
- •Vinnytsya National Medical University n.A. M.I. Pyrogov
- •Guide to case report writing, history taking and physical examination
- •Vinnytsia 2010
- •Passport part
- •1. Main complaints
- •2. Systems review
- •Life history (anamnesis vitae)
- •Morning exercises and physical training. Sport.
- •12.Trunsfusions.
- •Visual inspection of the chest
- •Visual examination of the precordial area
- •Investigation of the pulse and arterial pressure
- •Formulating suggested (primary) diagnosis.
- •Plan of the mandatory laboratory and instrumental examination
- •Cardiac system
- •Gastrointestinal system
- •Genitourinary system
- •Nervous system and sense organs
- •History of the present illness (anamnesis morbi)
- •Life history (anamnesis vitae)
- •Physical examination The general visual inspection
- •Examination of the respiratory system
- •Visual inspection of the chest
- •Examination of the cardiovascular system
- •Investigation of the pulse and arterial pressure
- •Examination of the Abdomen
- •Plan of the mandatory laboratory and instrumental examination
- •Results of the laboratory and instrumental examinations
- •Found and form clinical diagnosis according to classification.
- •Blood clinical chemistry биохимические показатели крови
- •Assessing of the ph-metry results (according to u. Linar) оценка ph-метрии ( по u. Linar)
- •Echocardiographic parameters основныe параметры эхокардиографии:
- •Ultrasonic examination of abdominal cavity organs ультразвуковое обследование органов брюшной полости
- •Further reading
UKRAINIAN MINISTRY OF PUBLIC HEALTH
Vinnytsya National Medical University n.A. M.I. Pyrogov
Mostovoy Y.M., Demchuk H.V., Konstantinovich T.V.
Guide to case report writing, history taking and physical examination
For the international English speaking medical students
Vinnytsia 2010
УДК616(075.8)=20
Клиническое обследование терапевтического больного:
Учебное пособие для иностранных студентов медицинских вузов, обучающихся на английском языке / Мостовой Ю.М, Демчук А.В., Константинович Т.В.-1-е издание. - Винница:, 2009.
Методическое пособие поможет англоговорящим студентам - медикам, обучающимся в Украине, получить практические навыки по обследованию больного, написанию и правильному оформлению истории болезни. Пособие будет полезно также врачам и преподавателям, интересующимся оформлением истории болезни на английском языке.
В учебном пособии приведена схема оформления учебной истории болезни на английском языке с учетом современной международной терминологии. Подобраны простые выражения на русском языке, которые может использовать студент - медик для сбора жалоб и анамнеза в клинике. Даны пояснения, как проводить физикальное обследование и оценивать его результаты. Приведены основные данные о нормальных лабораторных и инструментальных показателях в клинике внутренних болезней.
Рецензенты:
© Ю.М. Мостовой, А.В. Демчук, Т.В. Константинович, 2010
Contents
COVER PAGE OF A CASE HISTORY REPORT
PASSPORT PART
PATIENT COMPLAINTS:
Main complaints and specification of the main complaints, obtaining other complaints of affected system
Systems review with example of a brief systems review after revelation of chief complaints
HISTORY OF THE PRESENT ILLNESS (ANAMNESIS MORBI)
LIFE HISTORY (ANAMNESIS VITAE)
ASSESSMENT OF THE ANAMNESIS DATA
PHYSICAL EXAMINATION:
General visual inspection with assessment of the obtained symptoms and signs
Examination of the respiratory system with assessment of the obtained data
Examination of the cardiovascular system with assessment of the obtained data
Examination of the abdomen with assessment of the obtained data
FORMULATING SUGGESTED (PRIMARY) DIAGNOSIS.
PLAN OF THE LABORATORY AND INSTRUMENTAL EXAMINATION
PRESENTATION OF RESULTS OF THE LABORATORY AND INSTRUMENTAL EXAMINATION.
PRINCIPLES OF FOUNDING AND FORMING CLINICAL DIAGNOSIS
EXAMPLE OF THE CASE HISTORY REPORT.
SUPPLEMENTS:
Laboratory reference range values, adult
Ultrasound examination of the heart
Ultrasound examination of the abdomen
FURTHER READING
There is an example of a front page of a student’s case history report
Vinnytsya National Medical University n.a. M.I. Pyrogov Propedeutic Department to the Internal Medicine Chief of the Department prof. Mostovoy Y. M. Lecturer/Assistant_______________________
CASE HISTORY Patient’s name: ___________________________________________________
Diagnosis:________________________________________________________ ________________________________________________________ ________________________________________________________
Student of the 3rd year Medical faculty, group__________ Name________________________ Date of the beginning management: _______ Date of the finishing management: _______ |