Chair of internal medicine with clinical immunology and allergology

Endocrinology

 

Head of chair:___________

Teacher:________________

 

History of disease

(name, surname of the patient) ___________________________________________

 

Clinical diagnosis: __________________________________________________

 

 

 

Student _________________

Course______ group______

 

Time of curation: from

                           

                                till

 

 

 Patient questioning.

1 Passport part.

Initials of the patient ________

Age ______ Sex ______ Profession _______

Work place ________ Post ________

Address _________

Date of hospitalization ____________

2. Complains.

Describing complains on period of hospitalization. The best first question to patient is “What troubles you?”, or “What is the reason that you appear to doctor?”. All complains should be characterize detail, with the place of localization and feeling intensity. We must make clear the time and reasons of the pain (if patient know), prolongation, periodicity and irradiation of it. You have to ask, what decrease unpleasant feelings: some poses, using hot or cold, eating or vomiting, other factors (fresh air), using some drugs (what kind?), what accompany that feelings (fare, weakness, dubbing some parts of body, dispose).

3. History of disease.

In this part we must describe the dynamic of complains development, which were receive before.

Interview should be beginning from such question as: “How long are you sick?”. When did appear the first symptoms of disease, what was they, it chronologically development. Second question: “What troubled you for that time? ”

Circumstances of first features development; their dynamic in time, development other disease like feelings, it connection, reasons or circumstances of the disease. Then we should ask where was the patient treated, what kind of examinations and treatment methods where used, effectively of treating, periods of activation and remission of the disease. Influence of disease on patient work activity, time that he was on “hospital paper or on soldier group”, period of last activation, to determine we must. The last entry is about the real reasons and the kind of hospitalization (plan, or urgent).

4 Ascking on different organs and systems. (to write only that complains which are present)

First of all we must have to ask of the patient about health condition, so the question are “How do you feeling now?” “What can you say about your general condition?” As a rule, for this will be enough one phrase: “The patient feel himself: not bad, well, perfectly, bad, very bad”. Then we asking, about each organ separately.

Cardiovascular system.

Pain in the hart area: localization (on apex, out the sternum, left from sternum); character (stabbing, aching), intensity; irradiation: prolongation; frequency and time of pain arising, reasons (fast or slowly walking, hard physical work, emotional stress); behavior during the pain (trying to walk, finishing physical work, lay down on bed: presenting of increase sweating, imperative urination: affectivity of nitroglycerin and other treating methods.)

Heart beating: Regular or periodic, frequency and time of appearance (at night or day, during rest or physical work, during changing of body position, after eating, without any reasons).

Pulsation feeling: in the neck, head, or other body parts.

Paraesthesias: localization, prolongation.

Dyspnea: reasons (during physical loading, rest), prolongation and character (with hard breathing in or breathing out, mixing), level of hardness, present or not “music roughs”.

Edema: localization, local or general (anasarka), dynamic during the day and night, affectivity of diuretic drugs.

Broncho-pulmonary system.

Cough: intensity (moderate, strong) time of appearance, prolongation (regular, periodic) character (dry cough, or with sputum), factor that causes cough (or without any reasons).

Sputum: presenting, quantity, character (mucous, serous, mucoserous), small, blood presenting, and depending sputum excretion from body position.

Blood spiting: quantity of blood (a little, even dyeing, pure blood, blood clots), blood color (bright red, dark, orange, rose), reasons and frequency of appearance.

Chest pain: localization, character (acute, dull, stabbing) intensity (little, moderate, strong), prolongation (how long, constant or not); irradiation; connection with: breathing, changing of body position; promoting factors.

Asthma: time and reasons -of appearance, frequency, prolongation, breathing or breathing off hardness (or both of then), body position during the asthma, precursor factors, liquidates factors.

Fever: level of increasing (changing the temperature during the day and night, prolongation of fever period, sweating.)

Nose breathing: (free or hard), excretion from nose, (character and quantity), nose hemorrhage.

Voice.