Kingdom of Saudi Arabia ‫اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬

Ministry of Education ‫وزارة اﻟﺘﻌﻠﯿﻢ‬

‫ﺟﺎﻣﻌﺔ اﻟﺠﻮف‬
AL Jouf University ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬
College of Medicine

Al Jouf UNIVERSITY
FACULTY OF MEDICINE
DEPARTMENT OF INTERNAL MEDICINE
COURSE: MED 411 / MED 412
LOGBOOK
4th Year Medicine
From 29/8/2021 to 6 /1 /2022

Student Name:
Nowt Alumni
Student ID: 381205045
 Patient ( ) Clerking
Marah Khalid
Initial Patient Name :-------------------------------------------------------
Age :-------------years Sex female
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Sakata
Residence --------------------- Occupation student
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Martial Status single
-------------------- Informant of the History:------------------------------
Presenting Complaints:
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severeromittinganddiarrhea for last 4months
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History of the present illness:----------------------------------------------------------------
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vomiting sever and green yellow color
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the diarrhea wasbloody andrelated to fluid intake also relived
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by
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fasting
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she also complains
of
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epigastric pain
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Systemic Inquiry :
General:------------------------------------------------------------------------------------------
The patent baked ill and pale shealso tossed weight looked
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malnourished she was corrected to It lie
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CVS:--------------------------------------------------------------------------------------------
NAD
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Respiratory:------------------------------------------------------------------------------------
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NAD
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 Nagin vomiting decreaseapatite heartburn epigastric pain
GIT:----------------------------------------------------------------------------------------------
bloodydiarrhea
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Renal:--------------------------------------------------------------------------------------------
NAD
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CNS:--------------------------------------------------------------------------------------------
NAD
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Skin: --------------------------------------------------------------------------------------------
NAD
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Locomotor:-------------------------------------------------------------------------------------
NAD
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Endocrine:--------------------------------------------------------------------------------------
NAD
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Past Medical History:-------------------------------------------------------------------------
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no previous history
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Drug History:----------------------------------------------------------------------------------
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She was on omeprabale for her heartburn
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Social History:---------------------------------------------------------------------------------
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Mathies
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Family History:--------------------------------------------------------------------------------
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herparents has HTM DM
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Clinical Examination: General Examination :----------------------------------------------
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NAD
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Vital Signs:-------------------------------------------------------------------------------------
T 36 BP 122176
HR 971min 181min
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CVS: --------------------------------------------------------------------------------------------
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NAD
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Respiratory system :---------------------------------------------------------------------------
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NAD
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Abdominal Examination:---------------------------------------------------------------------
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NAD
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CNS Examination:----------------------------------------------------------------------------
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NAD
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Locomotor System:---------------------------------------------------------------------------
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NAD
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Endocrine:--------------------------------------------------------------------------------------
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NAD
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Skin ----------------------------------------------------------------------------------------------
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NAD
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Other Local examinations: -------------------------------------------------------------------
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NAD
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Provisional Diagnosis:------------------------------------------------------------------------
Chrome gastritis
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Plan for investigations:-----------------------------------------------------------------------
CBC ESR Electrolyte LFT RFT lipid profile
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Abdomined US
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Ct
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Result of Investigations: ---------------------------------------------------------------------
K I 5 chloride 129 Akp 16 HDL 18 LDL 26
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lipase 104 Albumin I G LDH 65 Cat 3 G
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uric acid 1.7 0.9
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phosphate
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Patient History and Examination Summary:-----------------------------------------------
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22g female presented with complain
of severe
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vomiting and diarrhea lasted for a months the
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patent looked ill pale dehydrated with
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epigastric
pain welughtloss and I apatite
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Final Diagnosis:-------------------------------------------------------------------------------

hypo albums
chronic
gastritis
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hypokalemia
Plan of Treatment: ----------------------------------------------------------------------------
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Iv supplements
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Drugs given: ------------------------------------------------------------------------------------
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omprool IV
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andasterore
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Follow Up:--------------------------------------------------------------------------------------
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monition electrolyte
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Outcome and Other Remarks:---------------------------------------------------------------
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not yet
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Name of Doctor:
Signature/stamp: