MINISTRY OF EDUCATION AND SCIENCE OF UKRAINE
V. N. KARAZIN KHARKIV NATIONAL UNIVERSITY
SCHOOL OF MEDICINE
DEPARTMENT OF PROPAEDEUTICS OF INTERNAL MEDICINE AND PHYSICAL
REHABILITATION
Head of department
PdD, assoc. prof. Mariia S. Brynza
MEDICAL HISTORY
MALINEE PRAVA DASH________________
CHRONIC CALCULOUS CHOLECYSTITIS_______________________________
PRARAMBHIKA PANIGRAHI
GROUP- 428
Teacher:
Assistant of department,
Dr. Nataliia Bogun
Kharkiv - 2021
PASSPORT DATA
Patient full name: MALINEE PRAVA DASH
Age: 48
Marital status: MARRIED
Profession: NURSE
Place of residence: BHADRAK, INDIA
Clinical diagnosis: CHRONIC CALCULOUS CHOLECYSTITIS
PATIENT COMPLAIN
THE MAIN COMPLAINTS: The patient reports about dull right upper abdominal
pain(RUQ) for several years which worsened over past 2 months. Pain radiates around
the waist to the mid back region. Nausea and occasional vomiting are also reported by
patient . Usually these are seen in evening or at night time.
Additional complaint: increased bloating and flatulence and rapid weight loss
ANAMNESIS MORBI
1. Patient has been ill foe several years but it was asymptomatic, and symptoms started
to worsen since past 2 months. On admission patient complain about dull RUQ pain ,
nausea, vomiting sometimes, increased bloating , flatulence, rapid weight loss.
Temperature is high- fever
2. MPV slightly slightly decreased. RUQ ultrasound which shows thickened wall and
inflammation. CT scan reveals cholelithiasis and gall bladder wall thickening and hyper
enhancement of gallbladder wall.
3. patient was taking ursodiol but it has been of less help and did not help in full remedy
ANAMNESIS VITAE
1.patient having alcohol: NO
Smoking: NO
Drug intake: NO
2. patient has diabetes since 5 years. Is married, no regular exercise routine
3. stressful life. Working 7-8 hours in hospital as a nurse and then doing household
chores has taken few sick leaves
4.Nutrition: diet excludes intake of sweet and sugar as diabetic patient
drinks tea hot 2 times a day
eating fresh fruits daily 2- 3 in no
protein intake is less
5. Allergy history: NO
PRESENT STATUS(STATUS PRAESENCE)
1.General condition- moderate
2.patient has clear consciousness
3.active position of patient
4.painful facial expression
5.looks bit older than her age
6.asthenic body type, 5.6, 65kg, correct posture, normal gait
7.high temperature
8.normal skin colour
9.dry skin
10.absence of rash
11.skin turgor increased
12.normal color of mucous membrane, conjunctiva
13.female type hair growth, brittle hair
14.nail shape color and surface: normal
15.increased subcutaneous fat, stomach and thigh has fat deposition, edema absent
16.peripheral lymph node normal
17.muscle development in weak, decreased strength
18. joint swelling absent , joint pain present while climbing stairs
RESPIRATORY SYSTEM
chest shape- normal
chest deformity- absent
spine curvature- normal
patient chest-symmetrical
dyspnea- absent
respiratory rhythm- normal
CHEST PALPATION:
no tender mass
chest wall elasticity- normal
vocal fermitus- normal
CHEST PERCUSSION:
comparative percussion- normal
topographic percussion abnormality- absent
LUNG AUSCULTATION:
breathing sound- normal
extra added sounds- absent
CARDIOVASCULAR SYSTEM
CHEST INSPECTION
scar on chest- absent
chest deformity- absent
visible apex beat
vein distention on chest- absent
de musset sign- absent
CHEST PALPATION
apex impulse- normal
thrills- absent
HEART PERCUSSION
right border: 4th intercostal space 1 cm laterally of the right edge of the sternum
upper border: 3 rd intercostal space in the left parasternal line
left border: 5th intercostal space 1,5 cm medially of the left midclavicular line
transverse lenth 12 cm
vascular bundle 5 cm
HEART AUSCULTATION
normal heart sound (s1, s2..)
extra, or abnormal sound- absent
heart murmurs- absent
splitting of sound- absent
THE DIGESTIVE SYSTEM
EXAMINATION OF ORAL CAVITY
gums-normal, not swollen, no bleeding
teeth- normal
dry tongue, strongly coated
mucous of mouth- normal
pharynx- normal
tonsils -not increased
INSPECTION OF ABDOMEN
scar or vascular changes, or protrusion- absent
abdomen is prominent
AUSCULTATION OF THE ABDOMEN
increased bowel sound
gurgling bowel sound
PALPATION OF THE ABDOMEN
superior wall of abdomen elevated
no peritonitis been found,
Murphy's sign- present
PERCUSSION OF THE ABDOMEN
size of abdomen- normal, other organs normal
fluid wave test doesn't show ascites
liver, spleen palpation and percussion- normal
costovertebral angle tenderness- absent
ENDOCRINE SYSTEM
thyroid gland-(normal value of tsh, t3, t4)
palpable thyroid gland- absent
PRELIMINARY DIAGNOSIS
1. Chronic calculous cystitis
2. complication- acute cholecystitis or pus collection
proliferation of bacteria in gallbladder
3- gallstone ileus
LABORATORY AND INSTRUMENTAL RESEARCH DATA
1. FBC- slight decrease in MPV and slight increase in WCC
2.Liver enzymes- mildly abnormal
3.RUQ ultrasound- gallbladder thickening (>3mm) and inflammation
4.CT with intravenous contrast- reveals reveals cholelithiasis and gallbladder wall
thickening
5.HIDA cholescintigraphy- delayed gallbladder visualization(>1hr)
reveals gallbladder emptying(ejection fraction-EF)= <35%
THE MAIN SYNDROMES IN THE PATIENT
1.dull RUQ pain radiating around waist to mid back region
2.dyspnea- absent
3.valve dysfunction- absent
4.abdomen palpation confirms presence of Murphy's sign
5.fever- present (>38degree C)
5.slight weakness and fatigue
CLINICAL DIAGNOSIS
• Patient is suspected with CHRONIC CALCULOUS CYSTITIS
• chief complaints- RUQ dull pain, pain excarbated by fatty food intake, nausea,
vomiting, increased bloating, flatulence, fever
• RUQ ultrasound and CT scan reveals cholelithiasis with gallbladder thickened
• WCC slightly raised and MPV slightly decreased
MAIN DISEASE- chronic calculous cholecystitis
COMPLICATIONS- acute cholecystitis or pus collection
CONCOMITANT DISEASE- gallbladder ileus
----------------------------------