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Keywords: a case history, a propedeutics, 3 course, medical faculty, a peptic ulcer of a stomach, disease, an anamnesis, the diagnosis
the CASE HISTORY
the Diagnosis: a peptic ulcer of a stomach
Date of a curatio: on April, 23 2002
NAMEPLATE DATA
- the Surname, a name, a patronymic of the patient ******** ******* *********
- the Sex - Man's
- Age - 76 years
- the Marital status - It is married
- Formation - the Supreme military
- the Trade, a post, a place of work - the Pensioner
- the Residence - *********************
- Date of entering in clinic - on April, 22, 2002
- the Name of medical establishment - the City hospital ¹20
COMPLAINTS
The patient complains of strong, cutting pains in range of an epigastrium and the left hypochondrium, irradiating in the left half of thoracal cell. Pains arise in 30-60 minutes after reception of nutrition. Weaken after reception of antacides and spasmolytics. The patient shows complaints to a heartburn, a nausea in 1 hour after meal. The patient complains of downstroke of mass of a body (10 kg for 6 months). Marks restless dream, hardly falls asleep, often night awakenings.
ANAMNESIS MORBI
The heartburn, a nausea, an eructation counts itself the patient within 10 days when pains in epigastriums have appeared. In some days of a pain have amplified also the patient has been compelled to address in a polyclinic where the preliminary diagnosis of a peptic ulcer of a stomach is put and the patient has been hospitalized. The patient does not bind development of disease to any provoking factors.
ANAMNESIS VITAE
Dews also educed in conformity with the years. Has received the supreme military formation. Since 1975 - the reserve officer. Marks series of disputed situations at an output on pension then the peptic ulcer of a stomach has developed. Smokes within 40 years on 1 pack in day. 2 months ago has transferred fracture of ribs. Consumption of alcohol moderate.
The infectious disease, tuberculosis, venereal and mental diseases at itself and denies relatives. The intolerance of foodstuff and medicines denies. STATUS PRAESENS COMMUNISthe General state of the patient satisfactory. Consciousness clear. The patient is quiet, questions answers adequately. A position of the patient awake. A body build correct, the constitution asthenic. Body height of 180 sm, weight - 65 kg. the Form and the dimension of a head and a neck - usual, a look quiet, the form of a nose correct, the dentition is kept, tongue pink, wet. A moderate swelling of bulbar veins. Integuments moderately wet, light pink with an icteric shade without rashes. The turgor of a skin is reduced. The form of nails - correct. Mucous clean, pink, wet. The hypodermic fatty layer is weakly advanced. submandibular and occipital lymph nodes in size with a pea - spherical, painless, mobile, not commissured with environmental tissues Are palpated. the Muscular system is well advanced, tone is kept, force of muscles is sufficient. 11-12 ribs on the left side of a thoracal cell Are deformed. A configuration of joints usual, are painless, locomotions in full. the Form of a thoracal cell normal, symmetric. Phylum of respiration - belly. Both half of thoracal cell participate in the act of respiration. Frequency of respiratory locomotions 16 in one minute. Respiration rhythmical, deep. A percussion note on symmetric fields of a thoracal cell identical, character of a note - clear pulmonary. Excursion of the inferior pulmonary edge - 7 see. The data of a topographical percussion: the inferior border dextral mild on a mammilar line - 6 rib, on an average axillary line - 8 rib, on a scapular line - 10 rib; The inferior border left mild on a mammilar line - 6 intercostal space, on an average axillary line - 8 rib, on a scapular line - 10 rib. Cardiovascular system. An apical beat - in 5-th intercostal space on a mammilar line. A Crocq's disease it is not revealed. It is not marked pulsings of pots. Cervical veins are not enlarged, supraclavicular fossas flattened. Arterias without pathological changes. the Form of a gaste - spherical, small augmentation on the right. The gaste participates in the act of respiration. At a superficial palpation morbidity in range of an epigastrium is marked. A percussion note - tympanic. the Liver on 4 sm acts because of a costal arch. Edge of a liver - equal, painless. The dimensions on Kurlovu: on a dextral sredinno-clavicular line - 13 sm, on forward midline - 11 sm, on the left costal arch - 9 sm (hepatomegalia). At an endoscopy the ulcer in range of a body of a stomach in diameter 2,5 see is found. the general analysis of a blood, urine, analysis of a gastric juice, the test on Helicobacter pylori. the PRELIMINARY DIAGNOSISAre necessary
On the establishment of a clinical picture (early pains in epigastriums and left the hypochondrium) and the data of an endoscopy is possible to put the preliminary diagnosis - a peptic ulcer of a stomach.
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