Acute Local Primary Infectiou Peritonitis, reactive stage. Due to acute appendicitis

Federal State Budgetary Educational Institution of Higher Education «National Research Ogarev Mordovian State University»

Medical Institue

Department of Faculty Surgery

CASE HISTORY

Semenova Nadia Alexandrovna

THE FINAL CLINICAL DIAGNOSIS:

Acute Local Primary Infectiou Peritonitis, reactive stage. Due to acute appendicitis

Prepared by: AL-SALIH ALI S.S

Group: 427-A

Checked by: Dr. AL-KUBAISI SHEIKH-AHMED S.M.

Saransk 2020 – 2021

PATIENT'S ID:

Full name: Semenova Nadia Alexandrovna

Age: 45 years old

Gender: female

Education: secondary school

Occupation: cashier

Marital status: married

Home adress: Ul'itsa Vasenko, 7A, Mordovia, Saransk

Date of admission: 9.03.2022

DIAGNOSIS AT ADMISSION:

Acute abdomen

THE PRELIMINARY DIAGNOSIS:

Acute peritonitis

DIFFERENTIAL DIAGNOSIS:

Acute appendicitis, phlegmonous appendicitis, pancreatitis, intestinal obstruction, cholecystitis, perforated gastric ulcer, myocardial infarction,

THE FINAL CLINICAL DIAGNOSIS:

Acute Local Primary Infectiou Peritonitis, reactive stage. Due to acute appendicitis

COMPLICATIONS:

absent

CONCOMITANT DISEASES:

Acute complicated appendicitis

COMPLAINTS

Complaints at admission: the patient complained of pain in the epigastrium and right iliac region, nausea, vomiting twice.

ANAMNESIS MORBI

The patient considers himself sick for about 4 hours ago when there was «knife» pain in the epigastrium, and then spread to the right iliac region. She was disturbed by nausea, vomiting twice. Urination is not disturbed, the stool is of usual color. When compressed by the sensor, pain is noted in the epigastrium, the right iliac region and above the bosom.

ANAMNESIS VITAE

Biography: born on July 5, 1976, Republic of Mordovia, Saransk.

Work history: has been working as a cashier since the age of 23.

Household history: social conditions are satisfactory

Meals: regular, moderately high in calories, does not follow a diet.

Bad habits: smokes half a pack of cigarettes everyday. Drinks alcohol on the weekends.

Past illness: corona virus infection, influenza virus infection. No previous surgical operation.

Allergic history: no history on allergic reactions.

Heredity: the father had essential arterial hypertension and the mother  had diabetes mellitus II.

STATUS PRAESENS

The general condition of the patient is of moderate severity.

The state of consciousness is clear.

Normosthenic physique

Height: 169 cm, weight: 75 kg, body temperature: 37.4 ° С

GENERAL INSPECTION:

The skin: normal color and moisture. The skin turgor is preserved. No pathological rash or peripheral edema.

Visible mucous membranes: the tongue is dry and white coated. Visible mucous membranes of the oral cavity, pharynx, conjunctiva of a pale pink color, white sclera, pathological changes and the severity of the vascular pattern were not found.

Subcutaneous fat: moderately developed, no edema and pastiness.

Lymph nodes: normal lymph nodes

Musculoskeletal system: no changes

Joints: the configuration is not changed, active and passive movements in the joints are fully preserved, painless.

RESPIRATORY SYSTEM

Examination of the chest: the shape of the chest is normal, symmetrical, the type of chest is normosthenic, there are no deformities.

Breathing: thoracic breathing, RR 26 per miute. Breathing through the nose is preserved,.

Palpation: no pathological signs were detected on palpation.

Percussion:

        Comparative percussion: clear pulmonary sound is noted when percussion over symmetrical areas.

        Topographic percussion: lung boundaries within normal  limits

Auscultation: during auscultation, vesicular breathing is heard, it is evenly carried out in all departments, wheezing is absent in all departments.

CARDIOVASCULAR SYSTEM

Eamination of the chest area: On examination of the heart region, protrusions, apical and cardiac impulses, pulsations in the II intercostal space near the sternum were not found. There are no pulsations and swelling of the veins of the neck, no pathological precordial and epigastric pulsations. Veins in the sternum are not dilated.

Palpation:

        Apical impulse: localized in the V intercostal space along the left mid-clavicular line, 2 cm wide, strong, low, moderate resistance.

        Heart beat: not detected

        Trembling in the region of the heart: not detected

Percussion:

        The  boundaries of  the  relative  dullness  of  the  heart:

- Right - along the right edge of the sternum at the level of the IV intercostal space

- Left - on the left mid-clavicular line at the level of the V intercostal space

- Upper - at the level of the III rib along the left edge of the sternum