Tbilisi State Medical University
Department of surgery
DR. liana saginashvili
6th year student Raghad Shakib Younus
Medical Case
Isamilova tamam
69 year old
Married, retired/house wife
Admission date: 13/11/2018 9:10a.m.
Clinical diagnosis:
Main diagnosis – massive ventral hernia
Complication – none
Concurrent diseases –
Main Complications:
abdominal mass at the anterior abdominal wall
weakness
difficulty walking
Before admission hernia was incarcerated, but then it resolved by itself
Anamnesis morbi:
Abdominal mass for 10 years, it was small then increased gradually, now doesn’t resolve
completely, she was admitted for the plan operation.
Anamnesis Viti:
She is married, she has healthy children, she has arterial hypertension
Status presence:
Patient general condition is good
Skin and mucus – normal
She is 2nd degree obese
Bone and joint – normal
Temperature – 36.9c
Cardiac –
o HR – 85
o BP – 140/70
o Dull heart sounds
Respiratory –
o RR – 17
o Clear sounds on percussion
o Vascular breathing on auscultation
GTI –
o Tongue is wet, free swallowing, no pain
o Abdomen is distended
o Under the umbilicus there is a big mass 15cm. which by pressing doesn’t
reduce
o Painless abdominal wall
o No irritation of peritoneum
Perirectal investigation –
o Rectal ampulla is free, painless without pathology
o Defection is normal
UT –
o Normal urination
o Kidneys are normal
o pasternatsky sign is negative
nervous system –
o conscious
o alert
Primary diagnosis:
Massive ventral hernia
Investigations:
Lab tests
Imaging tests – US and chest X-ray
Consultation of cardiologist, therapist and anesthesiologist before surgery were done
Operation consultation:
Confirming diagnosis – Abdominal mass for 10 years, it was small then increased
gradually, now doesn’t resolve completely, she was admitted for the plan operation.
Indication for surgery – massive ventral hernia
Operation plan – hernioplasty by using mesh (non-tension)
Type of anesthesia – endotracheal
Signature: R
Informed consent
During operation can be:
Iatrogenic damage
Anatomical abnormality
Bleeding
Post operation complications:
Suppuration of wound
Bleeding
Thromboembolism
Peritonitis
Recurrence of hernia
Patient signature: I.T.
Operation date: 13/11/2018
Started at 1:00 p.m.
Finished at 2:05 p.m.
Intra operative diagnosis:
Operation name: ventral hernioplasty by using only mesh
Courses morbi:
General condition – good
Wound condition – good
Urination and defection – normal
Medications –
o Antibiotics – rasiosef, fracsipalrin 0.4g p/d
o Pain killers – analgin 50% 2g. , dimedrol 1g.
Differential diagnosis:
Ventral hernia
Hiatal hernia
Lipoma
Tumor
Epicrisis:
Ismailovsa tamam was admitted to the hospital complaining of abdominal mass at the
anterior abdominal wall which was diagnosed after making the necessary tests and massive
ventral hernia, consultations were done and operation was planned as hernioplasty with
mesh.
After operation condition of the patient was good with no complications
Patient was discharged 5 days after operation.
