARTS


His head is round, proportionate to his body constitiution, symmetrical and his facial and cerebral part is corresponding. His face is symmetrical, expression is usual and shape is regular. His hair covering is of a male type and corresponds to his age. The width of his eyes slits are moderate, eyes shape is normal, no squints, no hyperlacrimation and sclera are normal. His pupils are in normal shape and size. His nasolabial fold are normal, size and shape of nose is normal. Colour of the skin of ears is normal. No carotid or jugular pulsation noted.

LOCOMOTER SYSTEM
All active and passive movements of the joints are full except right shoulder joint. No pathologic deformation is seen in the spinal column. Its function is full. The muscles are developed moderately, tone and muscle force are identical on both sides. Palpation and tapping of the bones are painless. Joints are regular in shape, painless during palpation and movements. The muscles, bone and joints are in a generally good condition.

*RESPIRATORY SYSTEM

INSPECTION At sitting position, patient breathes through his nose. His chest shape is normal without pathological signs. Chest is symmetrical at supra and subclavicular space. The patient has a normosthenic and regular chest, the epigastric angle is 90 . The chest is symmetric, supraclavicular fossae are pronounced. Ribs are moderately inclined when viewed from the side, scapular are closely fit to the chest and are at the same level. Respiratory rate is 18 per min and it is regular. Movement of the chest is symmetrical during respiration. PALPATION There is no tenderness noted along the ribs, intercostal spaces, trapezoid muscles and intercostal nerves points. Resistance of chest at longitudinal and transverse direction is moderate. Vocal fremitus at the anterior, lateral and posterior is symmetrical and normal. Pleural friction is absent.

PERCUSSION At comparative percussion, symmetrical normal tympanic sound is heard over both sides of the lungs. Traubes space is present. At topographic percussion, lung borders as the following is determined. Lower Borders. Lines Right lung Left lung th Parasternal 5 rib -th Mid-clavicular 6 rib -th Anterior axillary 7 rib 7th rib Middle axillary 8th rib 8th rib Posterior axillary 9th rib 9th rib Scapular 10th rib 10th rib

Paraspinal Upper Border Anterior Side Posterior Side

11th thoracic vertebra

11th thoracic vertebra

4cm above clavicle At spinal processes of 7th cervical vertebra

Mobility of the lungs Right lung Topographic lines Midclavicular Midaxillary Scapular Left lung Topographic lines Midclavicular Midaxillary Scapular AUSCULTATION Over auscultation, vesicular breathing sound is heard over all symmetrical points of the chest. No adventitious sounds or rales were present. Inhalation (cm) 3 2 Exhalation (cm) 3 2 Total(cm) 6 4 Inhalation (cm) 2 4 2 Exhalation (cm) 2 3 2 Total(cm) 4 7 4

*CARDIOVASCULAR SYSTEM
Cardiac rate is 75 beats per minute. Pulse is normal, its rate is 75 beats per minute, pulse is rhythmical and diameter of vessels approximately 2.5mm and the filling tension is satisfactory. Temporal and carotid arteries are well palpated and pulsation on both sides are equal. Pulse rate : 75 per min regular Arterial pressure : systolic-120 mm Hg, diastolic-80 mm Hg,

INSPECTION No visible pulsation is noted at the carotid, jugular or temporal vessels. There is no protrusion in the heart area (cardiac humpback), no pulsation is visible apex beat or at any other chest zones. No epigastric pulsation is noted. Mild cyanosis was seen in right forearm. Edema was noted in the right arm. PALPATION Apex beat is not palpated - restricted. Cats murmur phenomenon is not determined. PERCUSSION Borders of relative cardiac dullness: Right border 1cm outside from right edge of sternum. Upper border On lower edge of 4th rib. Left border 1cm medially from mid-clavicular line.

AUSCULTATION At auscultation 2 sounds we heard over all points. The sounds are rhythmic, slightly strengthened 1st sound at apex of heart and tricuspid valve. The 2nd sound is louder at the base of the heart. Cardiac rate is 75 beats per minute.

*DIGESTIVE SYSTEM
The patient complaints of severe pain in hypogastric diarrhea 5 time a day. also vomiting in the morning .. INSPECTION Patient has odour in oral cavity, normal size of tongue with pink colour, dry condition and normal condition of papillae. Teeth is of healthy condition. Gums are pink in colour without ulceration, edematous or hemorrhages. Soft and hard palate is normal. Tonsils are absent. Abdomen shape is normal, symmetrical and mobility of the abdomen during respiration is active. Skin of the abdomen is without pigmentation and striae. Signs of scratches present. No visible peristalsis, navel is normal and no hernia is noted.

PALPATION/PERCUSSION Superficial palpation: Strain of muscles of abdomen is normal, muscle resistance is normal, no tenderness or hernia palpated. Mendels symptom is negative. SchetkinBlumbergs symptom is negative. Deep palpation :
1. sigmoid is palpable in the left inguinal region as a smooth firm cylinder

2cm in diameter, it is painless, does not produce rumbling sounds, tightelastic consistency and mobile. 2. caecum is palpable in the right iliac region as a smooth, soft , painl cylinder with diameter 3cm and mobile. 3. descending colon is palpable in left lumbar region with elastic cylinder, diameter 3-4cm, pain and with limited motility. 4. ascending colon is palpable in right lumbar region with elastic cylinder, diameter 3-4cm , pain and with limited motility. 5. transverse colon is palpated as soft painless, cylinder with diameter 2-3 cm without rumbled. On auscultation of the abdomen, peristalsis of the intestine is of moderate sound and frequency is heard. Vessel murmurs are absent.

Stomach Greater curvature of the stomach is determined as soft smooth ridge 3cm above the navel, it is painless, displaces on 1.5-2.0cm,produces slightly rumbling sound. Other parts of the stomach are not palpable.

Examination of the liver Visible enlargement of the liver is absent. 1. Upper border of absolute hepatic dullness on the right mid-clavicular line is on the VI rib,. 2. lower border on the edge of costal arch 3. Kurlov size = 8 7 7 4. Obraztov size = 9- 7- 6 Liver is palpable on 1cm below of rib of arch along linea midclavicularis, edge is soft-elastic, equal, painless and easily tucked Examination of the gall bladder Kera symptom : negative Murphy symptom : negative Lepene symptom : negative Vasilenkos symptom : negative Orthers symptom : negative No pain is felt at the choledocho-pancreatic, diaphragmatic, acromial, subscapular and paravertebral points at the right. Examination of the pancreas: Pancreas is not palpable. There are no any pain complaints during palpation. Tenderness in the points conforming to the head,the body, tail, diaphragmatic, acromial, subscapular,point of phrenic nerve and paravertebral points to the left are equal on both sides and any increased hypereshesia on the left side is not determined. Spleen: Spleen is not palpable. Borders of the splenic dullness are situated Upper- at level of the IX rib Lower- at level of the XI rib Sizes of the splenic dullness are Transverse- 6cm

Vertical 7cm

*URINARY SYSTEM
INSPECTION Visible pathology of the lumbar region is absent. Patient has no complaint over disturbance in urination of rhythm of urination. Colour of urine of patient is straw colour. No edema in face and loins are noted. PALPATION Kidneys are not palpated. PERCUSSION Pasternatskys symptom is negative.
*ENDOCRINE

SYSTEM

During inspection, changes of the eyes (exophthalmus or enophthalmus) are not visible. Ocular symptoms like Grafes, Kochers, Moebius, Stelwags are negative. During palpation, the thyroid gland is not enlarged. Its isthmus is palpated as soft, painless and 1cm in diameter. Organs of Internal Secretion (Endocrine Organs) Thyroid Gland No presence of tumors in the neck region. No pain in the neck region .No complaints of compressing of internal organs of the neck. No difficulty in breathing, stridor breathing, husky voice, aphonia, dysphagia, oedema on face and swelling of veins. No bulging out of eye ball, eye pain, biting & compressing feeling, pain or diplopia. Parathyroid Glands No attacks of convulsions, no parathesia, pain in leg muscles or bones, no fragility of nails or falling of hairs, no fracture of bones. Islet of Langerhans of Pancreas Patient does not have weakness. He does not have abnormal thirst. He feels hungry at regular interval. Adrenal Gland Progressing weakness was absent. There is no change of shape, moon face or scarlet colour of skin. Redistribution of fat tissue is absent. He has not lost hair and has not experienced hirsutism.

Genital Glands He has not experienced any physical changes characteristic to genital development. He has not lost hair. He has regular development of secondary sexual manifestations.

BLOOD SYSTEM
INSPECTION Colour of the skin is pale. However, no hemorrhagic spots are noted on skin or mucosa. Hair is normal consistency. No regional swelling in the neck. PALPATION There is no pain upon tapping on flat tubular bones. The palpation of the lymph nodes was done in the following order.
LYMPH NODES 1.SUBOCCIPITAL 2.PREAURICULAR 3.ANTERIOR CERVICAL 4.POSTERIOR CERVICAL 5.SUBMAXILLARY 6.SUBLINGUAL 7.AXILLARY 8.EPITROCHLEAR 9.INGUINAL RESULT OF PALPATION NOT PALPABALE NOT PALPABALE NOT PALPABALE NOT PALPABALE NOT PALPABALE NOT PALPABALE NOT PALPABALE NOT PALPABALE NOT PALPABALE

Conclusion:- all lymphatic nodes is normal . Examination of the spleen There is no visible enlargement of the spleen. Spleen is not palpated.

NERVOUS SYSTEM
INSPECTION

Patient responded actively to out interview and answer all the questions consciously. His gait is regular. Paresis and paralysis is absent. Pupils are identical in size and respond to light. Nystagmus is absent. the depression, stupor and coma is absent. the headache it was then normal.dizzness absent .dreams is normal. memory and speech is normal. the gait is normal. symptomes of Romberg is negative. all reflexes is normal. the vision normal. nystagmus absent.

THE HYPOTHETICAL DIAGNOSIS


Based on the symptoms during inquiry, inspections, palpation, percussion and auscultation the initial diagnosis is

Acute Gastroenteritis - middle stage PLAN OF ADDITIONAL INVESTIGATIONS


1. Full Blood Count 2. Urinalysis 3. Biochemical test

RESULTS LABORATORY INVESTIGATIONS


LABORATORY FINDINGS 01.12.2006
Blood analysis 1.Hemoglobin 2.Erthrocyte REVALES IN PATIENT 155 g/L 4.650 x 1012 /L NORMAL F:-120-140 g/L M:135-180 g/L F:- 3.9-4.7 x 1012 /L M:- 4.0-5.0 x 1012 /L 0.85-1.15 4.0-9.0 x 109/L 0.5 -5.0 % 1-6 % 47 72 %

3.Color index 4. Leucocytes 5.Eosinophils 6.Stab neutrophils 7.Segmented neutrophils

1.0 4.3 x 109/L 0.7 % 5% 49 %

8.Lymphocytes 9.Monocytes 10.ESR

19 37 % 3 11 % F:- 2 15 mm/h M:- 2 10 mm/h Conclusion: -Increase Hemoglobin, Eosinophils and lymphocytes indicate inflammation and infectious process. Blood analysis 1.bilorobin 2. ALT REVALES IN PATIENT 23.6 0.7 NORMAL Not more 20.5mkmol/l 5-40 u/l

44 % 04 % 04 mm/h

3.ALP 39-117 u/l 4. Leucocytes 0-1 4.0-9.0 x 109/L 5.Erythrocyte 0 -1 0.5 -5.0 % Conclusion: - Normal leukocytes, Increased stab neutrophils, and ESR indicate inflammation and infectious process .

Microscopic examinations: stool Leucocyte 1-2 Epithelium 01 Consistent: Stool is yellow ,color like jelly .The microbe is salmonella.

DIFFRENTIAL DIAGNOSIS
Is performed with other intestinal diseases shigellosis ,toxic food born infections,esherichiasis,cholera,with surgical diseases appendicities,pancreatities,cholecytitis,thrombosis of mesentrical vessels,gynecological pathology and with therapeutic pathology (myocardial infraction ,chronic gastritis, aggravation ,enterocolitis,ulcerous disease),with acute gastroenteritisnof viral origin ,poisning by organic and inorganic poisons,poisoning by mushrooms. Generalized form of salmonelosis is necessary to differentiate from sepsis of different etiology ,pneumonia ,malaria, acute pyelonephritis ,tuberculosis.

Final Diagnosis : According to analysis and symptoms of patients and according to source of infection there is gastroenteritis bacteriasalmonelosis

Acute Gastroenteritis middle stage


Treatment :
*For washing stomach and intestine with boild water (isotonic solution of sodii chloridum )
*

-Antibiotic therapy -Levomyceti sodium succinate : can be given (100 mg/kg for 6-8 days ) -Ampicillin : (150-200 mg/kg aday). *Norflaksatsean 0.4 2 times aday *Mezeam 1000 U *Latsedophil 2 times aay *Silakc 12 mg

Prognosis
The prognosis for work and life is favorable after complete recovery from the gastroenteritis.

EPICRISIS
The Patient Sergeah Pative ,age 47,the disese strated with him befor tow weeks administration to hospital due to severe pain in the hypogatric region. When he admitted to hospital in 31.11.2006 he diagnosed with Gastroenteritis . before admitted he complained The patient complaints of severe pain in hypogastric diarrhea 5 time a day. also vomiting in the morning .clinical signs skin pallor and not soft , peristalasis in the abdomen .there is objective examination Strain of muscles of abdomen is normal, muscle resistance is normal, no tenderness or hernia palpated. Mendels symptom is negative. Schetkin-Blumbergs symptom is negative.Deep palpation : sigmoid is palpable in the left inguinal region as a smooth firm cylinder 2cm in diameter, it is painless, does not produce rumbling sounds, tight-elastic consistency and mobile.caecum is palpable in the right iliac region as a smooth, soft , painl cylinder with diameter 3cm and

mobile.descending colon is palpable in left lumbar region with elastic cylinder, diameter 3-4cm, pain and with limited motility.ascending colon is palpable in right lumbar region with elastic cylinder, diameter 3-4cm , pain and with limited motility.transverse colon is palpated as soft painless, cylinder with diameter 2-3 cm without rumbled.On auscultation of the abdomen, peristalsis of the intestine is of moderate sound and frequency is heard. Vessel murmurs are absent.Stomach Greater curvature of the stomach is determined as soft smooth ridge 3cm above the navel, it is painless, displaces on 1.5-2.0cm,produces slightly rumbling sound. Other parts of the stomach are not palpable. Visible enlargement of the liver is absent. Upper border of absolute hepatic dullness on the right mid-clavicular line is on the VI rib,lower border on the edge of costal archKurlov size = 8 7 7. Obraztov size = 9- 7- 6.Liver is palpable on 1cm below of rib of arch along linea midclavicularis, edge is soft-elastic, equal, painless and easily tucked Examination of the gall bladder:Kera symptom : negative,Murphy symptom : negative,Lepene symptom : negative,Vasilenkos symptom : negative,Orthers symptom : negative.No pain is felt at the choledocho-pancreatic, diaphragmatic, acromial, subscapular and paravertebral points at the right. Examination of the pancreas:Pancreas is not palpable. There are no any pain complaints during palpation. Tenderness in the points conforming to the head,the body, tail, diaphragmatic, acromial, subscapular,point of phrenic nerve and paravertebral points to the left are equal on both sides and any increased hypereshesia on the left side is not determined.Spleen: Spleen is not palpable. Borders of the splenic dullness are situated Upper- at level of the IX rib.Lower- at level of the XI rib.Sizes of the splenic dullness are.Transverse- 6cm.Vertical 7cm

LITRATURE
*Medical Microbiology: David Greenwood and d C.B.Slack *Clinical Medicine for Kuumar and Clark *Internal Medicine : HARRISONS. *Infectious Diseases for E.Nikitin and M.Andrechyn.

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