Entrance examination – Case 3

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

   Pacient ing. K o u t n ý Jindřich, PIN: 290513/088, address: Praha 5, V hůrkách 28, home telephone number: 76410812, insurance company 111,
   admitted to the Clinic of Internal Medicine, Teaching Hospital Motol on January 14, 1999, at 10:30 a.m.,
   for anorexia, weight loss, blood in stools.
First hospitalisation.
Relatives: son Koutný Jan, address: Praha 3, Chrudimská 5, telephone: 733264.
FH: Father died of tuberculosis during the war at the age of 30,
mother died of cerebral infarction at the age of 77, treated for hypertension, strumectomy
2 brothers, 1st died at the age of 75 of myocardial infarction, treated for chronic ischaemic heart disease, state after cerebral infarction, 2nd brother died at 68 years of pulmonary embolism after abdominal surgery, patient doesn't know the reason for the operation.
One son 44 years, healthy.
SH: Widower, lives alone, in care of son, retired.
Worked as a chief of project office.
PA: Anopyrin 100 mg 1-0-0 tablet (anti-aggregating therapy)
Agapurin R 1-0-1 tablet (central and peripheral vasodilator with rheologic effect)
Isoptin SR 240 mg 1-0-0 tablet (calcium channel blocker, antihypertensive)
Maninil 1-1-1 tablet (antidiabetic, sulphonylurea derivate)
Glucophage F 1-0-1 tablet (antidiabetic, biquanid derivate)
AA: Hypersensitivity to strawberries (exanthema), no drug allergy.
PH: Common child diseases.
No operation.
Injuries: fracture of right forearm in 1986 and fracture of ankle of left lower limb in 1987.
Habits: non-smoker, doesn't drink coffee, alcohol: 1 beer a day.
In 1990 experienced cerebral infarction (ictus) with central paresis (paralysis) of n. 7 on the left, and slight left hemiparesis, which recovered to normal. Since 1990 he has been also treated for hypertension. In 1993 Type 2 diabetes mellitus was diagnosed, treated initially by diet, since last year by oral antidiabetics. No cardiological problems, doesn't have claudication, no digestive problems, no dysuria.
Due to urinary retention and nycturia he underwent a urologic examination 2 months ago, which revealed slightly prostate hypertrophy. Conservative treatment was recommended.
CD: Last 6 months he suffered from loss of appetite and complete exhaustion. During this time he lost 8 kg of bodyweight. Doesn't have any stomach ache, but 2 days ago fresh blood appeared in the stool. Hospitalised to have the digestive system examined.


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