Form Case Study
( One
Student one disease )
Example
for Student
1. .Patient’s Chief complaints
: Vertigo and
Headache
2. History of Present illness :
Mr. k is 40 years old
from Kandal Province , who has had difficulty controlling his blood
pressure , he is visiting his primary care provider
for a thorough physical examination
and to renew a prescription to continue
his blood pressure medications .
3. Past Medical History :
-Chronic sinus infection
10 years ago
-Pneumonia 6 years ago .
- Hypertension for approximately
11 years ago .
4. Family history :
- Father died at age
59 years ago by hypertension .
-Mother has Diabetes
and Hypertension .
5. Medication :
- Hydrochlorothazide
- Beclomethasone dipropionate
6. Allergies :
- Rash with penicillin use .
7. Review of systems :
-State that his overall health has
been fair to good during for 12 month .
-Weight has increased
by approximately 20 pounds during
the last year .
- Chest pain , shortness of
breath at rest , headache , nosebleed
-Nausea , vomiting , diarrhea
8. General appearance :
** The patient is an obese black in
no apparent , He appears to be his
stated age.
** Vital Signs :
-Blood Pressure
: 135/90 mmHg - Heart Rate
: 74/mn
-Respiratory
Rate : 16/ mn -Temperature :
37 C
** HEENOT ( Head , Ears , Eyes , Nose , Throat , Oral )
:
Normal
** Neck :
-Thyroid normal
- No Lymphadenopathy .
** Lung :
-
Mild basilar crackles bilaterally
-
No Wheezing sound
** Heart :
-
No murmurs
** Abdominal :
-No mass in the abdominal
- Normal
** Rectal :
-
Normal size .
** Extremity :
-
Normal
** Neuromuscular :
-
Normal
9. Laboratory
Test :
- Glucose fasting : 110mg/dl
- Uric acid : 6mg / dl
- HDL 60mg /dl
- LDL 180mg/dl
-Cholesterol 275mg/dl
10 . Specialized
Test :
-
ECG :
increase QRS Voltage
suggestive of LVH .
-
Echocardiography
: Moderate with EF = 46%
11. Diagnostic :
- What
is the grade of hypertension disease ? Why ?
The grade of hypertension is : 1 grade
By Clinical and signs and symptoms
of the patient : Vital Signs :
-Blood Pressure : 150/90 mmHg
- Heart Rate : 74/mn
-Respiratory Rate : 16/ mn
-Temperature : 37 C
-Test :
- Glucose fasting : 110mg/dl
- Uric acid : 6mg / dl
- HDL 60mg /dl
- LDL 180mg/dl
-Cholesterol 275mg/dl
-
ECG :
increase QRS Voltage
suggestive of LVH .
-
Echocardiography
: Moderate with EF = 46%
Title
of Disease
1. Asthma
2. chronic
obstructive pulmonary disease (COPD)
3. bronchiectasis
4. bronchitis,
pulmonary fibrosis
5. sarcoidosis
6. lung cancer.
7. Pneumonia
8. pulmonary edema
9. Pulmonary
Embolism
10.
Pulmonary Fibrosis
11.
Pulmonary Hypertension
12.
Pulmonary Sarcoidosis
13.
Tuberculosis
14.
Pneumothorax
15.
Diabetes Meletus type II
16.
Diabetes Meletus Type I
17.
Diabetes Insipidus
18.
Gestational
diabetes
19.
Stroke
20.
Hypertension type I
21.
Hypertension type
II
22.
Crisis
hypertension
23.
Gastritis
24.
Colitis
25.
Hepatitis
26.
Pharyngitis
27.
Laryngitis
28.
Tonsilitis
29.
Rhinitis
30.
Diarrhea
31.
Gonorrhea
32.
Syphilis
33.
Cystitis
34.
Urethritis
35.
Kidney stone
36.
HIVES
37.
Pharyngitis
38.
Laryngitis
39.
Tonsilitis
40.
Rhinitis
41.
Diarrhea
42.
Gonorrhea
43.
Syphilis
44.
Cystitis
45.
Urethritis
46.
Kidney stone
47.
Hyperthyroidism
Disease
48.
Goiter Disease
49.
Cystitis disease
50.
Hypoglycemia Disease
51.
Hepatitis B
52.
Hepatitis C
53.
celiac disease
54.
Crohn disease
55.
ulcerative colitis
56.
diverticulitis
57.
malabsorption
58.
short bowel syndrome
59.
intestinal ischemia
60.
Gastroesophageal reflux disease (GERD)
61.
peptic ulcer disease
62.
Respiratory
Syncytial Virus ( RSV)
63.
Tuberculosis
Disease