Patient history gastritis
Автор: Ahmad Elsakr • Апрель 19, 2023 • История болезни • 5,370 Слов (22 Страниц) • 124 Просмотры
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
- [pic 3]Childhood period: physical development was normal
- Current Medications (list) the patient is not taking medication
- Occupation and Education retired
- Housing conditions: he lives in flat
- Allergic Anamnesis: he does not have allergies
- Family anamnesis: he does not have relatives with health problem
- 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
- General State: satisfactory
- Consciousness: clear
- Position of the patient: active
- Height: 170 cm
- Weight: 100 kg
- 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
- Complaints: No complaints
- Visual examination:
- nasal breathing is free.
- No visible discharge from the nose
- Voice is clear and speech is coherent
- Larynx: Is regular shape without abnormalities.
- Chest shape: shape is bilaterally symmetric and elliptical in cross section.
- Circumference of the chest: excursion on inspiration and exhalation is normal
- 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
- Palpation of thorax: Painless, equal fremitus
- Percussion of the lungs: resonant percussion note (normal)
- Topographic Percussion: normal
- 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.
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