Case story
- Passport part
- Pirozhkov Dmitriy Vasilevich
- 05.01.1985
- RK, East-Kazakhstan region, Ust-Kamenogorsk city, Pushkin street, house 29, flat 300
- Bus driver
- 13.09.2017
- Dudcov V. I. (gastroenterologist)
- Peptic ulcer
- Peptic ulcer complicated with bleeding
- Patient’s complaints
Strong tenderness in the epigastric region and slightly to the right of the median line; Blood vomiting, not bringing relief, the color of the coffee grounds. Fecal masses are colored black with a trace of blood. Severe weakness, dizziness, sensation of heaviness in the abdomen; Hungry and late pain, stopping after eating.
III. Anamnesis of disease
Soreness in the epigastric region began a year ago, the patient independently took painkillers, which only provoked the development of this disease. In 2015, there was an operation for cholelithiasis. Abundantly eats, as the pain is almost always docked by another meal. He often applied for medical help in private clinics about abdominal pain, but the patient refused to do FGDs. September 13, I went to the city clinical hospital number 2, from where I was sent to consult a surgeon, where he was diagnosed with two large ulcers. The patient was sent for surgery.
- IV. Anamnesis of life
Was born in the city of Ust-Kamenogorsk. Congenital pathology is not available. He grew up in a poorly provided family, studied at the gymnasium number 10, entered the technical college, where he was 4 years old, majoring in mechanical engineering. He is married and has two children. Has a smoking experience of more than 15 years, there is a predilection for drinking alcohol. Does not observe a diet, likes to eat abundantly. Among the transferred diseases there is gastritis, cholelithiasis, cholestasis. In the family, only the father was sick, who had surgery for a perforated stomach ulcer, he underwent surgery for a distal stomach resection according to Billroth-1. There is an allergic reaction to dairy products.
- Objective status
The state of severe severity. Consciousness is clouded. The situation in bed is passive. He was assigned strict bed rest. According to the constitutional type of physique – hypersthenic. Skin and visible mucous membranes are unchanged, with the exception of the tongue, which is covered with a white bloom. Subcutaneous fat is excessively developed. In particular in the abdomen, neck and face. Lymph nodes are unchanged, not palpable. Muscle tissue is poorly developed, muscle tone is normal. There is no pain in palpation. The bone-joint apparatus is normal, unchanged, there is no pain in palpation of bones and joints, the bones are symmetrical with respect to each other.
- Survey on systems and organs
Oral cavity examination
Inspection: the mouth is dry, tongue is covered with white coating, there is an unpleasant smell from the mouth.
Examination of the stomach and duodenum
Palpation: severe soreness in the epigastric region and in the right side, with irradiation to the right lower back.
Liver examination
Inspection: the liver without pathological changes, bulging and pulsations in the right hypochondrium region were not detected
The size of the liver: the dimensions correspond to the norm
Spleen examination
Inspection: during the inhalation phase, the spleen does not come out from under the edge of the left hypochondrium.
- Preliminary diagnosis
On the basis of the patient’s complaints, the history and results of the physical examination, one can think of duodenal ulcer.
- Laboratory data
General blood test: Erythropenia; Decreased hemoglobin; Leukocytopenia;
General urine analysis: Increased acidity of gastric juice, hypersecretion; Increased pepsin formation and ureppsin excretion; An increase in the blood content of bilirubin and ALT
Blood chemistry: Reduction of total protein and electrolytes; Progressive anemia; Achilles
Stool analysis on latent blood: positive
- Justification of the final diagnosis
On the basis of the patient’s complaints, the history of the disease and the results of the physical examination, laboratory and instrumental research data, one can think of duodenal ulcer complicated by hemorrhage.
- The final diagnosis
Peptic ulcer of duodenum, complicated by bleeding.
