Nombre de la Materia: Inglés Médico II

Nombre de la Licenciatura o Maestría: Medicina General

Nombre del Alumno (a): Adela Sarahí Martínez Guerrero

Matrícula/Número de identificación: 1822338546

Nombre de la Tarea: Clinical case S2

Unidad/Módulo 1: Inglés y medicina general

Nombre del Profesor (a): Dra. Ana Paulina Nájera Soto

Fecha: 20/02/2023
History

A man of 45 consults his general practitioner (GP) with a 6-month history of reduced appetite and
weight loss, from 78 to 71 kg. During the last 3 months he has had intermittent nausea, especially
in the mornings, and in the last 3 months the morning nausea has been accompanied by vomiting
on several occasions. For 1 month he has noted swelling of his ankles. Despite his weight loss he
has recently noticed his trousers getting tighter. He has had no abdominal pain. He has no relevant
past history and knows no family history as he was adopted. He takes no medication. From the
age of 18 he has smoked 5–6 cigarettes daily and drunk 15–20 units of alcohol per week. He has
been a chef all his working life, without exception in fashionable restaurants. He now lives alone
as his wife left him 1 year ago.
Examination
He has plethoric features. There is pitting oedema of his ankles. He appears to have lost weight
from his limbs, but not his trunk. He has nine spider naevi on his upper trunk. His pulse is normal
and the rate is 92/min. His jugular venous pressure (JVP) is not raised and his blood pressure is
146/84 mmHg. The cardiovascular and respiratory systems are normal. The abdomen is
distended. He has no palpable masses but there is shifting dullness and a fluid thrill.

INVESTIGATIONS
Normal
Haemoglobin 12.6 g/dL 13.3–17.7 g/dL
Mean corpuscular volume (MCV) 107 fL 80–99 fL
White cell count 10.2 % 109/L 3.9–10.6 % 109/L
Platelets 321 % 109/L 150–440 % 109/L
Sodium 131 mmol/L 135–145 mmol/L
Potassium 4.2 mmol/L 3.5–5.0 mmol/L
Urea 2.2 mmol/L 2.5–6.7 mmol/L
Creatinine 101&mol/L 70–120&mol/L
Calcium 2.44 mmol/L 2.12–2.65 mmol/L
Phosphate 1.2 mmol/L 0.8–1.45 mmol/L
Total protein 48 g/L 60–80 g/L
Albumin 26 g/L 35–50 g/L
Bilirubin 25 mmol/L 3–17 mmol/L
Alanine transaminase 276 IU/L 5–35 IU/L
Gamma-glutamyl transaminase 873 IU/L 11–51 IU/L
Alkaline phosphatase 351 IU/L 30–300 IU/L

Urinalysis: no protein; no blood

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Answer the following.

1. How old is the patient? 45 years old.

2. What does GP mean? General practitioner

3. What symptoms is the patient experiencing? reduced appetite, weight loss,

intermittent nausea, vomit.

4. What is the patient’s occupation? Is a chef.

5. How’s the patient’s blood pressure? blood pressure is 146/84 mmHg. It is considered
like hypertension.

6. How are the patient’s ankles? There is pitting edema of his ankles, due to swelling in
his ankles.

7. How many cigarettes does the patient smoke? How often? And since when? From
the age of 18 he has smoked 5–6 cigarettes daily.

8. Does the patient drink alcohol? How often? And how much? drunk 15–20 units of
alcohol per week.

9. How is the patient’s pulse and rate? His pulse is normal and the rate is 92/min.

10. For how long has the patient experience nausea and vomiting? During the last 3
months.

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 BIBLIOGRAPHIC REFERENCES
• 100_Cases_in_Clinical_Medicine - Стр 4. (s. f.). StudFiles.

https://studfile.net/preview/14638465/page:4/