Trifonescu Smaranda

Vlad Silvia
Anul II, grupa I

Patient-doctor dialog
Smara:Good evening, doctor.
Silvia:Good evening! You can sit down right there. Now, what is bothering you?

Smara:I came to you with a problem, and I don’t know what is wrong with me.

Silvia: What kind of problem do you have, what is bothering you?

Smara: I've been experiencing an unbearable pain for a while.
Silvia: How does it hurt?
Smara: It’s like a burning sort of ache.
Silvia: I understand. On a scale of one to ten, how painful it is?
Smara: I would say a six. Most often I would describe it as moderate pain to
moderately strong pain that’s enough to disrupt my normal daily activities.
Silvia: An extremely important aspect, from which area do you feel the pain comes
exactly?
Smara: I feel this pain in my stomach, but sometimes it seems to radiate to other parts
of my body, such as my chest.
Silvia: To better understand the process, when you assume that this pain has started, I
don't need accurate data, just to make an idea.
Smara: I think it started about 2 months ago, but I can’t say it bothered me every day, I
had better days and worse days.
Silvia: I understand. Do you think there are factors that have a positive or negative
influence on this condition that you describe?
Smara: I take some painkillers, but I feel like it only relieves my pain for a short period
of time. My stomach hurts most often after a meal, but at the same time the water
seems to calm the pain. These are the only things I have noticed over time.
Silvia: I have a few more questions before I can make a possible diagnosis.
Smara: I'm listening
Silvia: Have you experienced any type of bloating? The feeling of fullness and
swelling of the stomach?
Smara: Yes, sometimes.
Silvia:: What type of diet do you follow? Do you eat often spicy and fatty?
Trifonescu Smaranda
Vlad Silvia
Anul II, grupa I

Smara: Yeah, I could say it happens a lot. I don’t follow a particular diet, I have quite
irregular meals, sometimes even in the middle of the night
Silvia: Do you smoke?
Smara: Yes, i've been smoking for a year.
Silvia: These habits that you have, the unhealthy diet, eating during the night,
smoking, they made me belive we are dealing with an early stage of gastritis. It can be
extremely easily treated by changing the old diet that you had, a healthier lifestyle and
properly treatment.
Smara: I’m glad to hear that it’s not something serious, I was very concerned.

Silvia: Now that we have clarified what the problem would be, I would like to find out

more about it your past madical history. Is that fine with you?

Smara: Yes, of course.

Silvia: Well then. Do you have any chronic diseases that still affect you today?

Smara: Yes, I have an autoimmune disease, psoriasis. I have it since I was eighteen

years old, it has started because of a personal problem.

Silvia: So you have faced problems related to stress over time.

Smara: Yes, I am quite a stressed person.

Silvia: What type of psoriasis do you have?

Smara: I have guttate psoriasis, but at the moment the disease is kept under control by

avoiding stressful situations.

Silvia: Are you taking any prescription medication for this condition?

Smara: In general, I use a moisturizing cream, and when it gets worse, I use a cream

based on cortisone.

Silvia: Can you tell me the name of the cream?

Smara: Yes, it’s Dermovate.

Silvia: Have you ever been admitted to hospital, and if you were, for what reason?
Trifonescu Smaranda
Vlad Silvia
Anul II, grupa I

Smara: Yes, I was hospitalized in the past because I had appendicitis, and my appendix

was removed.

Silvia: I understand. Were there any complications due to the anaesthesia or the

surgical condition?

Smara: No.

Silvia: Do you have any allergies?

Smara: No, none that I know of.

Silvia: Are you up to date in the immunizations against viral colds?

Smara: I usually catch a cold almost every winter. I take antibiotic or anti-

inflammatory treatments, under the guidance of the consultant.

Silvia: You also told me that you follow a fatty, generally unhealthy diet. Considering

the condition that you have, I would suggest a low-protein diet for psoriasis.

Have you received any mental health treatment?

Smara: No, I never had any psychiatric problems, just stress related problems.

Silvia: Do you have someone in your family who is dealing with an autoimmune

disease?

Smara: Yes, my grandmother has rheumatoid arthritis.

Silva: Do you drink or use other drugs?

Smara: I drink alcohol only on special occasions, and I have never used drugs.

Silvia: Now I will prescribe your medication. You will need to eliminate or alternate

the high-fat diet with a healthy one, composed mostly of boiled foods and everything's

gonna be fine. I'll see you in 2 weeks to tell me how you're feeling. I also analyzed

your medical history, and it does not interfere with the current condition that you have.

Smara: Thank you very much, I hope to bring good news to you, goodbye!

Silvia:Goodbye!
Trifonescu Smaranda
Vlad Silvia
Anul II, grupa I