ABSTRACT Of CASE HISTORY #16173

To be presented to the surgeon of local policlinic.

1. The patients' full name:


2. Date of birth:  3.08.1951


3. Home address:


4. Place of work: retired, does not work


5. Dates: a) in-patient: Admitted on 24.08.2010

                                      Discharged on 5.09.2010

1. Diagnosis: Chronic calculous cholecystitis. Chronic gastritis. Diabetes of II type, moderate, compensated.


2. Complaints and anamnesis: considers herself to be sick from 2009, when she was initially bothered by pains in epigastrium and right hypochondrium. The examination (US, fibrogastroduodenoscopy (FGDS) revealed chronic calculous cholecystitis in the right subcostal area, choric gastritis. Referred for consultation to the surgeon of MONIKI Consultative-Diagnostic Department to resolve the issue of gall bladder removing. She was hospitalized for the scheduled laparoscopic cholecystectomy in the 1^st Surgical Department of MONIKI.


3. Health state at admission: the patient's status is moderate. Skin and sclera are of ordinary color. Heart tones are rhythmic. Arterial pressure: 140/90 mm Hg. Heart beat – 78 per minute. Lung breathing is vesicular, no rale. The tongue is wet. No peritoneal symptoms

9. Examination data:

a)      Blood count of 25.08.10: hb – 130 g/l; leucocytes – 5.6x10⁹/l; er. – 5.35x10¹²/l.

b)      Blood biochemical analysis; bilirubin – 16.1 µ;  total protein – 66 g/l; creatinine – 69 µmol/l; sugar – 11.3 mmol/l; alanine-aminotransferase- 47, AST – 33.

c)      Clinical urine analysis:  light-yellow, density – 1010; pH – 6.0.

d)     Blood group: A(II), RH-factor – positive, AIDS, RW, HbsAG – negative (of 25.08.10).

e)      ECG of 25.08.10- sinus rhythm with heart beat rate of 67-73 per min.Normaldirection of electrical axis.

f)       Glycemic profile of 26.08.10: 4.0 - 4.4 - 6.3 - 4.4 - 4.2.

1. Treatment: after additional examination, on 2.09.10 had laparoscopic cholecystectomy. No complications of abdominal cavity in the port-surgical period. Safety drainage was removed on the 1^st day. Intestine passage is restored. Normal body temperature. The wound is healing with initial tension.

Therapy: Infusion therapy - Glucose 5% - 500.0 ml + insulin 6 units + KCL 3% - 100.0;  saline -400.0 + Vit B₁B₆, Vit C – 5.0, Cerucal intramuscularly 2.0 x 3 times a day; Zantac intramuscularly – 20.0 x twice a day; Mezim Forte (Pancreatin) 1 pi;; x 3 times a day; Glibomet 1 pill in the morning.

Endocrinologist’s consultation of 27.08.10: 9^th grade diets, Metmorfin (Siofor) 500 mg (1 tablet) at night. The examination and treatment were performed in compliance with MONIKI requirements.

11. Health state at discharging is of average severity.


12. Recommended: diet, taking for 2 weeks of the following: Nexium 20 mg x I  at night. Mezim Forte (Pancreatin) 1 tablet x 3 times a day. Local surgeon's follow-up, seeing the local polyclinic’ surgeon on 6.09.10.  Suture have to be removed on 13.09.10.

No sick leave certificate is required.

September 5, 2010

Physician,

Candidate of medical sciences                       (signed)          Yu. I Zakharov

Chief of Department

MD                                                                (signed)           A. I. Lobkov