Life history (anamnesis vitae)

Biographical data: Patient was born in family of military men in Russia. He was the second child. He has a brother. He grew in satisfactory financial and living conditions. During childhood he was sick rare, commonly acute upper respiratory tract viral infection. He successfully finished school and technical university. His occupation was building engineer.

Past medical history: Patient has not had any cardiovascular, nervous, psychiatric, endocrine diseases, traumas and operations. He has not been sick anything like this before.

Epidemiological anamnesis. Patient did not have diarrhea, fever, tuberculosis, venereal diseases, HIV, hepatitis. He did not go abroad or outside the region you live in the last 3 years. He has not received immunizations anywhere. Patient had contact with colleague who had respiratory infection one week before.

Occupational history. After university he worked as an engineer for building company during 10 years. Then he formed his own small repair firm where he is working now. The working conditions include changing temperature, frequent overcooling, and dust. He worked whole week and duration of the working day may be 8-14 hours. He has benevolent relations with his colleagues.

Social history: Patient lives in own apartments at the 4^th floor. Apartments are convenient, warm, and dry, with satisfactory hygienic conditions and illumination. They have separate automatic heating system. Family monthly income is satisfactory.

Nutrition. Patient nutrition usually is irregular. He always has a breakfast and dinner at home, but sometimes omits his lunch at the work. Patient eats different products but prefers meat and vegetables. He drinks a lot of coffee (near 8-10 cups per day).

Morning exercises and physical training. Sport. Patient does morning exercises. When he was a student he engaged mountain climbing. But now he has stopped.

Harmful habits: Patient does not Smoke, uses of alcohol drinks very rare (4-6 times in a year) not more then 100-200 ml. He does not use of drugs, toxic agents.

Being in the army. Patient was in the army two years when he was 18-20 year old. He did not have any wounds or contusions.

Family history: Patient has been married. His wife is healthy. He has 2 children: a doter 10 years old and son 6 years old. They are healthy. Patient parents died. Mother died three years before due to myocardial infarction, father - two years before due to stroke. His brother suffers due to essential hypertension. Patient’s family does not have any hereditary diseases.

Allergological history: Patient does not have any allergic reactions to food products, cosmetics, odor, drug, dust, plants. Patient has not had transfusions.

Assessment of the anamnesis data

The patient complains of a moderate stabbing, chest pain in the right side without irradiation that increases due to cough and deep breathing, mixed dyspnea which increase due to physical exertion, a permanent cough with purulent sputum without smell indicate that he has affecting respiratory system.

The patient is filling sick during 4 days. It means that disease is acute.

During first three days disease was progressing because patient condition was become worse. But now patient says that his condition is better. It means regression of disease is beginning.

We suggest the disease developed due to overcooling and contact with sick colleague.

PHYSICAL EXAMINATION

Дата добавления: 2015-11-14