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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
Patient’s 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
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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) .
He’s 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
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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
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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
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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
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6. Prognosis
Hepatitis symptoms resolve on their own; most patients fully recover in 3 to 6 months
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7. Prognosis
Hepatitis symptoms resolve on their own; most patients fully recover in 3 to 6 months
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