Entrance Examination Case 2

Basic Information
Family History
Social History
Pharmacological Anamnesis
Allergic Anamnesis
Gynaecological Anamnesis
Personal History
Current Disease

   Patient D v o   k o v  Milena, PIN: 565318/078, address: Praha 5, J. Machka 129, home telephone number: 778126, health insurance company 111,
   admitted to the Clinic of Internal Medicine of Teaching Hospital Motol on January 22,1999, at 9.30 a.m.
   for abdominal pain in the right subcostal region and repeated vomiting.
 
Hospitalisation: first.
 
Husband Jaroslav, identical address.
 
FH: mother 65, alive, state after cholecystectomy, father 68, alive, treated for bronchial asthma,
1 sister, 38 years, healthy,
2 children, healthy.
 
SH: married, lives with her husband in a prefabricated block of flats on the 6th floor with an elevator.
Works as an accountant.
 
PA: does not take any medication permanently.
 
AA: negative.
 
GA: 2 children, abortion: none, menses since 12 years regularly, menstruation cycle 27 days, last menses Jan.15,1999, no gynaecological operation, does not use any hormonal contraceptive.
 
PH: common child diseases, tonsillectomy at 12, appendectomy at 18.
Injuries 0, smoker, 5-10 cigarettes a day since youth till now.
Coffee: 2 cups a day, alcohol occasionally.
 
Overweight following the childbirth, endocrinologic examination found no thyreopathy.
She is not aware of cholecystolithiasis, so far she has not had any digestive disorders, infectious hepatitis, or icterus.
No treatment for cardiac problems, hypertension 0, DM 0, CMP 0, no dysuria.
 
CD: She had a roast andouille for dinner yesterday, after a couple of hours she felt colic pain in the right infracostal region irradiating into the spine, repeatedly vomited the food and later gastric juices. Examined by the emergency service, she was given an injection, followed only by short-term relief. The problems became again more intensive, therefore in the morning she visited her  doctor and due to persisting complaints she was recommended for hospitalisation. No fever was found, neither icterus, or diarrhoea.

 

Your notes, observations, and proposals are welcome either via e-mail at the address int-prop@lfmotol.cuni.cz, or via the WWW Form.