Dniepropetrovsk State Medical Academy

Propaedeutics of Internal Diseases Department

Head of Department, professor Khomazyuk T.A..

Teacher:

The curator: the third year student of foreign faculty _____ group

Full student’s name __________________________

THE EDUCATIONAL CASE REPORT (HISTORIA MORBI)

__________________________________________________________________

(Surname name, first name and patronymic name of the patient)

1. Inquiry (interrogatio)

1. Personal details (identification data)

Full name of the patient (surname, first name and patronymic name)

_____________________________________________________________

Date of birth __ __ _____________ __ __ __ __

Age _________ (full years)

Home address: Smolensk region, town ______________, st. ______________, house № ________, flat № _______.

Place of employment __________________________________

Occupation __________________________________

Date of patient’s hospitalization __ __ _____________ 2005

Date of examination by student __ __ _____________ 2005

2. Patient’s complaints

Complaints at the moment of admission to the hospital:

Pains: questions:

• Localization (main site)

• Radiation

• Character

• Severity

• Duration

• Frequency and periodicity

• Special times of occurrence

• Aggravation factors

• Relieving factors

• Associated phenomena

Complaints on the day of examination by the students:

Sleep: not broken; changed (insomnia, falling asleep with difficulty, frequent awakening, early awakening and troubled sleep), the increased drowsiness in the afternoon.

Appetite: not changed, increased, reduced, poor, loss.

Stool

Frequency: _____ times per day, _____ times per week, 1 time per _____ days

form (formed, unformed, pappy)

consistence (hard, soft, watery, liquid)

colour of faeces (brown, yellow, black, grey)

pathological admixtures in faeces (mucus, blood, pus, undigested food)

with/without tenderness of defecation

Urination

Frequency _______ times a day (24 hour), during daytime _____ times, during night time ______ times

volume _____________ ml

tenderness (pain, difficulty)

night urination

colour of urine (light/straw/intense yellow, deep/intense brown, “meat waste”, tea-coloured)

3. History of present illness (anamnesis morbi)

Patient considers that he has been ill since ________________ when

Patient was admitted to the ____________________ department of Smolensk regional hospital at the

4. Personal history (anamnesis vitae)

1. Family History and Heredity

Patient was born in __ __ _____________ __ __ __ __ in ____________________ in the family of _____________________.

He was _______ by birth from _______ (number of children).

Mother was __ __ -year-old, father was __ __ -year-old at the moment of his birth.

He started to go at the age of ________ .

He started to speak at the age of ________ .

Patient had (not) any delay in his physical and mental development.

He entered school at the age of ________ , graduated (primary, secondary, high) school at the age of ________.

He entered _______________ institution, academy, university, technical school, college in __________, graduated in _________. He got the profession of _________________.

He served in army, navy in _________ years.

His occupation was _________________and now ______________ is. He did not work _________________ due to _________________________

He changed the places of residence

Patient is married, has _________ children of age.

Family diseases and heredity (and specify who from patient’s close relatives suffered from):

Diabetes

Hypertension

Tuberculosis

Apoplexy

nervous diseases

mental diseases

cancer

other significant diseases

Patient’s parents are alive, died of _____________ at the age of __________