Kharkiv National Medical University

General Surgery Department №1

The chief of the department

prof. R.S. Shevchenko

CASE HISTORY

The patient’s name

Patronymic

Surname

Patient’s age

CLINICAL DIAGNOSIS

Main diagnosis:

Complications:

Associated pathologies (Comorbidities):

Every diagnosis should be classified by ICD-10,

In cases with cancers – by tnm classification also.

Student (Curator)

Faculty

Course Group

Teacher

Date of submitting

Mark

1. Passport part

1. Patient’s name, surname

2. Patient’s age in years

3. Date of birth

4. Gender

5. Occupation

6. Date of admission to the hospital

2. Complains

Complains at the moment of admission. Separate main complain from secondary complains and describe in details their character from the main complain to the secondary complain.

1. The main complains are the leading conditions that brought the patient to the hospital.

2. The secondary complains are not typical to the main disease.

3. General complains are the complains that are not specific to any disease like headache, weakness, tiredness, depression.

3. Anamnesis of the disease (Anamnesis Morbi)

Development of the disease expanded in chronological order since the moment of the onset of the disease to the moment of examination, the reason of disease, exso- and endogenic, information about medical care, dynamic of symptoms, results of paraclinical investigation, treatment, its effectiveness, side effects of antibiotics and chemical preparations. The disease should be described in details from the very onset (when exactly he felt sick, date and time if possible), what was the cause of the disease, list of first symptoms, the patient’s reaction (did he consult a doctor, or self curing procedures).

Describe the indication for admission into the hospital, the reasons for aggravation of the patient’s state, the aim of admission into the hospital.

4. Anamnesis vitae

1. Biographical data (Date of birth, childhood life, living conditions, occupational conditions).

2. Previous medical history. Infection and somatic diseases in past, information has to be done in chronological order. It is necessary to mark the character of the disease, peculiarity of the clinical characteristic, to pay attention to diseases of the allergic cause, to the nutrition and medicine intolerance. Previous surgeries and traumas.

3. Information about contacts with infectious patients during last 3 weeks before admission, with tuberculosis patient and other infections (occasional, family, flat contact)

4. Information about prophylactic vaccination, reactions on vaccination.

5. Family anamnesis

5. Present state:

A. General condition and neural system characteristic.

General state of the patient is (satisfactory, moderate severity, grave, extremely grave). Patient’s position is (active, forced patient’s attitude position, passive patient’s position). State of consciousness. Mental state , estimate of intelligence, memory, speech. Abnormalities of gait, posture, coordination. State of sensitive organs: vision, hearing, skin sensitivity, olfactory, taste characteristic.

B. Physical development and its assessment.

Weight, length, head and chest circumference of patient. The result of investigation must be compared with age standards.

C. Skin and mucous membranes characteristic

Colour (cyanosis, jaundice, pallor, erythema), texture , hydratation, turgor and elasticity(good, satisfactory, decreased). Edema , hemorrhagic manifestations, scars, rash (character and location), dilated vessels. Character nails and hair distribution, colour of visible mucous membranes.

D. Subcutaneous tissue characteristic

Thickness of subcutaneous fat fold, turgor, edema and subcutaneous formation, it`s location and sizes.

E. Lymphatic system characteristic. Palpation of groups of lymphatic nodes (suboccipital, preauricular, anterior cervical, posterior cervical, submaxillary, sub-linqual, axillary, epitrochlear and inguinal), there quantity, shape and size, conjunction of each with other, with near-by tissues.

F. Muscle system characteristic.

Tone, strength.

G. Bone system characteristic. Head size, shape, asymmetry. Configuration of joints , active and passive movements.

H. Respiratory system characteristic. State type of respiration (thoracic, abdominal, mixed). Appreciate respiration rhythm (rhythmic respiration, arrhythmic respiration, Chene-Stoke`s respiration, Biot`s respiration, Kussmaul`s respiration). Respiratory rate ,

Palpation of the chest. Elasticity of the chest (the chest is elastic, elasticity of chest is decreased, the chest is rigid). Pain in the chest wall (“surface” pain) (the chest is painless, pain of the chest wall is determined, to indicate location).

Percussion of lungs. Comparative percussion of the lungs (clear pulmonary sound, dulled pulmonary sound, tympanic sound, bandbox sound, cracket-pot sound, metalic sound, dull with tympanic tone and to indicate location).

Auscultation of the lungs. The main respiratory sounds (puerile, vesicular breathing, decreased vesicular breathing, to indicate location of weakening of vesicular breathing, increased vesicular breathing, harsh breathing, vesicular breathing with longer expiration, bronchial breathing, amphoric respiration. Adventitious respiration sounds

(dry rales-high-pitched-sibilant, low-pitched-sonorous, moist rales (fine bubbling, medium bubbling, coarse bubbling, consonating and non-consonating, crepitation – initial, resolve, pleural friction sound, to indicate location of adventitious respiratory sounds.