The Republic of Uzbekistan, the Ministry of Healthcare, Fergana region, Fergana district medical union, hospital #1

Allergic anamnesis: During inspection allergic reactions were not detected to medicine-tablets and meals.

Status praesens: General condition of patient is relatively bad condition, not faint. Body in hypersthenic type. Antropometer measures: height 172sm, weight 90kg, obesity 30,4kg/m2. Clean skin in wheet colour. No dots. Underskin fat is in good condition. Mucus layers are in light pink colour. Lymph knots – not hurts in palpation, soft consistency.

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

Conservative treatments:

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

Physiotherapy treatments:

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