The form of keeping a dairy of the practical training

Date	Scope of the work done	Notes, remarks, signature of head of the training

A model of the dairy record concerning the work at an in-patient department

2002. I got acquaintance with the therapeutic department (quantity of wards, beds, the staff, the department equipment, functional subdivisions, working regime, some quantitative and qualitative indications of the department, etc.)

I was present at a morning medical conference and listed to a doctor on duty report. It is obvious that there are 2 severe cases demanding close observation and treatment in the department:

1. Surname, name, patronymic of the patient, age with the diagnosis: Bronchial asthma of infectious allergic origin, hormone dependent, onset period, hard course. Chronic obstructive bronchitis in acute stage, Emphizema, diffuse pneumosclerosis. Complications: chronic pulmonary heart of the second degree, HK of the 2^nd stage. Asthmatic condition of the 2^nd-3^rd stages. Accompanying diagnosis: 3r stage obesity of alimentary-constitutional character. Chronic bacterial cholecystitis in remission period. Dyskinesia of bile-excreting, ways of hypomotor type. Lower extremities variscosity, post thrombophlebitis syndrome with vein insufficiency and skin atropholysis.

The patient has been supervised for 6 hours after admission. During the night watching the following urgent and scheduled therapy was carried out (indicate the given preparations in Latin transcription, dosage, quantity of the preparation given, the mode and frequency of introduction).

The following actions are carried out: (indicate which ones). Consultations of specialists (which ones, their conclusions and recommendations) are given.

Indicate the result of the performed actions (clinically and objective, what the dynamic positive or negative changes expressed at). What tactics is applied for the patient treatment at the next stage (procedures, treatment, consultations, further examination, etc.)

2. Surname, name, patronymic, age of the patient with the diagnosis: ischemic heart disease, post infarction cardio sclerosis (1992, 1996, 1999) and atherosclerotic cardiosclerosis, exertion angina pectoris 3ФП , rhythm impairment according to ciliary arrhythmia type, tachysistolia in constant form, polytopic extrasistoles are often present. Complications: HK of the 3^rd stage, right-side hydrothorax, cardiac fibrosis of liver. Acute left-ventricle insufficiency with pulmonary edema in the primary stage.

Accompanying diagnosis: Chronic bilateral pyelonephritis, secondary, in cute stage with concentration kidney function impairment and moderate anemia. ХПН of the 1^st stage. Prostatic gland adenoma of the 2^nd stage. Acute urinary retention. Diabetes mellitus of the IInd type, moderate, sub-compensation. Micro-angiopathy diabetic retinopathy.

The patient has been under supervision for 10 hours after hospitalization. Further a description of the treatment and other measures should be given.

I have got a ward for supervision. Together with a doctor-in-charge (surname, name, patronymic) I made a daily round of the ward, examined 5 patients with the following diagnoses:

1). Surname, name, patronymic of the patient, age. Diagnosis (a detailed diagnosis according to the modern classification, complications of the basic diagnosis. Accompanying diagnosis also according to classification).

2). Surname, name, age. Diagnosis: ___________________________________________

3). Surname, name, age. Diagnosis: ___________________________________________

4). Surname, name, age. Diagnosis: ___________________________________________

5). Surname, name, age. Diagnosis: ___________________________________________

I examined a newly admitted patient (surname, name, patronymic, age) with the diagnosis: Duodenal ulcer. There is a recurrent ulcer located on the frontal wall of the bulb, average size (1,4*1,2*0,4 cm) in progression, average case, with increased secretory function, acute phase with superficial gastritis, and solitary erosion in the antral part, erosive duodenitis. Gastric motor fucnction impairment according to duodeno-gastric reflux type. Xelico bacter invasion. Complications: periduodenitis, accompanying diagnosis: deforming osteo-arthrosis with primary involvement of knee-joints, talocrural and small hand joints in subcompensational period, the second degree impairment of joints function. Spinal column osteohondrosis.

I filled in the patient’s case history and a list of indications (prescriptions).

The patient was prescribed a regime, a diet (indicate which ones), additional examinations (indicate exact methods of laboratory and functional research), treatment (indicate doses, frequency, other measures including physiotherapy, reflexotherapy, barotherapy, therapeutic physical training etc.)

I was called by a nurse to the supervised ward for emergency examination and giving first aid to a patient of 70 years old with the diagnosis (indicate a detailed diagnosis) who felt a sudden, severe, squeezing pain in the substernal area after meal. After taking nitroglycerin the pain didn’t subside.

The patient also had a headache in the occipital area (part), dizziness, flashing of “points” in his eyes appeared. Objective data on examination are: (name all the noted changes in systems and organs) and first of all, in the cardio-vascular system (arterial pressure, pulse, heart contraction rate). The indicated parameters are connected with arterial hypertension. The following preparations have been introduced at once (indicate which ones, dosage, way of introduction).

Electrocardiogram has been taken urgently. No ischemia and necrosis features in the cardiac muscle have been noted. Nevertheless changes connected with hyperthrophy of the left ventricle are clearly determined (describe these features, where they are located). Correction of the scheduled therapy has been done (indicate which preparations are cancelled, which are prescribed again, frequency of their taking and way of introduction).

29.06.2002 I attended a morning medical conference. Patient (Name, age) died in the department. A clinical diagnosis was being discussed. Differential diagnostics was made either of acute myocardial infarction or pulmonary artery thromboembolia. The corpse was sent for autopsy with the diagnosis: ischemic heart disease, acute extensive transmural myocardial infarction in the anterior lateral wall of the left ventricle. Complications: cardiogenic shock of the second stage. Pulmonary edema. Accompanying diagnosis: hypertension of the 2^nd stage, cerebrocardial form, deterioration period with persistently high blood pressure.

Myocardial infarction data were (indicate anamnestic, objective, laboratory, ECG and other findings). But there was not enough certainty in the diagnosis (indicate certain circumstances making the diagnosis difficult). Evidence indicating pulmonary artery thromboembolia was also present. The disease could be a complication or an independent illness.

The diagnosis was confirmed at autopsy (indicate what pathoanatomical changes were evidence of the clinical diagnosis). Nevertheless at autopsy the following changes were found (indicate pathoanatomical changes not corresponding to the clinical diagnosis or changes which were not evident clinically).

I was supervising the patients from the ward. Patient (names age) was discharged with the diagnosis: hypertension of the 2^nd stage, cerebrocardial form, slow course. Complications: hypertonic crisis of the 2^nd stage. HK 2 A-stage. Accompanying diseases: ischemic heart disease, exertional angina pectoris 1-2 Ф.К. Chronic superficial gastritis B-type in acute phase with normal secretory function. Stomach motor function impairment according to gastroesophagus reflux type. Catarrhal esophagitis. Acute erosions of the antral part of the stomach.

Epicrisis with detailed recommendations on healthy way of living has been written out: a diet (№ according to Peuzner), feeding regime and food allowance, optimal working and resting regime, physical exertion character, their frequency, harmful habits exclusion, professional detriment, autogenic therapy, medicament therapy with certain preparations, their dosage, frequency of intake and intake period, antirecurrence treatment.

I was working in a procedure room. Instillator with polarizing mixture was filled in and the mixture was introduced to patient (surname, name, age) with the diagnosis: ischemic heart disease, progressing angina pectoris, post infarction cardiosclerosis (1998). Complications: rhythm impairment according to ventricular premature beats type. HK 2-A stage.

I myself gave 4 intramuscular injections and 6 intravenous drop-by-drop introductions of the following medicines (indicate which medicines, doses, boluses, with solvent, which one).

Together with the doctor-in-charge made a pleural puncture to a patient (surname, name, age, diagnosis).

OR: was present at the procedure.

Indications for the puncture were (which ones).

The puncture was made as the following (describe).

I was working in EGC room. Took ECG in 2 cases (surnames, names, patronymics, ages, diagnosis) ECG investigation was made with the apparatus (type of the device) in the following way (describe). What changes were noted and their meaning.