4. Urinary System

Inspection

Lumbar region not changed swelling

Distended urinary bladder

PALPATION

Kidneys impalpable palpable both right left lower pole

in the lying and standing patient’s positions

Shape

Size

Surface smoothed tubercular

Tenderness painless tender

Mobility mobile immobile

Consistency densely-elastic elastic dense

Renal points

Costal-vertebral right left tender painless

Costal-lumbar right left tender painless

Description of any abnormality ___________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Urinary bladder

Ureteral points

upper right left tender painless

lower right left tender painless

PERCUSSION

Pasternatsky’s symptom positive negative doubtful right left

Urinary bladder revealed _____ cm above pubis

AUSCULTATION

Renal arterial bruits

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

5. Endocrine System

Height gigantism dwarfism proportional body

Thyroid

Enlargement goiter

Consistency

nodular bruit

hands tremble fine tremor

ocular symptoms Graefe’s Stellwag’s Kocher’s Moebius’ signs

Secondary sex characteristics

consistent with age infantile masculinization in female feminization in male

6. Nervous System

Orientation disorientation in time space surrounding person own personality

Mental state

Mentality normal precocious retarded

Attention normal distractable blunted

Memory for recent past for remote past amnesia falsification

Emotional sphere

Mood high good bad euphoria depression change of mood agitation alarm emotional lability apathy indifference anxiety tension phobia panic.

Evident signs of nervous system impairment

disorders of sensitivity and coordination Romberg’s test hemiparesis reflex of oral automatism meningeal irritation speech disturbance

Deep tendon reflexes: biceps, triceps, knee, ankle, radialis, Achilles

Normal increased decreased absent

Superficial reflexes: plantar response (Babinski), superficial abdominal reflex

Absent present

3. THE CLINICAL DIAGNOSIS (DIAGNOSIS)

Main disease:

Complications of the main disease:

Concomitant diseases:

4. THE SUBSTANTIATION OF THE DIAGNOSIS

Clinical diagnosis is established on the basis of

• complaints of …

• data from the history of current illness about …

• data from the personal history about …

• findings revealed by the physical examination (by general examination, by private inspection, by palpation, by percussion, by auscultation).

5. THE PROGRESS NOTES (CURSUS MORBI)

The third year medical students do not fill this section.

6. SUPPLEMENTARY METHODS of INVESTIGATION

Plan of further investigations that are necessary for verification of diagnosis and their expected results.

7. THE CONCLUSION (EPIKRISIS)

PROGNOSIS

The prognosis (favourable – bona, doubtful – dubia, bad – mala, unfavourable – pessima, lethal – lethalis):

• For life (prognosis quoad vitam)

• For health (prognosis quoad valitudinem completat)

• For work (prognosis quoad laborem)

8. THE LITERATURE USED

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