Patient History

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lasha chkhikvadze

Tbilisi State Medical University - USMD program - BAD

Health & Medicine

Our visit to
High technology medical centre university clinic

History Taking
FPH
Allergies
Medications
Family History
Data and Chief Complaint
History Of Present Illness
Past Medical History
Social HistoryReview of systems

Data and CC
MARKET
ANALYSIS
TECHNICAL
ANALYSIS
FINANCIAL
ANALYSIS
ECONOMIC
ANALYSIS
ECOLOGICAL
ANALYSIS
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Patient Name: L.B.
Patient age: 63
On 19.12.2018, 00:10 ,the patient was
brought to the hospital with the
following chief complaint: panting,
difficulty in breathing, swollen legs,
reducing in the amount of urine.

And then we asked – “Tell us more about it…”
A rainy day – a month ago
She caught a slight chill
Gradually she felt more and more
freezing
Described as severe
Could not stop shivering
Warmth alleviated the feeling
Positive associated symptoms:
 Rise in the body temperature
 fatigue
 loss of consciousness

The patient was diagnosed a med urethral stone disease. She was in a postoperative period of
right nephrectomy. She had stones in her left kidney.
due to hydronephrosis (swelling of kidney), she underwent external ureteral stent procedure,
but no stent was found in the kidney.
In the hospital in Kutaisi

Urinalysis
19.12.2018, 02:45
color Light yellow
turbidity Cloudy
Specific gravity 1,015 (the higher number, the more dehydrated
you are)
Ph 6,0
Leukocytes 500 Leu/ul
Nitrite bacteria Negative
protein 0,3 g/l
Glucose Negative
Ketones Negative
Erythrocytes 80 ery/ul

8 and 9 mm konkrements were detected
in the kidney

Blood analysis
ABO, Rh I +
Urea 14,0 mmol/L
C reactive protein 149,1 mg/L
Prothrombin time 15,5 sec
Prothrombin index 59,5%
APTT 37,9
FIB 6,119

Final diagnosis
Based on the clinical research she was diagnosed with
acute insufficiency of kidney (no known genesis),
hyper hydration,
acute insufficiency of breathing,
med urethral stone disease,
urinary tract infection.
After diagnosing the patient, she was inserted Foley catheter and put in the
hospital.

PMH
• Up to date with all essential vaccinations;
• + eager to get a shot against seasonal
influenza;
• Prior surgeries – right nephrectomy;
• Hospitalizations – in Zugdidi, Kutaisi, Tbilisi;

Allergies
o No known allergies on food;
o No allergies on medications;
o Allery on the environment –
corn blossoming period
Symptoms: tearing, sneezing;
She takes Alertec against allergy – 1 pill per day

medications
The patient was given :
1) Oxygen therapy with a mask;
2) Dehydration therapy – Furosemide 40 mg.
Interveneous injection;
3) Antibacterial therapy – Ceftriaxone 1.0 g, 2
times a day, IV;
4) IV infusion of NaCl 0,9%, 100ml per hour;

Family history
• Both parents died of old age
• Her 4 siblings are healthy
• Her children are healthy
• She denies any genetic disorder being spread in her family.

 She lives in Zugdidi, in her house;
 She lives with her son, and son’s family;
 She was a music teacher for 36 years;
 Now she is a house wife and works in her own
farm;
 She follows active way of life;
 She eats natural food, dairy product and
consumes salt;
 She denies using any alcohol, drug or tobacco;

ROS
• Cardiovascular system – no problems;
• Respiratory system – no problems; no free fluid or
air in the pleuritic chest;
• Digestive system – no problems. Bowel movement
normal;
• Nerve system – no problems;

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