The Republic of Uzbekistan, the Ministry of Healthcare, Fergana region, Fergana district medical union, hospital #1
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The republic of Uzbekistan
- Bu sahifa navigatsiya:
- Concomitance
- Epidemiological anamnesis: (SanT and M according 0342-17)
- Allergic anamnesis
- Digestion system
- Treatmen
- Physiotherapy treatments
- Ambulatory illness
[stamp]The Republic of Uzbekistan, the Ministry of Healthcare, Fergana region, Fergana district Hospital #1 4 September 2020year #343
Mindon village Illness history duplicate#1758/445 Name: Akramov Javokhir Shokirjon ugli Age: 02/0/1993 Hospitalized: 20/08/2020y Discharged: 30/08/2020y Address: Fergana district, Markaz citizens’ gather, Kizil kuch street #86 Ds: Ostechondrosis of lumbar-sacral part of spine. Diskal hernia level VL3-4 and VL4-5. Concomitance: Obesity 1st degree (30,4 kg/m2) Complaint: to pain in back area, limited action, pain in left leg area. Anamnesis morbi: patient has been in anamnesis for couples of weeks. He connects the cause of his illness with heavy physical stress and cold. With above mentioned complaint he was hospitalized stationary treatment. Anamnesis vitae: He grew up in middle class family. He can’t remember illnesses in his childhood. He rejects genetic illnesses. Married, has one child. Works in South Korea. (now in service-holiday) Epidemiological anamnesis: (SanT and M according #0342-17) 1.Registration, in working or studying condition (unerline) didn’t contacted with infectious illnesses (paratyphoid, other salmonellosis illnesses, dysentery and other infectious illnesses, hepatite, tuberculosis ) and patients. 2.Since the illness started he didn’t go out from his living place between 2 weeks and 2 months. 3.He has never been treated for infectious illnesses. 4. For the last 6 months, he wasn’t in stationary treatment, wasn’t tested for blood transfusion (blood and its components), didn’t have surgeries and massive surgery operations. 5.He wasn’t in other parenteral treatments and also wasn’t treated with acupuncture. 6.He didn’t use manicure, pedicure, piecing, tattoo and others.
Bone joint system has no deformation. No swellings. Respiratory system: Smooth breathing via nose. Chest in cylindrical shape. Verbal tone is equal in both sides. Breathing 18 times per minute. Auscultation in lungs vesicular breath. Heart and blood system: Heart’s inner pushing is not visible. While touching in middle clavicle line between V rib, heart pushing is spreading, width 3 sm. Heart’s relatively border in from right – right front rib line IV rib, from lest – from left middle clavicle 1 sm outer, between V ribs. From above left rib front line III rib. Heart beat is rhythmic, clear, AB 120/80mm.sm.t.Ps-78` Digestion system: Wet tongue, clean. Soft stomach without pain. Liver and spleen is normal not extended. Defecation in normal condition. Urination: Back side has no change, in palpation kidney area has no pain. Symptoms in both sides are negative. Urinating is smooth and without pain. Nevrostatus: Conscious. 15 according to KGSH. He can answer to the questions. Orientation is good. Irises OD=OS. Photoreaction remains. Symmetric face. Tongue in middle line. Swallowing and phonation is not destroyed. Stomach and muscular reflexes D=S. Below wal points has pain. Arm and legs muscular power till 5 score. Sensitivity in left leg femur area destroyed in hypesthesia type. Muscular reflexes are good. Knee and Achilles reflexes decreased. Meningeal and other pathologic reflexes are not detected. Bowl organs functions are not destroyed. Inspections: General blood analysis: Nv 130g/l, erythrocyte 4,3x10^12; 가 0,9; leucocyte 8,1x10^9; COE 12mm/s General urine analysis: Color yellow, clear. Protein/bulla pigment-abc; leuc 2-3+ Coagulation: KIV start 4:35 Str 5:10 Bioch.analy: Alt-0,40mmol;/l; Bilirubin17,1mmol/l; urea 5,7mmol/l; kreatinine 78mkmol/l; bloodsugar 4,44mmol/l MRT: Scoliosis of lumbar-sacral part of spine; Diskal ostechondrosis in VL3-4 level; diskal hernia in VL 3-4 and VL4-5 Treatmen: Room regime Diet #12
Sol Dexametazoni 0.4% 1ml Sol Trentali 2% 5ml Sol Natrii chloride 0.9% 200ml >>>>> in/v drop *Microcirculation treatment, angioprotektor Pulv Artoxani 20mg Sol Natrii chloride 0.9% 100ml >>>>> in/v drop Against inflammation nosteroit preparat Sol L-lizini escinatis 0.1%15ml Sol Natrii chloride 0.9%15ml>>>>> in/v slowly Against swelling in inflammation centre Sol Midokalm 2ml into muscle Miorelaxant Tab Glukoflex 300mg 1tabx1time after meal for 1 month Matbolic process in knots Supp Naklofeni 50mg 1suppository from anus Physiotherapy treatments: Electrophorese (with Novokain) back spine parts Ultrasound gel Hydrocortisone back spine parts
Treated Doctor: (sign) I.Kodirov Department director: (sign) M.Kosimov Head Doctor: (sign) A.Umarkulov [stamp] The Republic of Uzbekistan, the Ministry of Healthcare, Fergana region, Fergana district Hospital #1
Ambulator patient’s medical record [stamp]The Republic of Uzbekistan, the Ministry of Healthcare, Fergana region, Fergana district Mindon pliclinics #625
04.09.2020y Dupliocate #9196 Ambulatory illness: 07/07/2020y 12/08/2020y General doctor cabinet Name: Akramov Javokhir Shokirjon ugli Age: 02/0/1993 Address: Fergana district, Markaz citizens’ gather, Kizil kuch street #86 Ds: Ostechondrosis of lumbar-sacral part of spine. Diskal hernia level VL3-4 and VL4-5. Concomitance: Obesity 1st degree (30,4 kg/m2) Complaint: to pain in back area, limited action, pain in left leg area. Anamnesis morbi: patient has been in anamnesis for couples of weeks. He connects the cause of his illness with heavy physical stress and cold. With above mentioned complaint he was hospitalized stationary treatment. Anamnesis vitae: He grew up in middle class family. He can’t remember illnesses in his childhood. He rejects genetic illnesses. Married, has one child. Works in South Korea. (now in service-holiday) Epidemiological anamnesis: (SanT and M according #0342-17) 1.Registration, in working or studying condition (unerline) didn’t contacted with infectious illnesses (paratyphoid, other salmonellosis illnesses, dysentery and other infectious illnesses, hepatite, tuberculosis ) and patients. 2.Since the illness started he didn’t go out from his living place between 2 weeks and 2 months. 3.He has never been treated for infectious illnesses. 4. For the last 6 months, he wasn’t in stationary treatment, wasn’t tested for blood transfusion (blood and its components), didn’t have surgeries and massive surgery operations. 5.He wasn’t in other parenteral treatments and also wasn’t treated with acupuncture. 6.He didn’t use manicure, pedicure, piecing, tattoo and others.
Bone joint system has no deformation. No swellings. Respiratory system: Smooth breathing via nose. Chest in cylindrical shape. Verbal tone is equal in both sides. Breathing 18 times per minute. Auscultation in lungs vesicular breath. Heart and blood system: Heart’s inner pushing is not visible. While touching in middle clavicle line between V rib, heart pushing is spreading, width 3 sm. Heart’s relatively border in from right – right front rib line IV rib, from lest – from left middle clavicle 1 sm outer, between V ribs. From above left rib front line III rib. Heart beat is rhythmic, clear, AB 120/80mm.sm.t.Ps-78` Digestion system: Wet tongue, clean. Soft stomach without pain. Liver and spleen is normal not extended. Defecation in normal condition. Urination: Back side has no change, in palpation kidney area has no pain. Symptoms in both sides are negative. Urinating is smooth and without pain. Nevrostatus: Conscious. 15 according to KGSH. He can answer to the questions. Orientation is good. Irises OD=OS. Photoreaction remains. Symmetric face. Tongue in middle line. Swallowing and phonation is not destroyed. Stomach and muscular reflexes D=S. Below wal points has pain. Arm and legs muscular power till 5 score. Sensitivity in left leg femur area destroyed in hypesthesia type. Muscular reflexes are good. Knee and Achilles reflexes decreased. Meningeal and other pathologic reflexes are not detected. Bowl organs functions are not destroyed. Inspections: General blood analysis: Nv 130g/l, erythrocyte 4,3x10^12; 가 0,9; leucocyte 8,1x10^9; COE 12mm/s General urine analysis: Color yellow, clear. Protein/bulla pigment-abc; leuc 2-3+ Coagulation: KIV start 4:35 Str 5:10 Bioch.analy: Alt-0,40mmol;/l; Bilirubin17,1mmol/l; urea 5,7mmol/l; kreatinine 78mkmol/l; bloodsugar 4,44mmol/l MRT: Scoliosis of lumbar-sacral part of spine; Diskal ostechondrosis in VL3-4 level; diskal hernia in VL 3-4 and VL4-5 Treatmen: Room regime Diet #12
Spray Dynaper QPS 4% 15ml 2times to pain areas for 10 days Tab Midokalm 150mg 1tab*2times for 20 days Miorelaxant Tab Glukoflex 300mg 1tabx1time after meal for 1 month Matbolic process in knots Supp Naklofeni 50mg 1suppository from anus
Electrophorese (with Novokain) back spine parts Ultrasound gel Hydrocortisone back spine parts Treated Doctor: (sign) I.Kodirov General doctor for treatmen: (sign) N.Kodirjonov Policlinic director: (sign) Kh.Toshboev [stamp] The Republic of Uzbekistan, the Ministry of Healthcare, Fergana region, Fergana district Mindon pliclinics Download 34.19 Kb. Do'stlaringiz bilan baham: 
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