2. Dietary History and Habits

Patient had natural / artificial feeding at an early patient’s age.

Nutrition sufficed for living, did not, malnutrition, starvation or overeating.

Patient’s nutrition is balanced, includes enough amount of proteins, lipids and carbohydrates, vitamins.

Meals are regular, irregular.

Patient prefers sharp, salty, spicy food.

Patient has smoked since __________ year up to ___________ cigarettes a day, gave up smoking in __________.

Patient has drunk since __________ year up to ___________ ml of ___________, prefers __________.

Patient has never used narcotics or has never had any drug abuse.

3. Gynaecological History

menses (date of onset, interval, regularity, duration, amount of flow, date of the last period, dysmenorrhoea, menorrhagia, irregular bleeding)

pregnancies (number, pathology, toxaemia, labour complications, abortions, miscarriages)

use of contraceptives

gynaecologic diseases, operations

the climacteric period (from what age, its manifestation, vegetovascular disorders, age of coming on menopause).

4. Past Medical History

Patient was ill with _______________ in __________.

measles

whooping cough

chickenpox

scarlet fever

flu

diphtheria

malaria

typhoid fever

epidemic typhus

virus hepatites

jaundice

tuberculosis

AIDS

venereal disease

cancer

poisonings

injuries

operations

5. Allergological History

Patient had allergic reaction as (vasomotor rhinitis, nettle-rash, angioneurotic Quincke’s oedema, bronchiospasm, anaphylactic shock) on

medicines

foodstuff

domestic and other dust

hair of animals, feathers of birds, fur

pollen of plants

household and industrial chemical substances

temperature and other weather factors.

Patient had not any allergic reaction on foodstuff, medicines and chemical substances.

6. Sanitary-and-Epidemiological History

Patient lives in (flat, house, own, rented) of size _________________ with

lack of conveniences, home comfort.

Patient had, did not have contact with sick people (infectious, icteric, with febrile state, with intestinal disorders) and sick animals.

Patient had departure (during last 2-3 months before hospitalization) to _________________.

Patient’s family received guests from ____________________________.

Patient was vaccinated against ______________ in and had injections of _____________ within last _________ months.

Patient had blood tests for antibodies to HIV, virus hepatitis (B, C) in _____________.

7. Ecological History

Patient’s residence is situated in the region without or with the industrial enterprises (thermal power plant, nuclear power plant and others) ___________________, with environmental pollution (air, ground, reservoirs) of hazardous, nuclear, radioactive and toxic wastes.

8. Occupation History

Patient’s labor conditions and occupational hazards includes:

industrial dust, humidity, intense noise, vibration, high ambient temperature, lack of illumination

work with industrial hazards (lead mercury, acids, alkalis, arsenic, nickel, benzine, benzol, radioactive substances and others)

labour features (work at the conveyor, night shifts, business trips, overtime work, work without holiday)

Patient has had disability (of _____ disability group) due to ___________________, since _____________________.

9. Insurance History

Patient was on sick-leave due to the present disease ______________ days in the current year in total.

2. PHYSICAL EXAMINATION (STATUS PRAESENS)

1. THE GENERAL EXAMINATION

   1. Anthropometry

Weight_____.__ kg, height __ __ __ cm, body mass index _____.___kg/m², body temperature ____.__ °C.

2. The General Inspection

General condition: good, satisfactory, moderately grave, grave, extremely grave.

Consciousness: clear, alert; clouded; stuporous; soporouse; comatose; confused, irritative disorders (delirium, hallucinations).

Position: active, passive, forced.

Posture: right, erect, incorrect, stooped.

Gait: easy, steady, confident, paralitic, paretic, ataxic, hemoplegic, retarded, wobbly, spastic, waddling.

Physique (body build): asthenic, hypersthenic, normosthenic (athletic) type, regular, irregular.

Nutritional state: well nourished; poorly nourished; cachectic; obese; emaciated.

Head: correct, incorrect shape, square, flattened on top, normal size, microcephaly, macrocephaly, tremor, Musset’s sign, scars _________________________________

Face: puffy, Corvisart’s facies, facies febrile, acromegalic, myxoedematous, facies basedovica, moon-like, facies leonine, Parkinson’s mask, sardonic grin, Hippocratic face, symmetrical, asymmetric, serene, lifeless, dolorosa, adenoid, Stokes’ collar, asymmetric movements of facial muscles, unilateral ruddiness.

Neck: not changed, dilatation of veins (swelling and pulsation of the external jugular veins), pulsations of veins, arteries, “carotid shudder”, scars.

_________________________________________________________________

Eyes: not changed; sunken, dilated eye slit, narrowing of the eye slit

Lids oedema ptosis width of palpebral fissures not changed

Sclera jaundice hemorrhage injection "rabbit eyes" not changed

Conjunctivae pallor injection petechiae not changed

Cornea scars ulceration arcus senilis not changed

Pupils not changed round equal miosis mydriasis anisocoria reaction to light and accommodation equal non-equal "pulsation" exophthalmos enophthalmos xanthomas

Ears: hearing not changed, decreased, tophi.

Skin

Colour flesh-coloured red pallid cyanotic icteric brown greenish tint cafe au lait

colour of palms

pigmentation not changed foci of depigmentation of the skin (vitiligo)

texture wrinkled

turgor and elasticity not changed decreased

moisture normal moist dry

moisture of palms

peeling

eruption

lesions

cutaneous striae

spider angiomata

scratch marks

scars

xanthomas

Nails: not changed, cyanosis, flattened, thickened, fragile, stratified, Hippocrate’s (like watch glass), spoon-like, brittle.

Hair: not changed, falling out, alopecia, hirsutism, hypertrichosis, fragility, grey.

Subcutaneous fat

Development moderate poor excessive

Distribution uniform nonuniform deposited in only certain parts of body

____________________________________________________________________

Oedema evident generalized (anasarca) localized

____________________________________________________________________

Lymph nodes impalpable palpable

Site occipital tonsillar anterior and posterior cervical preauricular postauricular supraclavicular axillary epitrochlear popliteal inguinal

Consistency soft elastic densely-elastic dense hard

Tender painless

Fixed mobile

size _____ × _____ mm

Breasts symmetrical ____________________________________________

nipple, ulceration, secretion, pigmentation, areola, tenderness, masses.

Blood vessels not changed varicose veins

Muscles __________________________________________________________

Development well poor developed muscular system hypotrophy atrophy

strength (force) normal weak powerful

tone normal hypertonia hypotonia rigidity

cramps tonic clonic

Joints _______________________________________________________________

Shape

Articulation active and passive mobility full reduced volume

tenderness present absent

swelling or deformity present absent

hyperthermia and oedema of the adjacent tissues present absent

Heberden’s nodes present absent

Bones ______________________________________________________________

Abnormality present absent

Deformation clubbing of fingers scoliosis present absent

Mobility

Curvature

vertebral tenderness to percussion