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Ivano

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Mohammad AL-Rawashdeh
Mohammad AL-Rawashdeh

A 34-year-old male presented with epigastric pain, vomiting, and jaundice. His liver enzymes were elevated and he tested positive for HCV. He was diagnosed with viral hepatitis based on his lab results and clinical presentation. He has a history of hypertension but no other significant medical history. He is being treated with hepatoprotective medications and supportive care. The prognosis is that hepatitis symptoms typically resolve within 3-6 months and most patients fully recover.

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"Ivano-Frankivsk National Medical University" Department of Internal Medicine Head of Department - Professor Teacher of group Case history Patient : Vasil Demotrovich Clinical diagnosis: Viral Hepatitis Curator: the student: Al-Rawashdeh Mohammad of the: 4th course: 59- group Faculty: general medicine I. Passport part Patients surname, name, patronymic : Vasil Demotrovich Age: 34 Birth date 09/05/1971 Home address: ivano frankivsk Place of work: ivano-frankivsk Date of admission: 22/05/2015 Date of discharge: still in the clinic End of the disease improvement, Clinical diagnosis: Hepatites 1
II. PATIENT COMPLAINTS Epigastric pain which later moved to right hypochondrium Vomiting Hearing loss III. Disease anamnesis (Disease duration. Dynamics of the process. What factors does the patient connect with the onset of disease and its exacerbation? Treatment that was carried out, its results and tolerability.) The patient start to complain about pain in the epigastric which moved to right hypochondrium vomiting any food he ate , also had yellowish colored sclera and oral mucosa and he looked pale. IV. Life anamnesis (Heredity, development in childhood, working life, working and living conditions, family history, earlier diseases). The patient had no hereditary disease and had a good development of his body during childhood but he have a blood hypertension ( once reached 180110) . Hes married and have two boys and a girl and work as an owner of an clothing shop His family had no diseases but his father was hypertensive, Bad habits: alcohol and cigarrets Allergic anamnesis: negative 2
V. OBJECTIVE EXAMINATION 1. General state of patient The patient alert The body temp = 36,8 C Blood pressure = 12080 Respiratory rate = 22 min 2. Skin and mucosa No signs of jaundice in the skin or in the mucosa The face is pale No other abnormalities 3. Musculo-skeletal system The joint has a good range of motion The muscles are well development No other abnormalities 4. Lymphatic system Tonsils are normal The state of other lymph nodes is good with no abnormalities 5. Cardiovascular Percussion and auscultation showed normal results Pulse = 72 Pulse is rhythmic and with no abnormalities 6. Nervous system The patient has a normal response and normal reflexes No abnormalities 7. GIT No abnormalities during percussion and palpation of the abdomen 3
Vomitting happens after having a meal Palpation of the liver shows tendresse 8. Respiratory No abnormalities were found during percussion and palpation The auscultation showed vesicular respiratory sound and no pathological sounds . 9. Endocrine No abnormalities were found during examination of endocrine glands 10- urinary The patient doesn't have any abnormalities But The urine is dark VII. Preliminarily diagnosis Cholecystitis VIII Diagnosis : Lab studies : ALT 98.8 L ( normal 7-56 ) AST 38.1 L ( normal 10-40 ) A positive HCV result with ELISA Ultrasound : Hepatomegaly and peri portal edema 4
IX. Clinical diagnosis On the basis of lab results ( serological test ELISA ) : clinical diagnosis was determined: Viral hepatitis X : Differential diagnoses Aneurysm, Abdominal Cholangitis Cholecystitis and Biliary Colic Cholelithiasis Gastritis and Peptic Ulcer Disease Gastroenteritis Obstruction, Small Bowel Pancreatitis Treatment - The patient take arginine glutamine tablets - Domperidone - hepatoprotective drug ( antral ) - Cardonat 5
Prognosis Hepatitis symptoms resolve on their own; most patients fully recover in 3 to 6 months 6
Prognosis Hepatitis symptoms resolve on their own; most patients fully recover in 3 to 6 months 6

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Ivano

  • 1. "Ivano-Frankivsk National Medical University" Department of Internal Medicine Head of Department - Professor Teacher of group Case history Patient : Vasil Demotrovich Clinical diagnosis: Viral Hepatitis Curator: the student: Al-Rawashdeh Mohammad of the: 4th course: 59- group Faculty: general medicine I. Passport part Patients surname, name, patronymic : Vasil Demotrovich Age: 34 Birth date 09/05/1971 Home address: ivano frankivsk Place of work: ivano-frankivsk Date of admission: 22/05/2015 Date of discharge: still in the clinic End of the disease improvement, Clinical diagnosis: Hepatites 1
  • 2. II. PATIENT COMPLAINTS Epigastric pain which later moved to right hypochondrium Vomiting Hearing loss III. Disease anamnesis (Disease duration. Dynamics of the process. What factors does the patient connect with the onset of disease and its exacerbation? Treatment that was carried out, its results and tolerability.) The patient start to complain about pain in the epigastric which moved to right hypochondrium vomiting any food he ate , also had yellowish colored sclera and oral mucosa and he looked pale. IV. Life anamnesis (Heredity, development in childhood, working life, working and living conditions, family history, earlier diseases). The patient had no hereditary disease and had a good development of his body during childhood but he have a blood hypertension ( once reached 180110) . Hes married and have two boys and a girl and work as an owner of an clothing shop His family had no diseases but his father was hypertensive, Bad habits: alcohol and cigarrets Allergic anamnesis: negative 2
  • 3. V. OBJECTIVE EXAMINATION 1. General state of patient The patient alert The body temp = 36,8 C Blood pressure = 12080 Respiratory rate = 22 min 2. Skin and mucosa No signs of jaundice in the skin or in the mucosa The face is pale No other abnormalities 3. Musculo-skeletal system The joint has a good range of motion The muscles are well development No other abnormalities 4. Lymphatic system Tonsils are normal The state of other lymph nodes is good with no abnormalities 5. Cardiovascular Percussion and auscultation showed normal results Pulse = 72 Pulse is rhythmic and with no abnormalities 6. Nervous system The patient has a normal response and normal reflexes No abnormalities 7. GIT No abnormalities during percussion and palpation of the abdomen 3
  • 4. Vomitting happens after having a meal Palpation of the liver shows tendresse 8. Respiratory No abnormalities were found during percussion and palpation The auscultation showed vesicular respiratory sound and no pathological sounds . 9. Endocrine No abnormalities were found during examination of endocrine glands 10- urinary The patient doesn't have any abnormalities But The urine is dark VII. Preliminarily diagnosis Cholecystitis VIII Diagnosis : Lab studies : ALT 98.8 L ( normal 7-56 ) AST 38.1 L ( normal 10-40 ) A positive HCV result with ELISA Ultrasound : Hepatomegaly and peri portal edema 4
  • 5. IX. Clinical diagnosis On the basis of lab results ( serological test ELISA ) : clinical diagnosis was determined: Viral hepatitis X : Differential diagnoses Aneurysm, Abdominal Cholangitis Cholecystitis and Biliary Colic Cholelithiasis Gastritis and Peptic Ulcer Disease Gastroenteritis Obstruction, Small Bowel Pancreatitis Treatment - The patient take arginine glutamine tablets - Domperidone - hepatoprotective drug ( antral ) - Cardonat 5
  • 6. Prognosis Hepatitis symptoms resolve on their own; most patients fully recover in 3 to 6 months 6
  • 7. Prognosis Hepatitis symptoms resolve on their own; most patients fully recover in 3 to 6 months 6