Patient history gastritis

Requirements for History Case

1.HC should be presented in a final full version at classes.

 2.In HC you must use font Times New Roman 13 Normal(regular).

3.All section have text in italic font that explain what should be written in this section or give you a hint. All this italic text should be replaced with your information about your patient.

 4. The HC pages should be numbered.

5. HC Assessment table should stay at the end of HC.

In the right column it contains maximum units that you may receive for itch part of HC. In the left I will write your units and total score for HC.

6. HC is presented at classes could receive maximal score 35 units.

7. HC is presented within one month after the end of the classes could receive maximal score 21 units.

8. Final version of HC should be presented in a file folder with fastener  or stampled in left upper angle by long and durable stample, so all lists of the HC should be stitched together.

9. If you have to send electronic file of HC, its name should have your name and family name, a group number!

[pic 1]RUDN UNIVERSITY

[pic 2]

Faculty of Medicine

Department of Hospital Therapy

Head of Department: Prof. Kisliy N.D.

PATIENT’S CASE HISTORY

Student: Ali Ahmed Yasser Dawoud                                     Teacher:  Martynov A.Y.

Year of study: 6th

Group: ML -618

2023

GENERAL INFORMATION

 Name: Фигорин З. О.

 Sex: male

 Age: 04/10/1956, 66 years old

 Profession: retired

 Address: Moscow, Kashirskoye sh., 11, building 1, apt. 103

 Date of admission: 13.03.2023

 Time of admission: 12:30

 Referral Source: polyclinic

COMPLAINTS

The patient was complaining form dark stool also burning sensation while drinking hot tea

He was

ANAMENESIS MORBI

The patient two weeks ago noticed a dark stool with no complain, he thought maybe because of the food, he didn’t visit doctor until he felt a burning sensation in his stomach while drinking tea, he told his daughter which is nurse, she directly send him to doctor because she has a medical experience.

After gastroscopy the doctor send him to hospital for further investigations by ambulance.

The patient in good condition he was not taking any drugs before hospitalization  

ANAMENESIS VITAE

1. [pic 3]Childhood period: physical development was normal
2. Current Medications (list) the patient is not taking medication 

1. Occupation and Education retired
2. Housing conditions: he lives in flat 
3. Allergic Anamnesis: he does not have allergies
4. Family anamnesis: he does not have relatives with health problem
5. Concomitant diseases: He always took care from his health

8.Past medical history all good

Childhood Illness: he had Chicken box, Measles, Bronchiolitis

       Adult Illness: Covid19, common flu

Surgical illnesses: never

Psychiatric illnesses: never

    9.Transfusions: Never

10.Harmful habits: the patient does not smoke or drink

Only he does not take care of his diet

STATUS PRAESENS

1. General State: satisfactory
2. Consciousness: clear
3. Position of the patient: active
4. Height: 170 cm
5. Weight: 100 kg
6. Body Temperature: 37 C

7.Сonstitutional type: The patient is normotonic with normal morphology

Symmetrical limbs developed normally

Normal circumference of chest

The patient had a has big of belly fat

Mesomorphic

The patient is generally obese

Skin and mucosa: pale skin, skin moisture normal, elasticity normal, no rash or turgor, no hemorrhage, no scars, no pigmentation; hair and nails features (they were normal).

Subcutaneous fatty tissue: degree of its development – excessive at the belly; mild edema, 

Lymphatic system: state of submaxillary, cervical, occipital, supraclavicular, axillary, ulnar, inguinal lymph nodes are normal and not palpable

Muscular-skeletal system: no complains normal development. Only because of the aging and obese the patient noticed reduce tension of all muscle

Joints: pain in back and knees 

RESPIRATORY SYSTEM

1. Complaints: No complaints
2. Visual examination:

• nasal breathing is free.
• No visible discharge from the nose
• Voice is clear and speech is coherent

1. Larynx: Is regular shape without abnormalities.
2. Chest shape: shape is bilaterally symmetric and elliptical in cross section.
3. Circumference of the chest: excursion on inspiration and exhalation is normal
4. Respiration: Ventral with symmetrical respiratory movement, rate is 18 per minute, rhythmic without difficulty of inhalation or exhalation. Patient doesn’t use the auxillary muscles
5. Palpation of thorax:  Painless, equal fremitus
6. Percussion of the lungs: resonant percussion note (normal)
7. Topographic Percussion: normal
8. Auscultation: Loud, high-pitched bronchial breath sounds over the trachea, Medium pitched bronchovesicular sounds over the mainstream bronchi, between the scapulae, and below the clavicles

CIRCULATORY SYSTEM

Complaints:  Patient does not have any complaints.

Inspection of the neck vessels: There are no abnormalities in the neck vessels. Also, palpation of the jugular veins is normal.

Examination and palpation of the arteries in various areas: Pulsation of the arteries (carotid, subclavian, brachial, radial, femoral, popliteal, posterior tibial and dorsalis pedis) are observed.

Inspection of veins: Peripheral veins do not have any abnormalities.