Задача 9
Больная Б., 60 лет, поступила в больницу с жалобами на желтушное окрашивание кожи и склер, кожный зуд, общую слабость, снижение аппетита. Из анамнеза: считает себя больной на протяжении 2-х месяцев, корда заметила, что моча темного цвета а кал светлый. Затем появилось желтушное окрашивание склер и кожи, вначале незначительное, а затем постепенно желтуха наростала, появился кожный зуд. За 2 месяца масса тела уменьшилась на 4 кг.
При обследовании: общее состояние больной средней тяжести, кожа и видимые слизистые оболочки интенсивной желтушной окраски, следы расчесов на коже. При пальпации: живот мягкий, умеренно болезненный в правом подреберье, печень выступает на 2 см ниже края реберной дуги, умеренно болезненная при пальпации. Желчный пузир пальпируется нечетко (дно пузиря), безболезненный. Симптомы раздражения брюшины отрицательные. При УЗИ выявлены признаки хронического воспаления желчного пузыря, конкременты отсутствуют, холедох в диаметре до 15 мм, в нижней трети его – сужение просвета.
Задача 10
Больная В., 56 лет, поступила в больницу с жалобами на желтушное окрашивание кожи и склер, кожный зуд, общую слабость, снижение аппетита. Из анамнеза: болеет около 3-х месяцев, корда заметила светлый кал и потемнение мочи, затем появилось желтушное окрашивание склер и кожи, интенсивность котрого медленно наростала. Масса тела за 3 месяца уменьшилась на 7 кг.
При обследовании: общее состояние больной средней тяжести, кожа и видимые слизистые оболочки интенсивной желтушной окраски, следы расчесов на коже. При пальпации: живот мягкий, умеренно болезненный в правом подреберье, печень выступает на 4 см ниже края реберной дуги, умеренно болезненная при пальпации. Желчный пузирь не пальпируется. Симптомы раздражения брюшины отрицательные. При УЗИ: внутрипеченочные желчные протоки расширены, в области ворот печени определяется новообразование, размером до 3,5 см в диаметре, с нечеткими контурами, диаметр холедоха 0,5 см.
Задача 11
Больной К., 40 лет, обратися к врачу с жалобами на желтушное окрашивание кожи и видимих слизистих оболочек, умеренную боль в правом подреберье. Из анамнеза: п’ять дней назад, после погрешности в питании возникла приступообразная боль в правом подреберье, а через сутки заметил желтушность склер и кожи, повісилась температура тела до субфебрильных цифр. В прошлом были приступы боли в правом подреберье, при УЗИ были выявлены конкременты в желчном пузыре.
При обследовании: общее состояние больного относительно удовлетворительное. Кожа и видимые слизистые желтушны. Живот симметричен, передняя брюшная стенка принимает участие в акте дыхания. При пальпации – живот мягкий, умеренно болезненный в правом подреберье, где пальпируется увеличенный, умеренно болезненный желчный пузырь. Симптомы Грекова-Ортнера, Кера отрицательные, признаков раздражения брюшины нет.
Задача 12
Больной Р., 48 лет, поступил в отделение с жалобами на желтушное окрашивание кожи и видимых слизистых оболочек, тупую боль в правом подреберье, обесцвечивание кала. Из анамнеза: желтуха появилась месяц назад, без видимых причин, постепенно нарастала. Кроме того больной отмечает, что за последние 3 месяца масса тела снизилась на 6 кг, появилась общая слабость. За 10 дней до поступлення в больницу больной обращался к семейному врачу, была выполнена ФГДС, при которой установлено, что большой дуоденальный сосочек увеличен, поверхность его бугристая, контактно кровоточит (биопсия не взята).
При обследовании: общее состояние больного средней тяжести, кожа и видимые слизистые оболочки интенсивной желтушной окраски. Живот симметричный, передняя брюшная стенка принимает участие в акте дыхания. При пальпации – живот м’який, чувтвительный в правом подреберье, печень выступает на 2 см ниже края реберной дуги, желчный пузирь увеличенный, напряженный, безболезненный.. Симптомы раздражения брюшины отрицательные.
Jaundice syndrome
CASE# 1
Patient B. , 50 y.o., complains of pain in the right upper quadrant of paroxysmal character , icteric staining of skin and mucous membranes, vomiting. Anamnesis : a year ago was investigated with regard to periodic pain in the right upper quadrant, established the presence of gallstones , no jaundice found. Three days ago there was paroxysmal pain in the right upper quadrant, and a day after onset- noticed icteric staining of the sclera and skin.
On examination : general condition of the patient of moderate severity , skin and sclera icteric , body temperature 36,8 ° C. Abdomen symmetrical, anterior abdominal wall is involved in the act of breathing . On palpation determined soreness in his right hypochondrium where clearly palpable enlarged painful gallbladder .Peritoneal symptoms are negative. Dark urine , feces discolored .
Jaundice syndrome
CASE# 2
Patient S. , 45 y.o., was admitted to hospital complaining of persistent pain in the right part of the abdomen , fever up to 38,0 ° C, icteric staining of the skin and sclera. Anamnesis : a year ago underwent cholecystectomy due to cholelithiasis , chronic calculous cholecystitis, after surgery felt satisfactory. 5 days ago suddenly appeared in the right upper quadrant pain , increased body temperature , and a day later noticed icteric staining of the sclera and skin , discoloration of feces.
On examination : general condition of the patient of moderate severity, skin and visible mucous are yellowish . On palpation - moderate pain in the right upper quadrant , liver -at the costal margin . Peritoneal signs are negative.
Jaundice syndrome
CASE# 3
Patient P. , 50 y.o., was admitted to the hospital complaining of paroxysmal pain in the right upper quadrant, icteric staining of the skin and sclera , increased body temperature to 38 ° C , periodic fevers . From history : sick for 5 days , the disease started with acute paroxysmal pain in the right upper quadrant, after that body temperature rised to 38 ° C , staining of the skin and sclera appeared jaundiced and secretary. Dark urine, feces discolored . Previously suffered cholecystectomy for chronic calculous cholecystitis.
On examination : general state of moderate severity , skin and visible mucous membranes moderately icteric . Somewhat swollen belly , the right half of the anterior abdominal wall behind in the act of breathing . On palpation - moderate pain in the right upper quadrant , peritoneal signs are negative. During ultrasound : choledoch 12 mm wide , its walls thickened.
Jaundice syndrome
CASE# 4
Patient M. , 30 y.o., was admitted to the hospital complaining of icteric staining of the skin, pain in the right upper quadrant, fever. History of jaundice appeared 7 days ago, gradually increased . Earlier periodically suffered from pain in the right upper quadrant . The patient is followed up by a proctologist due to ulcerative colitis of moderate severity.
On examination : general state of moderate severity , skin and visible mucous membranes ikteric . Stomach is not swollen, anterior abdominal wall is involved in the act of breathing . On palpation the abdomen slightly tense, determined soreness in the right upper quadrant . Liver 2 cm below the costal margin . Peritoneal signs are negative. Ultrasound : gallbladder not changed , no stones , common bile duct lumen uniformly narrowed to 0.2 cm , stones can not be visualized .
Jaundice syndrome
CASE# 5
Patient B. , 60 y.o., admitted to the hospital with complaints of the yellowness of the skin, itching , general weakness , weight loss , fever in the evening , discolored feces, dark urine . From history : about six months ago there was a dull epigastric pain radiating to the back , began to lose weight (10 kg for 6 months) ; two weeks ago by the yellowness of the sclera and then the skin , discoloration of feces.
On examination : general condition of the patient of moderate severity , skin and visible mucous intense jaundice color with a greenish tinge. Abdomen symmetrical , somewhat swollen . On palpation - the abdomen is soft , moderately tender in the epigastric region , where clearly defined tumor-like formation , dense , without contours, does not move . Liver extends below the costal arch is palpated 3 cm painless enlarged gallbladder .
Jaundice syndrome
CASE# 6
Patient S. , 65 y.o., was admitted to hospital complaining of icteric staining of the skin and sclera , skin itching , general weakness, weight loss, periodic aching pain in the epigastric region . Of anamnesis : sick for 4 months , when they began to appear periodically aching epigastric pain , noticed weight loss. Two weeks ago, noticed the yellowness of the sclera and skin, which gradually increased , there was itchy skin, discolored feces .
On examination : general condition of the patient of average severity , skin color yellow-greenish , reduced skin turgor . Tongue moist, coated at the root with a brownish patina . Abdomen symmetrical, anterior abdominal wall is involved in the act of breathing , palpation - the abdomen is soft , moderately painful in projection of the pancreatic head . Liver + 5 cm, tight, moderately painful . Painless palpable enlarged gallbladder. Digital rectal examination –feces of grayish color .
Jaundice syndrome
CASE# 7
Patient M. , 30 y.o., was admitted to the hospital complaining of fever up to 39 ° C , general weakness, pain in the right upper quadrant, icteric staining of the skin. Anamnesis : 2 months ago underwent surgery due to penetrating wound of the abdomen with the common hepatic duct injury, suturing of the duct was performed, discharged in a satisfactory condition. Two weeks ago there were aching pain in the right upper quadrant , and then noticed the yellowness of the sclera and skin, dark urine.
On examination : general condition of the patient of average severity , skin and visible mucous moderately icteric . On palpation - the abdomen is soft , moderately tender in the right upper quadrant , where palpable enlarged ( 4 cm) , sensitive to palpation liver, gallbladder notpalpated , peritoneal signs are negative.
Jaundice syndrome
CASE# 8
Patient S. , 40 y.o., admitted to the hospital in severe condition with complaints of intense pain in the right upper quadrant , fever, yellow skin . Anamnesis : from the words of relatives - get sick for two weeks , when there was paroxysmal pain in the right upper quadrant, and then - fever and yellowness of the skin and sclera . Did not applied any hospital ,used self-medication . Over the past two days the patient's condition progressively worsened, increased pain in the upper quadrant , the body temperature rose to 39-40 ° C.
On examination : general condition of the patient is severe , confused consciousness . Pulse 126 bpm, blood pressure of 80/ 60 mm Hg . body temperature of 40 ° C. Skin and visible mucous icteric . Stomach participates in the act of breathing , palpation - soft, tender in the right upper quadrant , where it is determined increased (up to 6 cm) , painful liver. Gallbladder not palpable . Peritoneal signs are negative.
CASE# 9
Patient B. , 60 y.o., was admitted to hospital complaining of icteric staining of the skin and sclera , skin itching , general weakness , loss of appetite . From history : feels sick for the past 2 months , the cord noticed that dark urine and feces light . Then came icteric staining of the sclera and skin , first a small and then gradually narostaet jaundice , pruritus appeared . 2 months body weight decreased by 4 kg.
On examination : general condition of the patient of average weight , the skin and visible mucous membranes intensive jaundiced color , traces of scratching the skin. On palpation : the abdomen is soft , moderately tender in the right upper quadrant , the liver performs at 2 cm below the costal margin , moderately painful on palpation. Gall puzir clearly palpable (bottom puzirya ) , painless. Peritoneal signs are negative. Ultrasonography showed signs of chronic inflammation of the gallbladder , stones missing, choledoch in diameter and 15 mm in the lower third of it - luminal narrowing .
CASE# 10
Patient B. , 56 y.o., was admitted to hospital complaining of icteric staining of the skin and sclera , skin itching , general weakness , loss of appetite . From history : sick about 3 months , noticed a light cord dark urine and feces , and then appeared jaundiced sclera and skin staining intensity MDM narostaet slowly . Body weight for 3 months decreased by 7 kg .
On examination : general condition of the patient of average weight , the skin and visible mucous membranes intensive jaundiced color , traces of scratching the skin. On palpation : the abdomen is soft , moderately tender in the right upper quadrant , the liver acts 4 cm below the costal margin , moderately painful on palpation. Gall puzir not palpable . Peritoneal signs are negative. Ultrasound : dilated intrahepatic bile ducts , in the gate of the liver tumor is determined , up to 3.5 cm in diameter, with indistinct outlines , common bile duct diameter of 0.5 cm
CASE# 11
Patient K. , 40 y.o., he turned to the doctor complaining of icteric staining of the skin and visible mucous membranes , mild pain in the right upper quadrant . From history : p'yat days ago , after the error in the diet originated paroxysmal pain in the right upper quadrant, and one day noticed the yellowness of the sclera and skin, body temperature to povіsilas subfebrile . In the past there have been episodes of pain in the right upper quadrant , ultrasound revealed stones in the gallbladder.
On examination : general condition of the patient is relatively satisfactory . Skin and visible mucous icteric . Abdomen symmetrical anterior abdominal wall is involved in the act of breathing . On palpation - the abdomen is soft , moderately tender in the right upper quadrant , where palpable enlarged , moderately painful gallbladder . Symptoms Grekova - Ortner , Kera negative signs of peritoneal irritation not.
CASE# 12
Patient R. , 48 y.o., entered the department with complaints of icteric staining of the skin and visible mucous membranes , dull pain in the right upper quadrant , discoloration of feces. History of jaundice appeared a month ago, for no apparent reason , gradually increased . Besides patient notes that over the last 3 months decreased body weight by 6 kg , have a common weakness. 10 days before admission the patient turned to the family doctor , EGD was performed , in which found that a large duodenal papilla increased its bumpy surface , a contact bleeding (biopsy is not taken ) .
On examination : general condition of the patient of average weight , the skin and visible mucous membranes intensive jaundiced color. Abdomen symmetrical anterior abdominal wall is involved in the act of breathing . On palpation - belly m'yaky , chuvtvitelny in the right upper quadrant , the liver performs at 2 cm below the costal margin , gall puzir enlarged , tense , painless .. Symptoms of peritoneal irritation negative .