A case history

_________________________________________________ _________________________________________________

(surname, name and patronymic of the patient)

Clinical diagnosis:

Main disease_____________________________________

Complication of the main disease ____________________

Related disease ___________________________________

Curator - student_______________of the course

__________ Group______________Department

_______________________________________

(surname, name, patronic)

Time of curation: from_________

to_________

Kharkov, The Year

I. Anamnesis (Interrogatio)

1. PASSPORT PART

Surname, name, patronic______________________________________

Age___________Sex__________Family status____________________

Education (primary, secondary, tertiary)

Occupation___________________________Post___________________

Place of employment_______________________

Permanent address_____________________________________________

Date of admission to the hospital__________________________________

Diagnosis at the day of admission_________________________________

2. Complaints of the patient (briefly)

(Molestiae)

Patients complaints on admission to the clinic and prior to the supervision are recsequently. First, describe the main feelings that were the reason for hospitalization of the patient, then - the secondary complaints of a minor nature. Then carefully characterized each of the complaints (in details).To define them is possible only when a doctor asks a patient additional questions. The review should be started from the main affected system. If the patient complains of pain indicate its localization, nature, time of occurrence, intensity, periodicity, duration, conditions for the appearance, relation to external factors, irradiation, etc.

It is necessary to find out what relieves the pain - taking medicine (which ones?), Heat, cold, and some (forced) status, etc., by what it is accompanied (by a feeling of fear, severe weakness, chills, vomiting, dispnoea, dizziness, etc. etc.).

In this chapter all other complaints of the patient should also be recorded.

3. History of present illness (briefly)

(Anamnesis morbi)

Briefly described is the development and course of disease with the onset of initial signs of illness until the day of curing.

4. Review of organs and systems

(Anamnesis communis)

Characteristics of the general status: overall health, weakness, fever, weight loss, presence of edema (localization, time of appearance, etc.).

The review should be started from the system which desturbances predominated in the clinical manifestation of the disease.

Blood system (systema circulationis sanguinis). Pain (dolor) in pericardial zone: localization (behind the breastbone, the left of the sternum, in the apex), character (crushing, piercing, constricting, aching, etc.), intensity, irradiation, the duration ( continuously, periodically), the frequency of occurrence and the cause (physical stress normal or increased, excitement, etc.) by what is removed (nitroglycerin, analgin or other means); behavior during pain (decrease or increase in locomotor activity, forced position, rest); appearance during the pain of fear of death, depression, increased sweating, urination, dizziness, headache, shortness of breath, breathlessness (a detailed description of them), memory disturbances, vision.

Palpitation (palpitatio cordis): its nature (after what it appears or is intensified), the relationship with excitement or physical exertion, food intake, change in body position, lack of apparent reason, the frequency, duration, continuity, paroxysmal; is removed with drugs or drug-free means. Intermissions in cardiac activity: constant, periodic, connection with the load, food intake, change in body position.

Shortness of breath (dyspnoe): periodic, continuous, paroxysmal, inspiratory, expiratory, mixed; relationship with the load, emotional load (no reason), asthma, their nature, duration, cause, time of appearance than removed (nitroglycerin, hihteneo body position, antiasthmatic agents).

Edema (edema): localization in the shins, feet, abdomen, lumbar region, or face; time when there are (in the morning or evening), frequency, severity and duration, the impact of diuretics and other means.

Respiratory system (systema respiratorium). Breathing quality assessment (free, through the nose); dryness during respiration, scratching behind the breastbone.

Cough (tusis): dry, wet, permanent, periodical, fitlike, appears in the morning or at night; factors that remove or relieve cough.

Sputum (sputum): mucoid, purulent, mucopurulent, blood streaked, foam, evaluation of color, smell; time of appearance, the amount, in what condition; expectoration of sputum (is it heavy or easy).

Shortness of breath (dyspnoe) and suffocation (astma. asphyxia): conditions of its appearance occurrence, difficulty of inhaling and exhaling (expiratory, inspiratory, mixed); constant, fitlike, after what appears or gets worse, factors that remove.

Pain (dolor) in the chest: localization, character, intensity, irradiation, connection with cough, breathing, change in body position.

Hemoptysis (haemoptoe) (blood spitting): the amount of blood in the sputum, clean blood, blood clots; the blood is purple, dark, rusty, pink; the frequency and conditions of discharging blood, pulmonary hemorrhage.

Fever (febris), shivering, sweating, relation to cough, sputum discharge, duration and frequency of fever.

Voice: normal, hoarse, aphonia (no voice).

Digestive System (systema apparatus digestorii). Pain: its localization, intensity, nature (acute, constant, periodical, fitlike, belting, dull, aching, stabbing, etc.); duration; irradiation; relation to food intake (immediately after 1,5-2 hours night, "hungry"); relation of pain to dification (feces); removing or relieving factors.

Appetite (orexis): violation of appetite and its absence (anorexia), increase (polyphagia), perversion, disgust, and saturation.

Diarrheal effects: nausea (nausea), vomiting (vomitus), eructation (eructatio), heartburn (pyrosis). Dysphagia (dysphagia) - a violation of the act of swallowing, the feeling of delay of food in the esophagus. The degree of dyspeptic and disfagiac phenomena, their relation to food intake. The nature of vomit, its amount, impurities of bile, blood (unmodified, type of coffee grounds), odor, deterioration or improvement of feeling well after vomiting. Abdominal bloating (metcorismus).

Excrements (liming) (feces), regularity, intake of laxatives, enemas. Constipation (obstipatio), diarrhoea (diarrhoea). The nature and amount of feces, stool liquid, solid, "sheep", watery, frothy, and others; the color (brown, yellow, black, gray, clay); the smell, the presence of mucus, pus, undigested food, blood, discharge of worms. Itching in the anus, pain during defecation, the presence of hemorrhoid, rectal prolapse.

Urinary system (systema urinaria). Pain: in the lumbar zone, iliac zones, of over the pubis, below abdomen, in the urine channel, character, the provoking and relieving factors; irradiation; constant, paroxysmal, sharp, dull; connection with physical exercise, change of posture, food, water, alcohol intake, etc.; nature of urination: the frequency, daily volume of urine (polyuria, anuria, oliguria); dysuric phenomena: frequent, interrupted, involuntary urination, pain when urinating, frequency of urination per night; colour of urine : straw-yellow, saturated yellow, the color of beer, dark meat mud, red), urine clear, turbid, the presence of blood in the sediment; assessment of urine smell; edema (detailed description).

Sexual system (for women).

Pain: localization (lower abdomen, in the groin area, in the sacrum, in the external genitalia); character; irradiation; conditions of appearing; relieving factors.

Menstruation: regularity, duration, periodicity, number of menstrual discharge, pain, menopause. Features of climacteric flow.

Pregnancy, childbirth, abortion.

Nervous system (systema nervosa) and the senses. Headache: localization, nature, duration, frequency, removing factors. Dizziness: association with physical exercise, change in body position, frequency, duration, tinnitus, nausea, vomiting with vertigo. Loss of consciousness: the frequency, duration, cause, periodicity. Memory. The mood, job satisfaction, aggression, hostility, depression, and indifference. Breach of skin sensitivity, itchy skin, assessment of vision, smell, taste, hearing.

Musculoskeletal system. The pain in the joints (in detail), bones, limbs, spine, muscles, feet; frequency, removing factors; change of gait, stiffness in the joints, morning stiffness in movements, tremor of limbs, convulsions.