- •3. History of disease.
- •4 Ascking on different organs and systems. (to write only that complains which are present)
- •Cardiovascular system.
- •Broncho-pulmonary system.
- •Digestive system (gastrointestinal system).
- •Urinary and sexual system.
- •Locomotory system.
- •Neurologic – psychiatric system.
- •Skin and appendages of the skin.
- •Short estimation of anamnesis data.
- •Objective conditions of patient (status presence objectives).
- •Cardiovascular system.
- •Respiratory system.
- •Organs of abdominal cavity .
- •Primary diagnosis
- •Plan of examination.
- •Differential diagnosis.
- •Clinical diagnosis.
- •Structure of clinical diagnosis.
- •Principles of treatment and prophylactic.
- •Epicrisis.
Digestive system (gastrointestinal system).
Abdominal pain: intensity, localization, character (acute, dull, aching, like colic) , connection with food eating, it quality (feting, salt, meeting, hot or cold), connection with defecation, with other situations, irradiation, prolongation, periodicity, what cause increasing of the pain ( body position, heat using, eating, drugs using).
Dyspeptic features: hard swallowing, food moving along esophagus; what kind of food, move easy – liquid or thick, hot or cold, eructation, brash, abdominal distention nausea, vomiting, connection with food eating; quantity and character of vomiting masses (with bile, blood), smell of vomiting mass (acidic, putrefactive, like feces), changing by self feeling after vomiting.
Appetites: normal, increased, decreased, absent. Felling an aversion for food.
Taste: normal or abnormal.
Salivation: normal, hyper- or hypo-.
Thirst: absent, how many liquor drinking per 24 hours.
Defecation: frequency, periodicity, pain during defecation, feces color (white, with blood, black, normal). Feces characteristic, it smells.
Urinary and sexual system.
Pain: in the urethral, suprapubic area, sacral area; it intensity, prolongation, irradiation; reasons and symptoms of the pain (during urination).
Urination: frequency, quantity per 24 hours; is urination hard fool or not?
Urine: color, quantity, transparent; mucous, blood or pus presenting.
For women: menstrual function, time of the beginning, regularity, volume of menstrual excrete.
About menopause – when was happen, specialties period of climax. How many times was pregnant, with what interval.
Locomotory system.
Muscular and joints pain, localization and factors that cause it, character of the pain, intensity.
Movement in joints, free or hard..
Feeling of numbness or hands (legs) coldness; muscular weakness.
Neurologic – psychiatric system.
Emotional sphere: reaction on external stimulus..
Psychiatric traumas: character, prolongation of the reactions.
Vertigo: presenting, reasons, frequency, accompanying factors (vomiting, head noise).
Headache: frequency, prolongation, localization, and intensity.
Losing of consciousness: presenting, frequency, reasons, prolongation, and other disorders of consciousness.
Mood: stabile, labile, apathy.
Temperament: tranquil, steady, lively, sluggish, instead, closed.
Skin sensitivity: hypostesias, hyperstesias, parestesias.
Vision: normal or depraved, some other changing’s.
Audition: normal or depraved, noise, pain, and excretion from the ear.
Sense of smell: normal, depraved.
Skin and appendages of the skin.
Color changings: if where: when, reasons of changings; ecchymosis on skin, size, color. Sweating, dry skin, rash, it reason, character and prolongation.
State of hair: character of hair (women or men type), hair loss.
Nails: presenting of pigmentation, deformation.
Body weight.
Constant or variable, how mush, under what circumstances (connection with nutrition, pregnancy, age or without clear reasons).
In this chapter we ask about life, work, climate factors, which could cause the disease.
Place where a person was born, age of parents at that time and now, condition of their health and health of close relatives, quantity of children in the family, what was the person’s number in the family ( first, second child etc.).
Physical development in childhood (normal, increased, decreased comparatively to children of same age). Success in studies (normal, high, low).
Life and social conditions during individual development. Character of nutrition (quality, regularity, peculiarities of kitchen).
Work activity: it’s beginning, character (kind) of work (level of hardness, regime of work day, professional harmfulness ), durations of vocation, how does a person use it.
For male: was a person in the army, if not – why?
What diseases had: in childhood, in teenagers and adult age, operations, traumas, allergic reactions to some substances (food, smell of grass, toilet water, drugs, alcohol drinks).
In every occasion of disease it’s necessary to determine its duration, peculiarities, place and results of treatment, presence of complications.
Family status, presence of children.
Chronic intoxications: smoking (from what age, how much, is “caught of smoking people” present); drinking of alcohol (episodic, chronic, in what quality, is pathological need in alcohol present); pathological need in drugs, medications. Period of this need.
