Plan of clinical history

1. GENERAL INFORMATION 1. Surname, first name: 2. Age: 3. Sex 4. Marital status: 5. Home address: 6. Place of work: 7. Profession: 8. Date of entrance to the clinic: 10. Date of discharge: 9. Who sent the patient: 12. Hospitalization (planned, emergency): 13. Diagnosis of the sending institution: 14. Entering Diagnosis 15. Clinical Diagnosis: Main: Complications: Additional diseases: 2. COMPLAINTS This section begins with a medical history listing major complaints that have bothered the patient at admission and were the reason for seeking medical attention or reason for hospitalization. With detalisation of each complaint. After identifying of main complaints all other complaints are listed.    3. HISTORY OF PRESENT ILLNESS (Anamnesis morbi) This section details in chronological order and describes all the features of development and course of illness from the time of first symptoms until present. Description of disease should always start with clarifying following points: 1) Characteristics of illness: - Time of occurrence (month, year and age) and duration of illness (how many time-feels sick); - Initial symptoms of disease ( first signs of illness and details of their specific features); - Factors that could initiate the disease (heredity, poor nutrition, infections, life style, stress, etc.); - Treatment and efficiency of it. 2) Indicate complications (in DM acute and late), time of their manifestation and treatment of complications. 3) Frequency of observations by a doctor,date of last hospitalization. 4) Maintenance therapy with the name of drugs, their dosage, efficacy, side effects, duration of admission (either permanently or occasionally), point if treatment is carried out uncontrollably like self-treatment. 5) Indications for present hospitalization (to detect diagnosis , unefficacy of treatment, progression of disease, occurrence or progression of complications requiring hospital treatment, preparation for surgery, etc.). Curator must carefully examine available patient's medical records from other clinics. Pay attention to the previously established diagnoses, and data of objective inspection, conducted research and treatment, efficacy of treatment (a positive dynamic or absence of it), the doses and combinations of a number of pharmacological drugs (steroids, antihypertensives, etc.).

4. Functional status (Status functionalis)

Interview the patient on supposed changes (complaints) in all other organs and systems aimed to detect an evidence of complications. General disorders: weakness, decrease or increase in body weight, fever, sweating, etc

Most often revealed neurological symptoms,

Changes in the psychic sphere.  Changes in motor activity.  Changes in basal metabolism. Changes in secondary sexual characteristics.  Changes in skin and its appendages

Reproductive system

5. HISTORY OF LIFE (Anamnesis vitae) Brief biographical information. Place of birth, social position, which account in childhood, the material conditions of life. Age of parents at the time of the birth of. From any account of pregnancy, maternal disease during pregnancy, childbirth. Character of feeding (natural, mixed, artificial).

Labor history. Household history. Material and living, housing and sanitary conditions throughout of life. Family composition. Eating habits and lifestyle.

In chronological list indicate additional diseases, surgery, trauma, injury, hepatitis. What kind of drugs patient is taking constantly, their efficacy, doses, frequency rate of reception. Gynecological and obstetrics history (females).

Allergological anamnesis.

Habits. Smoking. Alcohol.

6. CURRENT STATUS (Status praesens) 1. General examination The general state of patient: satisfact, moderate,hard. Consciousness: clear, stupor, sopor, coma, delirium, hallucinations. Smell of acetone in exhaled air.

Type of constitution: normosthenic, asthenic, hyperstenic. Body weight (in kilograms). Height (in cm). Body mass index -BMI (kg/m2).Normal BMI 18,5 -24,9 kg/m2 , overweight 25-29.9 kg/m2, obesity I 30-34,9 kg/m2, obesity II 35-39,9, obesity III - over 40 kg/m2. Waist size(cm), Femur size (cm), Waist/Femur relation. Body temperature - in degrees by Celsius. Facial expression.

Head: The pathological changes of shape, size, position, range of motion of the head, soft and bone tissues of the cranial vault on palpation, especially hair distribution. Skin and mucous surfaces: color, humidity( normal, high, low), turgor (elasticity) of skin (normal, low), temperature: normal, hot and cold (with localization). Pathological changes of skin. Subcutaneous fat tissue.

Edema. Localization and prevalence of edema (general - heart, kidney, mixed, local, regional, local and angioedema). Severity. Skin color and its density in areas of edema. Mucosal swelling of the skin and subcutaneous fat. Lymphatic nodes. The sequence of study: occipital and parotid, submandibular and chin, neck front and back, over and subclavian, axillary, cubital, inguinal and popliteal. Characteristics of lymphatic nodes: the shape, size, density, tenderness, texture, mobility, cohesion lymph nodes between itself and the surrounding tissues, skin color changes over lymphatic nodes. Musculature. Bone. 2. Respiratory system Inspection of the nose: nose shape (regular, irregular), nasal breathing (free or impeded), wings of nose (involved or not involved in the act of breathing). Inspection and palpation of larynx: a form (correct or changed), position (normal, shift to one side), tenderness on palpation, mobility of larynx on palpation (normal, restricted). Examination of chest a) Static: shape . b) Dynamic: participation of both halves of chest in act of breathing. Respiration rate . Respiratory rhythm. Palpation of chest. Percussion

Auscultation. 3. Cardio-vascular system Inspection of neck vessels Inspection and palpation of heart.

Arterial pulse and research vessels Indicate the state of veins and signs of varicose enlargement or presence of thrombophlebitis. Blood pressure: expressed . Results of three consecutive measurements on the right shoulder, compared with the corresponding values ​​of blood pressure on left arm, if necessary, compared with parameters of blood pressure, certain of the lower extremities. Pulse pressure (normal, increased, decreased). Percussion of heart (detect absolute and relative heart flatness bound). Auscultation of heart (detect arythmia – tachycardia, bradicardia, atrial fibrillation; heart murmurs with detection of localization –point of auscultation and relation to systole). 4. Gastro-intestinal system Tongue Teeths. Inspection of abdomen.  Abdominal percussion Palpation. Percussion of liver: detect sizes by Kurlov. Palpation of liver. Spleen. Palpation of spleen.. Pancreas. Identification of palpation pain of the head, body and tail of the pancreas. Muscle protection symptom. 5. Genitourinary System Inspection of lumbar region. Pasternatskii symptom (right, left side).To detect by palpation of kidney: size, shape, surface, texture, tenderness and mobility.

Primary and secondary sexual characteristics. Inspection and palpation of external genitalia. 6. Nervous system Eye slits: the same, not identified, ptosis, nystagmus. Symmetry of face, tongue sticking out straight.

Muscle strength (decreased or not changed).

Coordination of movements is preserved, broken. Pose Rehberg stable, unstable. Function of pelvic organs (disorderd, not disordered). Reflexes. Pathological reflexes. Receptor function (sencability: normal, decreased).

Autonomic function. 7. Endocrine System Inspection: physical and mental development, age, sex. Primary and secondary sexual characteristics

Distribution of body hair. Face. Eye symptoms

Palpation of thyroid gland. Detect the degree of enlargement of thyroid gland by WHO (0 degree – nondetected visually and by palpation, I degree – detected only by palpation, II degree – visual enlargement). Hand tremor.

Basal metabolism according to Reed's formula: 0,75 (P 0.74 AP) - 72 = + / -10%, where P - pulse rate, PD - pulse pressure.

Trousseau's, Khvostek's symptoms (positive,negative). Obesity (Weist/Femur relation) General examination.

7. PRELIMINARY DIAGNOSIS Main: Complication: Associated diseases:

8. PLAN OF ADDITIONAL EXAMINATION List of additional laboratory and instrumental methods of examination, consultations of other specialists, indicated for patient. Results of additional examinations and their interpretation.

9. CLINICAL DIAGNOSIS AND ITS PROF Main: Complications: Additional diseases: Scheme justification diagnosis Diagnosis __________ billed on the basis of: Complaints _____________________________________________________,

10. DIFFERENTIATED DIAGNOSIS Differentiate main disease with a 2-3 disease (Ex: patients with diabetes mellitus type 1 – differentiated diagnosis with type 2 and diabetes incipidus).