V. The rough basis of action (the scheme of a case history) Ministry of Health of Ukraine

Vinnitsa State medical university

It n.I.Pirogova

Faculty of the general surgery

Managing faculty: ______________

The teacher: _____________________

MEDICAL CARD __________

The INPATIENT

The student _______ a course ________ groups

Estimation for a writing of a case history ____

Estimation for protection of a case history _______

The signature of the teacher ________________

Reviewers: Godlevskij A.I. - professor managing faculty of faculty surgery of Vinnitsa state medical university it N.I.Pirogova;

Kukuruza J.P. - professor managing faculty of children's surgery of Vinnitsa state medical university by it N.I.Pirogova.

The blood on РВ is taken __________ Date and time of entering _____________ the Pediculosis ___________

Blood on TWISTED Date and time of an extract _________________ the Scabies ______________ is taken ________

Group of a blood ______________ It is lead bed-days ________________ the Virus hepatitis ____

Rhesus-accessory _____________

With an internal hospital regimen it is acquainted (on) _______________

Kinds of transportation (on a trolley, an armchair, can go)

Medical card _________ the in patient

1. A surname, a name, a patronymic ____________________________________________________________________________

2. Age (full years, for children till 1 year - months, till 1 month - days) _____________________ 3. A floor ________

4. A constant residence: city, village (to emphasize) _____________________________________________________________________________

________________________________________________________________________________

5. A place of work, a trade or a post (for those who studies - a place of training, for invalids - group) _______________________________________________________________

__________________________________

6. Whom the referred patient ________________________________________________________________________

7. It is delivered in a hospital behind emergency indications: yes, is not present through ______________________ hours after the beginning of disease it is hospitalized in the scheduled order.

8. The diagnosis at a direction ______________________________________________________________________________

9. The diagnosis at entering ______________________________________________________________________________

10. The diagnosis clinical ________________________________________________________________________________

_________________________________________________________ Date of an establishment

11. The diagnosis final clinical

The basic ______________________________________

________________________________________________________________________________

________________________________________________________________________________ complication of the core ____________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

accompanying ____________________________________________________________________

________________________________________________________________________________

12. It is hospitalized in current to year in occasion of the given disease: for the first time, repeatedly all ______________ time.

13. Surgical operations, a method of anesthesia and postoperative complications:

№	The Name of operation	Date, hour	The Method of anesthesia	Complication	Operated
1
2
3

14. Other kinds of treatment (for sick of malignant tumors - special treatment: surgical, radial, the chemotherapy, complex, palliative, symptomatic - to emphasize).

15. A side effect of medicines _______________________________________________________________________

16. A mark about delivery of the letter of disability:

№_________ with_______________ on _______________№___________ with ___________on

№_________ with_______________ on _______________№___________ with ___________on

17. A consequence of disease: written out with convalescence, with improvement, without changes, with the deterioration, written out on bails for the mental hospitals, translated in other establishment ________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________

Has died in a reception, the died pregnant woman up to 28 week, after 28 week, the parturient woman.

18. For insorance: the working capacity is restored completely, lowered, temporarily lost, constantly lost in connection with the given disease, for other reasons.

19. For acting for examination - conclusions ______________________________________________________________________________

20. Special marks: _______________________________________________________________

______________________________________________________________________________

• Survey on a pediculosis _________________________________________________________

• Survey on a scabies _____________________________________________________________

• Hemotransfusions __________________

• Allergy _______________________________________________________________________

Oncologist examination

The Skin _____________________________

The Labium _______________________________

The Stomach ___________________________

The Intestine ___________________________

The Rectum ______________________

The Uterus _____________________________

The Mammary gland _____________________

The signature managing unit ________________________

Date ______________________________

The Signature of the doctor _____________________

Date and time of survey ____________________________________________________________

Complaints (with detailed elaboration) ________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________

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______________________________________________________________________________________

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