A. Introduction:
Acquisition of accurate history is the crucial first step in determining the etiology of a patient illness. So, one of the most important thing to reach a suitable treatment is a good medical history. The good relationship between the patient and physician can facilitate the process of obtaining a medical history. medical history is an information obtained from the patient about his illness to aid in establishing a medical diagnosis and developing a suitable treatment plan.
B. Background and History:
When I went to the hospital the coordinator told me to go to the GIT department, I have been interviewing Mr. Abdulmohsen. He is Saudi, sixty-five years old male, married retired who has a history of irritable bowel syndrome.
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he has an allergy of spicy food and he does not have any allergy from any drugs.
Family history: his father is dead while mother still alive. his mother had diabetes, hypertension and hyperlipidemia. he has three daughters and one son. All of his daughters and son does not complain of any chronic diseases. And also his brothers and sisters does not complain of any chronic diseases. one of his cousin is complain of heart attack and died after a couple of years.
Social history:
His relationship with his family and his colleagues at work is very good and there is no effect of the disease on his life.
The habits and
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The major common symptoms of the IBS are: abdominal pain, diarrhea, constipation, and flatulence. In addition to the main symptoms, some people with IBS experience several other sings. These can include a lack of energy, feeling sick, backache, and bladder problems.
Many people have occasional signs and symptoms of IBS, but they are more usually to have IBS if they: are young because the IBS tends to occur in people under age 45, are female, have a family history of IBS, and Have a mental health problem.
Causes:
It's not known exactly what are the causes of the IBS but a different of factors play a major role in the development of the IBS. The walls of both small and large intestines are lined with layers of muscle that relax and contract in an arranged rhythm as the food move from the stomach through the intestinal tract to the rectum. In the case of the IBS, the contractions may be stronger and last longer than normal. On the contrary, with weak intestinal contractions slowing food passage and leading to hard, and dry
A 61-year-old gentleman was admitted on 25/1/2016 to Letterkenny General Hospital with central chest pain after history of a fall. He also had drastic weight loss and loss of motor and sensory function. He walks with the aid of a walking stick as he has problems walking due to his lower limb weakness. The patient was a heavy smoker of 90 pack years (3 packs/day for 30 years) and stopped nine years ago. He stopped drinking seven years ago. He is married and lives at home with his wife. He works as a plasterer. He has a strong family history of ischaemic heart disease and type 2 diabetes mellitus. Two of his brothers had coronary bypasses and stents. His father died of a myocardial infarction. Two of his brothers are also type 2 diabetics. During
in the first place and was suffering from other major illnesses. The society does not
IBS is a functional GI disorder, meaning it cannot be explained by any specific structural or biochemical abnormality. The disorder is subdivided into three different types, which are named on the basis of the predominant symptom – IBS-D (diarrhea-predominant), IBS-C (constipation-predominant), IBS-M (mixed diarrhea and constipation). Clinical presentation varies considerably with regard to the quality of the predominant feature and the overall severity of symptoms. Formal diagnosis is based on the most recent Rome III criteria, which require that a patient experience recurrent abdominal discomfort of at least 3 days per month over the previous 3 months, with a total symptom duration of at least 6 months, in...
Vesa, Tuula H, Leena M Seppo, Philippe R. Marteau, Timo Sahi, and Riitta Korpela. “Role of irritable bowel syndrome in subjective lactose intolerance.” American J Clinical Nutrition 1998; 67: 710-5. 1998. Web. 12 November 2013.
He also has history of chronic obstructive pulmonary disease, muscle weakness, type 2 diabetes mellitus, coronary artery disease, hyperlipidemia, and dementia. He has been a widow for 5yrs now and has one daughter. He currently takes 10 different scheduled medications. These include: Augmentin, Lasix, Aricept, Aspirin, Potassium, Aldactone, Zoloft, Prednisone, Flonase and Seroquel. My patient was diagnosed with congestive heart failure by labs and diagnostic procedures. Lab results: White count 3.7, hemoglobin 11.3, platelet cunt 164, Sodium 140, potassium 3.9, chloride 95, bicarb 28, BUN 19, creatine 0.9, glucose 108. Chest x-ray showed accumulation of fluid around heart and lungs. He also had an electrocardiogram and a cardiac catheterization done to rule that coronary artery disease was the cause of his
Medical patient history inlcude families history and the status of the family members death if known. It tells relationships of the patient, his or her career and schooling this helps the physician to know and explain behavior of a patient in relation to illness or loss. It contains different habbits such as smoking use , alcohol , diet and exercise. History of vaccination is included and blood test prooving immunity. If a patient is hospitalized there are daily updates that are entered in the medical record; it documents clinical changes and new information.
The patient that I wish to discuss is Mr. P. His medical problems include Hypertension, hypercholesterolemia and depression which he is taking medications. He was a chronic chain smoker for about 25 years.
At today's visit he found at his home, awake, alert and oriented. He complains of ne onset odorous yellowish,
At todays visit he is accompanied by his wife. He is awake but unable to speak due to the effect of his last CVA. The wife provides his history. She reports that he has increased poor appetite with weight loss. He used to be in the 140lb
If you are always bloated, you should avoid carbonated beverages and raw food foods. You should also consider eliminating gluten from your diet. IBS can cause diarrhea or constipation. Foods that are naturally high in fiber can cause constipation. You should take fiber supplements if your IBS causes constipation. Your doctor can prescribe
On the other hand, Ulcerative Colitis has a similar, but slightly different set of common symptoms. The most prevalent of these symptoms is diarrhea. Other symptoms of Ulcerative Colitis include a bloody stool, abdominal pain, and a feeling of urgency. The most noticeable complication related to Ulcerative Colitis is a general discomfort and difficulty with bowel movements.
“The history-taking interview should be of high quality and must be accurately recorded” (Craig & Lloyd, p.48). It is important that while obtaining a thorough health history, that the patient is treated with dignity and that their privacy is respected. A complete history involves the collection of physical and psychosocial aspects of one’s health.
Other: He doesn’t have any skin rash or any bleeding or bruising at any part of his body.
Inflammatory bowel disease is a life long disease, and it particularly targets the gastrointestinal tract (GI tract), which consists of the mouth, esophagus, stomach small intestine, large intestine (appendix, cecum, colon (ascending, transverse, descending, and sigmoid), and rectum), and anus. The gastrointestinal tract is very important to the human body; some of its functions include mechanical and chemical digestion of food, the movement of food and waste from mouth to anus, secretion of enzymes and mucus, and the absorption of nutrients. These are some reason why it’s so destructive when this part of the body becomes impaired or even damaged.
Irritable Bowel Syndrome. Mayo Foundation for Medical Education and Research, 2014. Web. 20 May 2014.