Course of surgical diseases

Tutor: Akimzhanov K.D.

Case history

Last name: Erbolatkyay

First name: Asem

Student: Abisheva Gulden

447 GMF

Semey, 2013

Passport data

Last name: Erbolatkyzy

First name: Asem

Gender: female

Age: 18

Date of birth: 04.06.1994

Weight: 51 kg Height: 168 sm

Blood group: B (III) Rh-factor: +

Department: Surgery

Room: 11

Nationatility: Kazakh

Address: VKO, Semey, 35 district, 24, apt. 95

Telephone: 77-45-00

Occupation: student at medical college – 2 course

Time of admitting to hospital: 28.03.2013 at 13.00

Admitted by: emergency ambulance

Diagnosis of directed organization: acute appendicitis

Diagnosis at admission: acute appendicitis.

1. Preliminary: acute appendicitis

2. Clinical: acute phlegmonous appendicitis, local serous peritonitis

Result of disease: recovery, improving after surgery, without changes, deterioration

Time of discharge: -

Number of spent berth-days: 6

Beginning of tutoring: 02.04.2013

End of tutoring: -

Primary examination

28/03/13

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

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.

Anamnesis vitae: Botkin’s disease, tuberculosis, venereal diseases are denied. No hemotransfusion.

Family anamnesis: not burdened

Past illnesses: ARVI 26/02/13-21/02/13

Status praesens: moderate severity. Consciousness is clear, skin are common color. Subcutaneous-fat layer is good. Motor-supportive system: without visible pathology. Peripheral lymph nodes: are not dilated, without pain during palpation. Respiratory system: breathing is free, through nose, form of chest cavity is conical, both parts participate at breathing equally. Auscultatively: breathing is vesicular, no rales. Frequency of breathing – 18 per min. Cardiac system: in the region of heart and great vessels no visible pulsation. Borders of heart are in norm. Apex beat feel in 5^th intercostal space. Percussion: relative borders of the heart from right – parasternal line on right, upper – III rib, left – on 1.5 sm inside to mid-clavicular line. Frequency of heart beats – 90 per min. BP 110/70 mm Hg. Digestive tract: complaint on vomiting, swallowing is free, abdomen is common size, at palpation abdomen is soft. pain in right iliac region. Liver: without pain at palpation. Spleen: are not palpated. Stool is regular. Urogenital system: kidney are not palpated. Symptom of knocking is negative from both sides, urination is free, painless.

Status localis: painless at right iliac region. Kocher’s, Rovzing’s, Sitkovsky’s, Vosckresensky’s, Bartomier’s symptoms are positive.

Date: 2015-01-12; view: 1491