"NICOLAE TESTMITANU" STATE UNIVERSITY OF

MEDICINE AND PHARMACY

DISCIPLINE – Gastroenterology

DISCIPLINE CHIEF: PR. Eugen Tcaciuc

PROFESSOR NAME: DR. Nicolae Proca
Group: M1537 Year : 5th
STUDENT NAME: Said Kashkush

CLINICAL OBSERVATION FILE

Patient Name: Cazacu Maria

Chisinau 2020
General data
Patient’s Name: Cazacu.
Family name: Maria.
Sex: female.
Age: 66 years.
Weight: 72 kg.
Height: 177 cm.
Profession: worked in a market.
Address: Orhei, Str.Iakir 53, Ap.9.
Entrance date to hospital: 10.01.2020. Hour: 10:08.
Duration of hospitalization: 1 week.
Final diagnosis: Hepatotoxicity with Cholestasis, iron
deficiency anemia.
First diagnosis: Hepatotoxicity with Cholestasis.
Clinical diagnosis: Hepatotoxicity with Cholestasis.
Main complaints:
Tuesday 14/01/2020:
Respiratory system:
-Dyspnea: difficult breathing during expiration
-Cough
Cardiovascular system:
blood pressure: normal, 130/80 mmHg.
Pulse: normal, 72/min.
General symptoms:
1. Fatigue and weakness.
2. Headache.
3. No fever.
4. No edema.
5. No allergy.
6. Jaundice
7. Pruritis

Wednesday 15/01/2020:
Respiratory system:
-Dyspnea
-Decreased cough
Cardiovascular system:
blood pressure: normal, 130/80 mmHg.
Pulse: normal, 73/min.
Normal temperature 36.7c.
Thursday 16/01/2020:
Respiratory system:
-Dyspnea
-Decreased cough
Cardiovascular system:
blood pressure: normal, 130/80 mmHg.
Pulse: normal, 75/min.
Normal temperature 36.7c.

Anamnesis morbid:
History of diseases:
my patient was healthy at birth, she has iron deficiency
anemia since 2014, in 2015 she did bone marrow
aspiration for anemia. She had high bilirubin and yellow
skin (jaundice) since 2018 and she took hepatic toxicity
from drugs.

Anamnesis vitae:
past patient history:
-No familial/ genetic mutations.
- Physical activities like sports or exercise - yes.
-No allergy.
- No sexual activities.
- No harmful habits like smoking, alcohol.
 Patient's condition
Objective examination:
Inspection:
-General state: Medium
-Consciousness: Normal
-Position: Active
-Constitution: Norm staining
-Skin inspection: yellow color (jaundice).
-mucosa: we checked mucosa of eyes and mouth,
it was little bit yellow (jaundice).
-Lymph: palpation (normal)
-Muscular system: normal, no pain
-Bones: normal, no pain.
-Joints: normal, no pain.
-Extremities: symmetrical.
-Degree of nutrition: normal.
-Edema: Absent
-Head: Proportional, without any painful points in
the anterior region of the face.
-Neck: Proportional, without deformities and
pathological pulsation of carotid arteries.
 Respiratory system
Inspection:
-Nose: Free nasal breathing, there is no nose
discharge.
-Position of thorax, clavicle and scapula are
symmetrical.
-Chest: Norm staining
-Spine: normal
-Breath: he had difficulty breathing (dyspnea).

Palpation:
-Lymph: normal, not enlarged lymph nodes.
-No painful chest
-Tactile fremitus: normal
Percussion:
-Comparative percussion: Dull sound
-Topographic percussion: Lungs
Upper border Lower border
Clavicle 3-4 cm Parasternal line +
Superior anterior
7th cervical vertebrae Midclavicular line +
Superior
Korenig's area Anterior axillary line +
perpendicular to
trapezius
Midaxillary line +
Posterior axillary line +
Scapular line +
Paravertebral line +

Auscultation:
-During auscultation, I heard normal breath sounds
-Respiratory sounds: normal
-Bronchophony: normal
 Cardiovascular system
Complaints:
-Dyspnea: yes
-Chest Pain: No
-Edema: No
-Cough: yes
Inspection:
-Pulsation of jugular vein
-Cyanosis: No
-Clubbing: No
we didn’t observe any cardiac pathology during
inspection ever for arteries or veins. Venous pulse is
positive.
Palpation: To check pain, press the thorax and different
regions like the arms.
-Pain: No.
-Edema: No
Percussion: Two types (Normal)
-relative dullness of the heart:
-Right border: R.intercostal space 4th, 1cm
Lateral right edge of sternum.
-Left border: L.Intercostal space 5th, 1-1.5cm
toward sternum from the left midclavicular line.
-Upper border: 1 cm to the left of sternal line, 3rd – 1st
interspace.

-Absolute dullness of the heart:

-Right border: 4th interspace on the edge of left sternum.
-Left border: 1-2 cm medial from left border of relative
heart dullness
-Upper border: 1cm to the left of the sternal line, on the
4th rib.
-Transversal length of the heart dullness is 5-6cm
Auscultation:
-Heart sounds : rhythmic sound(normal), in auscultation
there are two sounds:
1)Systolic: is made by closing of the mitral valve and
tricuspid valve after blood enter right and left ventricles
often louder at the apex synchronous with carotid
impulse, lower in the pitch and the 2nd heart sound.
2)Diastolic: is made by closing aortic and pulmonary
valves after the blood has entered from ventricle to the
aorta and pulmonary artery, louder in base if the heart
increase pitch in than s1, shorter than S1.
-pulse in 72/min
-Pressure in 130/80 mm Hg
 Digestive system
Complaints:
-She has no pain.
-Dyspeptic symptoms: Eructation, nausea,
vomiting, heartburn are not present.
-There is no loss of weight and there is no feeling
of bloating in the abdomen.
-Appetite is normal

Inspection:
-buccal cavity: no bad smell, without modification
and without pathological changes.
-Lips: are pink, dry without rashes or cracks.
-Mucosa: no ulcer formation
-Tounge: geographical
-Gingiva: Normal, pink color of the gums.
-Abdomen: symmetrical.
-Teeth: artificial.

Palpation:
-Superficial: no abdominal pain, abdominal muscle
reflex, no tumor.
Percussion: Tympanic sound
Auscultation: Rhythmic sound
 Liver
Inspection:
we did not observe pulsation of the right hypochondrial
region of the abdomen.
Palpation:
During palpation I felt liver little bit increased in size.
Percussion:
During percussion of liver we found 3 diameters:
Inferior border at midclavicular line 9cm.
Right border at medial line 8cm.
Left border at left costal arch 7cm.

Gall bladder:
we didn’t palpate gall bladder – normal.
Pancreas:
We didn’t palpate pancreas – normal.
 Excretory system (kidneys)
Inspection:
No modifications.
Palpation:
Two methods: standing position and lying down
position.
In both was normal without painful points.
Percussion:
during percussion the patient felt no pain, so Giordano
symptom is positive (-).

Hematopoietic system
There is no accusations
Inspection:
-The skin and the mucus yellow(jaundice). Nails,
hair without pathology.
Palpation:
-Regional lymph nodes are not palpated. Painless.
Percussion:
-Longitudinal diameter of the spleen 8 cm.
-Transversal diameter of the spleen 5 cm.
 Endocrine system
Accusations:
there is no accusations.
Inspection:
the patient does not complain about pain, he is not
suspected with endocrine problems because there is no
symptoms of acromegaly or “moon face”.
Thyroid gland does not show stretch marks or
enlargement, pigmentation or depigmentation
subcutaneous adipose tissue is deposited uniformly.
Palpation:
During palpation, we observed normal thyroid gland
without nodule appearance, without enlargement.

Nervous system
Mental Knowledge: clear.
Mood: relaxed.
Sleep problems (insomnia): no.
Convulsions: No.
Presumptive diagnosis: On the basis of anamnesis data
and patient’s complains and data of clinical examination (high
bilirubin, yellow skin (jaundice) and little bit increase liver
size); we can put the presumptive diagnosis:
Hepatic toxicity.

Diagnostic Plan:
Para-Clinical Investigations (laboratory and
instrumental investigations):

 blood analysis:
Component Value result Units
Hb 10.35 g/dl
RBCs 3.01 /1012l
Haematocrit 32.96 %
WBC 10.41 /109l
MCV 109.50 fl
neutrophils 48.70 %
Lymphocytes 34.71 %
Monocytes 4.79 %
Eosinophils 10.08 %
ESR - mm/hour
Conclusion : the results of general blood analysis show the
signs of anemia: decreased hemoglobin, low level of
erythrocytes and decreased hematocrit. Leukocytes are little bit
increased

Urine analysis:
Color – yellow- transparent
Density of urine – 1010
pH - acid
Reaction – acid
Glucose – absent
Proteins – absent
Leucocytes – 1-2 in the field of view
RBCs – 1-2 in the field of view
Bacteria – absent
No mucus, no salts crystals

Conclusion:
There are not pathologic changes in general urine analysis
 Biochemical analysis:

Component Value
urea 4.40 mmol/l
creatinine 68.70 mmol/l
Total protein 62.10 g/l
Asparat 12.30 U/L
aminotransferase
(ASAT)
Albumin 38.80 g/l
Cholestrol 5 mmol/l
Triglyceride 1.40 mmol/l

 Conclusion : the results in general in a

normal range. But total protein is little bit
decreased.

Renal/bladder/ovaries ultrasound:
shows normal shape and diameter of abdominal organs.

ECG EXAM: shows sinus rhythm.

The definitive diagnosis:

On the basis of anamnesis data and patient’s complains (high

bilirubin, yellow skin (jaundice) and little bit increase liver
size), and according to the clinical and paraclinical examination
(laboratory-instrumental investigations data) we can put the
definitive diagnosis:
Hepatotoxicity with Cholestasis, iron deficiency
anemia.

Differential diagnosis:
1) Viral hepatitis
2) Hepatic cirrhosis
3) Alcoholic liver disease
 Treatment
-Liver function will return to normal if the offending
drug stopped early.

-Monitoring hepatic enzyme levels

-N -acetylcysteine in the early phases of

acetaminophen toxicity.
-L-carnitine is potentially valuable in cases of
valproate toxicity

-Cholestyramine may be used for alleviation of

pruritus

For anemia:
-Fersinol-z