CRIMEA STATE MEDICAL
UNIVERSITY
Named after S.I. Georgievsky
DEPARTMENT (propedeotics of internal medicine )
CASE REPORT
Patient’s full name : Sonam Gupta
Age & sex
: 56 years old, male
Address
: D.57, Gorkovo Street, Simferopol.
CLINICAL DIAGNOSIS
Main Disease
Complications
Accompanying Disease
: Acute Ileus (Bowel Obstruction)
: None
: None
Name
: SYED AHMED RAZA
Group
: LA-2- 183A
1. PASPORT DATA
Name
Age
Gender
Date of birth
Marital status
Profession
Nationality
Address
Date of admission
: Sonam Gupta
: 50 years old
: Male
: 23 January 1951
: Married
: Engineer
: Indian
: D.57, Gorkovo Street, Simferopol.
: 08th October 2020
2. INQUIRY (INTERROGATIO)
COMPLAINTS
The patient is complaining about abdominal pain, nausea and vomiting.
HISTORY OF PRESENT DISEASE (ANAMNESIS MORBI)
The patient was admitted to our hospital with a two-day history of abdominal
pain and bilious vomiting. He had no history of abdominal surgery or any other medical
problems.
LIFE HISTORY (ANAMNESIS VITAE)
Patient was born in Simferopol. He is married and has a son. Both of them
are healthy and do not have history of any disease. Her was previously working in storage
department, but has retired now. Her condition at work was satisfactory. Work conflicts
were rare. Patient has regular meals (2 -4 times a day) mainly at home, patient prefers
eating salted food, mutton and sea food. Patient has harmful habit of smoking, he began
smoking at the age of 10, with almost 50 years of smoking habit. Patient drinks alcohol
occasionally.
Patient never suffered from infectious disease such as Tuberculosis, Hepatitis,
Malaria, AIDS, Syphilis and other venereal diseases before ther. Patient has no hereditary
diseases.
Patient bears medical preparation well without any allergic reactions. Allergic
reactions to various food and chemical substances are absent as well. He has not
undergone any blood transfusion and has not any record of donating blood. Patient had
not undergone any operations and dialysis in the past.
3. GENERAL EXAMINATION
(STATUS PRESENS)
General status of patient is satisfactory. Patient’s posture is passive. Consciousness is
clear. Facial expression is satisfactory. Gait of patient is weakened. Body build is
normosthenic. Lips are normal. Skin is pale and cold in area of pain (on lower
extremities). Subcutaneous fat is moderately developed. Edema is not present on both
legs.
Submandibular, posterior cervical, axillary, and inguinal lymph nodes are
determined with size from 0.5-1.0 cm in diameter, rounded form with smooth surface,
elastic consistence, and mobile, not changed.
The muscle are moderately developed, tone and muscle force are identical on both
sides. Palpation and tapping of the bones are painless. Joints are of regular shapes,
painful. Active movements in joints are limited and passive movements in joints are
painful. Pathologic deformation of spinal column is absent. Its function is normal.
The muscles are developed moderately, tone and muscle force are identical on
both sides. Palpation and tapping of the bones are painless.
Weight
Height
Blood pressure
Pulse
Respiratory rate
Body temperature
Blood group
: 80 kg
: 178 cm
: 130/80 mmHg
: 67/min (regular)
: 14 per minute
: 36.7ºC (normal)
: B (II) Rh-
System review
1) Skin:
The skin color of the patient is pale and cold at the both legs. The patient’s skin
humidity is usual. Patient’s hair is proper corresponding to her age. The patient’s skin has
normal turgor and elasticity. There are no visible rashes on the patient’s body. The patient
has post-operational scars on the body.
2) Fatty tissue:
Subcutaneous fat is markedly developed. The color of the mucous membrane is
pale-pink color. The mucous membrane was examined at the conjunctiva, nasal and oral
mucosa. The skin fold under the scapula is measured to be 1.5 cm. The skin fold on the
patient’s abdomen is measured to be 2.0 cm indicating abdominally localized fat.
The shape of the patient’s head is proportional, and symmetrical. The patient’s
facial expression is healthy. The shape of her eyes and nose is normal. The shape of the
neck is usual; carotid pulsations, jugular pulsations and dilated jugular veins are not
visible.
3) Muscle and joints
The muscles are developed moderately, tone and muscle force are identical on
both sides. Palpation and tapping of the bones are painless. Joints are regular in shape,
painless during palpation and movements except the lower extremities. The muscles,
bone and joints are in a generally good condition.
4) Lymph nodes
The palpation of the lymph nodes was done in the following order.
Occipital group
Not Palpable
Preauricular group
Not Palpable
Ant. Sternocleidomastoid group
Not Palpable
Post. Sternocleidomastoid group
Not Palpable
Submandibular group
Palpable
Submental group
Palpable
Supraclavicular group
Not Palpable
Cubital group
Not Palpable
Axillary group
Not Palpable
Inguinal group
Not Palpable
Popliteal group
Not Palpable
RESPIRATORY SYSTEM
Inspection
Respiration
: nasal breathing
Chest shape
: normal – normosthenic
Epigastric angle
: 90 degrees
Chest is symmetry, position of clavicle is symmetry, supra & sub-clavicular fossae are
expressed.
Position of shoulder blades fit to the chest
Type of respiration
: thoracic
Deep and rhythm of respiration
: normal
Respiration rate
: 16/min
Palpation
Tenderness along the ribs, intercostal spaces, trapezoid muscles, intercostal nerves
points are absent. Chest is slightly rigid. Vocal fremitus is of equal intensity in the
symmetrical parts of the chest (anterior, lateral and posterior). Pleural friction sounds are
absent.
Percussion
On comparative percussion of the lungs, clear lung sound is heard over
symmetrical points.
Traube’s space is determined, it is located in the inferio-lateral part of chest, in
has semilunar form.
On topographic percussion, the height of lung apexes is 3 cm above the clavicles
anteriorly and posteriorly, it is located on the level of the spinous process of the 7th
cervical vertebra. Lower border of the lung on different lines are showed in the following
table.
Line
Right lung
Left lung
Parasternal
5-th costal interspace
-
Midclavicular
6-th costal interspace
-
Anterior axillary
7-th costal interspace
7-th costal interspace
Midaxillary
8-th costal interspace
8-th costal interspace
Posterior axillary
9-th costal interspace
9-th costal interspace
Scapular
10-th costal interspace
10-th costal interspace
Paraspinal
11-th spinous process
11-th spinous process
Mobility of the lower lung borders along midclavicular, medial axillary and
scapular lines are as following:
Topographic line
Right lung
Left lung
Midclavicular
5cm
-
Midaxillary
6cm
6cm
Scapular
5cm
5cm
Auscultation
On lungs auscultation, vesicular breathing is heard over symmetrical points of the
lungs with appearance of medium bubbling rales. In bronchophony, illegible wherper
sound is heard over symmetrical points of the lungs.
CARDIOVASCULAR SYSTEM
Visible pulsation of arteries is absent. Venous pulse is negative. Cardiac hump
back and visible pulsation in the heart region is absent. Apex beat is palpated in the 5th
intercostals space 1cm medially from the left midclavicular line. It is restricted, low, and
of medium strength. Cat’s murmur was not determined. Systolic murmur at the apex beat
and nun’s murmur over jugular vein is absent. Pulse is equal on both arms. Pulse rate is
67 beats per minute. Pulse is rhythmic, moderate filling and diameter about 2mm.
Relative cardiac dullness:
Right border - along right edge of sternum
Upper border - at the level of 3rd interspace on left parasternal line
Left border - 1,0cm medially of the left midclavicular line at the level of 5th
inter costal space.
Absolute cardiac dullness:
Right border - along the left edge of the sternum
Upper border - on the inferior border of 4th rib on the level of mid clavicle
Left border - 2 cm medially from of the left midclavicular line
Borders of vascular bundle:
Right border - on the right sternal line
Left border - on the left sternal line
On auscultation of the heart the 1st tone is louder than the 2nd tone in apex and
below the sternum. The 2nd tone is louder than the 1st tone on pulmonary and aorta trunk
points. On Botkin-Erb’s point both the tones are equal. No murmurs. The tone is
rhythmic and can be heard clearly. Pulse of the temporal and carotid arteries are felt well,
pulsation on the both the sides are equal. BP - 130/80 mmHg. Pulse pressure is 50mmHg.
DIGESTIVE SYSTEM
Surface palpation of the patient’s entire abdominal region reveals a soft,
symmetrical and painless abdomen. Auscultation of the abdomen reveals normal
peristaltic sounds of the gastro-intestinal tract. There is also no diastasis of the abdominal
muscles though tonus of the muscle is lowered due to old age.
Tenderness, Mendel’s and Shchetkin-Blumberg’s symptoms are negative.
Sklyarov’s and Schlange’s symptoms are positive
The patient does not have any difficulty in swallowing or passing food through
the esophagus. There are no incidences of hypersalivation as well.
The mouth is in a generally clean condition, without any unpleasant smells. The
size of the patient’s tongue is usual. The tongue is in a generally normal state. However,
Mucous membrane of the mouth is normal.
Sign of liver enlargement is absent and it was palpable as soft, elastic and
painless.
After percussion on the patient, the upper border of the liver is situated along right
anterior axillary line on the level of 7th rib, along right midclavicular line on the level of
7th rib and along right parasternal line on the 5th intercostals space. The lower border of
liver is situated along right anterior axillary line on the level of 10th rib, along the right
midclavicular line on the lower edge of rib arch, along the right parasternal line on 2cm
below of rib arch and along the anterior mediana line on 4cm below xiphoid process. The
left border of absolute hepatic dullness is not displaced laterally of left parasternalis line.
The size of liver by Obraztsov is 11-10-9cm
The size of liver by Kurlov is 9-8-7cm
Gall bladder is not palpable. Symptoms of pressing and tapping of gall bladder are
negative and all tenderness point of gall bladder is negative. (Kera’s symptom, Murphy’s
symptom, Ortner’s symptom, Lepene’s symptom and Vasilenko’s symptom are
negative.)
Pancreas is not palpable. Kacha’s point and choledochopancreatic point are
negative.
Spleen is not palpable. On left side of costal arch, percussion of splenic dullness is
situated 9th-11th rib in transverse size, 5cm, and its length is 7cm. On auscultation of
abdomen, no pathological sounds are heard.
Patient’s defecation is regular, stool regular and normal. Patient does not have
diarrhea or constipation.
URINARY SYSTEM
Visible pathology of the lumbar region is absent. Kidneys are not palpable.
Palpation of the kidney’s region is not painful. Palpation along the course of ureters is
painless. Pasternatsky’s symptom is negative on the both sides. The urinary bladder is not
palpable. Palpation of the uterus and appendages region is painless. Volume of the
excreted urine is about 1450ml per day, colour is straw-yellow, clarity is transparent and
odor smells ammonia.
ENDOCRINE SYSTEM
There is no sign of gigantism, dwarfism, cachexia, obesity and habitus.
Expression of the patient’s face is normal. Secondary sexual signs of eunochoidism and
hirsutism are absent.
Changes of the eyes (exopthalmus or enophthalmus) and chair are not determined.
Ocular symptoms ( Graefe, Kocher Moebius, Stellwag, Dalrymple) are negative. Thyroid
gland is not enlarged. Its isthmus is palpated as soft, painless band 1 cm in diameter.
In accordance with decision of the WOPH 3 degrees of the thyroid gland
enlargement are distinguish:

O
- The thyroid gland is not visible. Its size is less than phalanx of thumb
finger of the patient.

I
- The thyroid gland is visible during swallowing and its size is more than
thumb finger of patient.

II
- The neck is deformed due to significant enlargement of thyroid gland.
BLOOD SYSTEM
Haemorrhagia on skin and mucosa are absent. Spleen is impalpable. The borders
of the spleen dullness are determined between 9th and 11th ribs. Skin color is normal
Patient’s blood group is A (II) Rh+.
NERVOUS SYSTEM & PSYCHIC STATE
Tendon reflexes are present. Pupils is identical size, react on light. Paralyses and
paresis are absent. Nystagmus is absent. The patient is fully competent in place and time,
quiet. Sleep is normal. Speech is correct, elocution. Thinking is logical. Gait is regular.
The patient in Romberg’s pose is steady.
6. PLAN OF LABORATORY & INSTRUMENTAL
DIAGNOSIS
Blood Analysis
Urine Analysis
Ultrasound
CT
Electrocardiogram (ECG)
7. DATA OF LABORATORY & INSTRUMENTAL TESTS
BLOOD ANALYSIS (on 18/04/2007)
Hemoglobin
Erythrocytes
Color Index
Leucocytes
-Basophil
-Eosinophil
-Neutrophil
Stab
Segmented
: 150 g/L
: 4.7 X 10l2 per litre
: 0.9
: 4.8 X 109 per litre
: 0.1%
:1%
: 2%
: 65 %
-Lymphocytes
-Monocytes
ESR
: 26 %
:6%
: 6 mm/h
Conclusion: Normal blood analysis
URINE TEST:
Color
Transparency
Reaction
Specific gravity
Glucose
Bilirubin
Urobilin
Protein
: light yellow
: transparent
: slightly acidic
: 1015
::::-
Microscopy of urine sediment:
Squamous epithelium
Leucocytes
Erythrocytes
Cast
Hyaline
Granular
Salt
Mucus
Bacteria
:: 6-8 in f.v.
:::::::-
Conclusion: Normal urine analysis
BLOOD GLUCOSE LEVEL: 4.7 mmol/L (Normal)
VASERMANN’S TEST: negative
ULTRASOUND : Revelation of bowel distension with horizontal level of fluids
CT: There is presence of neoplastic process as the reason for intestinal obstruction
ECG : Sinus rhythm, electrical axis without deviation.
8. FINAL DIAGNOSIS
Main Disease
Complications
Accompanying Disease
: Acute ileus (Bowel obstruction)
: None
: None
9. TREATMENT
1. Liquid diet to be given
2. No drinking
3. Conservative treatment
a). Mineralocorticoids
Rp.: Sol. Deoxycorticosteroni acetatis oleosae 0.5% - 1ml
D. t. d. No. 10 in ampules
S. 1ml IM 3 times per week
b). Analgesics
Rp.: Sol. Phentanyli 0.005% - 2ml
D. t. d. No. 10 in ampules
S. 1-2 ml IM, IV
4. Improvement of internal functions;
a) Heart: administration of cardiac prep., Glucose
b) Nervous system: Oxygen therapy, prevention of brain edema, pain
relief
c) Liver: Administration of Glu in combination with insulin, Vit. B1
and C, glutamic acid and protiens
d) Kidneys: control of diuresis, adjustment of normal amount of fluid,
recovery of oncotic pressure by transfusion of plasma or
polyglucan, improvement of renal blood supply
e) Adrenal gland: administration of Vit. C and hydrocortisone
5. Prevention of overtension and intestinal motility restoration
10. EPICRISIS
50-year-old woman was admitted to our hospital with a two-day history of
abdominal pain and bilious vomiting. She had no history of abdominal surgery or any
other medical problems. Physical examination revealed abdominal distention, tenderness
in the epigastrium and right hypochondrium without muscle guarding. Bowel sounds
were hypoactive. Rectal examination was normal. A plain abdominal X-ray film showed
several dilated small bowel loops with multiple air fluid levels. A contrast-enhanced CT
of the abdomen showed a distention of small bowel loops with transition point in the
right hypochondrium. Distended loops of small bowel were located in the left side of the
abdomen, whereas collapsed loops were located in the right side. The normal bowel wall
enhancement was preserved. After initial treatment with intravenous fluid and nasogastric
suction, he was operated. At laparoscopy a band obstructing the ileum was clearly
observed. This anomalous band extending from gallbladder to transverse mesocolon
caused a small window leading to internal herniation of the small bowel and obstruction.
The band was coagulated and divided. Postoperative outcome was uneventful and the
patient was discharged on the second postoperative day. There was no recurrence of
symptoms on subsequent follow-up.