Anamnesis morbi

As she said she is being ill from 8 o’clock when sudden symptoms appeared. Patient is admitted by emergency ambulance to БСМП.

Objectively: skin and mucous are common color. In lung the respiration is vesicular without rales, cardiac sound are muted, pulse 76/min, BP 110/70 mm Hg, tongue is wet, abdomen is soft, sharp pain in right iliac region, weakness, excitability, symptom of peritoneum is absent. Kocher’s, Rovzing’s, Sitkovsky’s, Vosckresensky’s, Bartomier’s symptoms are absent. Stool and diuresis are not changed.

DS: acute appendicitis

Operation

Name of operation: Appendoctomy

Date: 28/03/13

Method of anaesthesia: IV DA

Complications: no

Surgeon:

Preparation for anaesthesia: S. Cetamini 5%-5.0, S. Bruzepami 0.5%-2.0

Beginning: 14.00

End: 14.30

Special notes

Allergic anamnesis: not burdened

Epidemiologic anamnesis: without particularities

Individual features: without particularities

Past illnesses: Botkin’s disease, tuberculosis, venereal diseases are denied

28/03/13: examined by surgeon on duty at 11:15 o’clock with complaints on pain in right iliac region.

Justification of preliminary diagnosis

Complaints: pain in right iliac region, vomiting, fatique.

Anamnesis: As she said she is being ill from 8 o’clock when sudden symptoms appeared. Patient is admitted by emergency ambulance to БСМП.

Objectively: Kocher’s, Rovzing’s, Sitkovsky’s, Vosckresensky’s, Bartomier’s symptoms are positive.

Preliminary diagnosis: acute appendicitis.

Examination by head of surgical department

At 12.30 28.03.13 DS: acute appendicitis. She was directed to operating room.

Plan of Laboratory-instrumental investigation

1. CBC

2. Urine analysis

3. Ultrasound of abdomen and kidneys

4. Analysis of feces on helminthes eggs and simplest

5. Biochemical analysis of blood (protein, bilirubin, glucose, urea, creatinine, Alt, Ast, cholesterine)

6. RW-blood test

7. Coagulogramm

8. Blood on microreaction

9. Time of blood coagulation

10. Bacterial seeding

11. ECG

Plan of treatment

1. Regimen is bed

2. Table #0

3. Promidol 2%/10

4.

5.

6. Surgical treatment: appendectomy

Results of urine analysis (28/03/13)

GLU negative

BIL negative

KET negative

SG 1.020

BLD negative

PH 5.0

PRO negative

URO 0.2

NIT positive

LEU negative

COLOR yellow

Results of urine analysis (31/03/13)

GLU negative

BIL negative

KET negative

SG 1.020

BLD negative

PH 5.0

PRO negative

URO 0.2

NIT negative

LEU negative

COLOR yellow

Results of coagulogramm (28/03/13)

Thrombus formation:

· Prothrombine time 16 sec

· Prothrombine index 88%

· INR(international normalized relation) 1.18

Fibrinogen formation 3552 mg/l

Ethanol test: negative

Biochemical analysis of blood (28/03/13)

Urea 3.8 mmol/l

Glucose 6.6 mmol/l

Alt 0.2 mccat/l

Ast 0.16 mccat/l

General Bilirubin 18.18 mcmol/l

Results of CBC (28/03/13)

Hb 141 g/l

Er 4.4*10¹²/l

Color index 0.9

Leu 8.8*10⁹/l

Seg 86%

Eos 1%

Bas-

Monocytes 2%

Lymph 8%

ESR 4mm/h

Hematocrit 4%

Results of ECG

P-Q 0,14 sec

QRS 0,08 sec

QT 0,36 sec

R-R 0,80 sec

Rhythm: sinus

Frequency of heart contractions: 75/min

Electrical axis of heart: vertical

Results of Ultrasound of abdomen and kidneys (28.03)

Kidneys: form and size are edematous. Contour is straight. Parenchyma is saved. Calyx- pelvis system is not dilated, without deformations.

Abdomen: intestinal loop are not dilated. Peristalsis is present. At scanning of right iliac region there is region of intestine (width 1.7 sm) with liquid and thickened hyperogenic wall (0.4 sm) around of which there is a little amount of liquid. In lower part of abdominal cavity between loops of the intestine is little amount of liquid.

Conclusion: Symptoms of acute appendicitis, liquid in abdominal cavity.

Analysis of feces on helminthes eggs and simplest (29.03)

Helminthes : no

Simplest: no

Temperature chart

Diary

28/03/13 at 17.30

Transmitted from reanimation and intensive therapy department. Condition after appendectomy. State is moderate severity. Skin and mucous are common color. Cardiac tones are rhythmical. BP 110/70 mm Hg. Pulse 80/min. Tongue is wet. Abdomen is symmetrical, soft, painful at wound. Diuresis is not damaged. indications are made. Symptom of peritoneum irritation is absent.

29/03/13 at 6.00

State is moderate severity. Skin and mucous are common color. Cardiac tones are rhythmical. BP 110/70 mm Hg. Pulse 84/min. Tongue is wet. Abdomen is symmetrical, soft, painful at wound. Diuresis is not damaged. indications are made. Symptom of peritoneum irritation is absent.

at 10.00 complaints on pain in wound and fatigue. Was prescribed Sol. Promedoli 2%-1.0 and Sol.Dimedroli 1%-1.0 IM to relieve the pain.

30/03/13 09.00

State is moderate severity. Skin and mucous are common color. Cardiac tones are rhythmical. BP 110/70 mm Hg. Pulse 80/min. Tongue is wet. Abdomen is symmetrical, soft, painful at wound. Diuresis is not damaged. indications are made. Symptom of peritoneum irritation is absent

31/03/13 -

01/04/13 at 9.00 Examination by professor Botabayev S.K.

Loops of intestine are not damaged. Peristalsis is present. No liquid in abdominal cavity on ultrasound examination.

State is satisfactory. Skin and mucous are common color. Cardiac tones are rhythmical. BP 110/80 mm Hg. Pulse 71/min. Tongue is wet. Abdomen is symmetrical, soft, moderate painful at wound. Diuresis is not damaged. Symptom of peritoneum irritation is absent. No complaints.

02/04/13 at 9.00

State is satisfactory. Skin and mucous are common color. Cardiac tones are rhythmical. BP 110/70 mm Hg. Pulse 75/min. Tongue is wet. Abdomen is symmetrical, soft, moderate painful at wound. Diuresis is not damaged. Symptom of peritoneum irritation is absent. No complaints.

Justification of clinical diagnosis

Complaints: pain in right iliac region, vomiting, fatique.

Anamnesis: As she said she is being ill from 8 o’clock when sudden symptoms appeared. Patient is admitted by emergency ambulance to БСМП.

Objectively: Kocher’s, Rovzing’s, Sitkovsky’s, Vosckresensky’s, Bartomier’s symptoms are positive.

Laboratory-instrumental data:

Results of CBC (28/03/13)

Hb 141 g/l

Er 4.4*10¹²/l

Color index 0.9

Leu 8.8*10⁹/l

Seg 86%

Eos 1%

Bas-

Monocytes 2%

Lymph 8%

ESR 4mm/h

Hematocrit 4%

Biochemical analysis of blood (28/03/13)

Urea 3.8 mmol/l

Glucose 6.6 mmol/l

Alt 0.2 mccat/l

Ast 0.16 mccat/l

General Bilirubin 18.18 mcmol/l

Results of urine analysis (28/03/13)

GLU negative

BIL negative

KET negative

SG 1.020

BLD negative

PH 5.0

PRO negative

URO 0.2

NIT positive

LEU negative

COLOR yellow

Results of ECG

12. P-Q 0,14 sec

13. QRS 0,08 sec

14. QT 0,36 sec

15. R-R 0,80 sec

16. Rhythm: sinus

17. Frequency of heart contractions: 75/min

18. Electrical axis of heart: vertical

Operation: appendectomy 28/03/13

Macropreparate of appendix: length 10 sm, enlarged, with fibrin fibers.

Based on the above data the clinical diagnosis: Acute phlegmonous appendicitis. Complication: local-limited serous peritonitis.

Date: 2015-01-12; view: 1884