The Skin and mucous membranes

SUMY STATE UNIVERSITY

MEDICAL INSTITUTE

The head of the department

Of the general medicine

Doctor of Medicine,

Professor S.V. Popov

Manager of the group

Lecturer Melekhovets O.K.

MEDICAL CARD

Name, surname of the patient

_______________ age of the patient

Clinical diagnosis: basic diagnosis __________________________________________
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Complication _____________________________________________________________

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Concomitant disease _______________________________________________________

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Mark for the writing of the case history ______________	Curator ____________________________ The group __________, the course ______
Mark for the defense of the case history ______________

SUMY 2007

GENERAL INFORMATION ABOUT PATIENT

Name _________________________________________________________________

Surname _______________________________________________________________

Date of birth ____________________________, age ___________________________

Home address __________________________________________________________

Preschool or school institution _____________________________________________

Date of admission to the hospital ___________________________________________

Institution which has directed patient to the hospital ____________________________

Pre-admission diagnosis __________________________________________________

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Patient’s department _____________________________________________________

I. COMPLAINTS

Main: ________________________________________________________________

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Additional: ____________________________________________________________

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II. ANAMNESIS OF THE DISEASE

The onset of disease acute, subacute, gradually (the necessary underline). The duration of the diseases is ______________. What preceded the disease (cooling, defects of nutrition, viruses infection, the contact with ill person, etc) ______________________________________________________________________

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The development of disease _______________________________________________

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The result of previous additional methods of investigation (if they were presence) _______

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The previous treatment (if it was presence): _____________________________________

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The effect of previous treatment ____________________________________________

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The reason of hospitalization _______________________________________________

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III. ANAMNESIS VITAE

Housing conditions is satisfactory or not satisfactory (the necessary underline and explain why) ________________________________________________________________________

Conditions of work _______________________________________________________

Conditions of life _________________________________________________________

The patient had such diseases (before admission) ________________________________

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Character of nutrition before present disease (character of meal, schedule of feeding) __
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The dynamics of body weight ______________________________________________ ______________________________________________________________________.

Allergological history

Presence of allergy symptoms _____________________________________________. The intolerance of products __________________________________________________

The intolerance of medicament (drug) _________________________________________

that accompanied with ______________________________________________________

The nearest relatives have such chronic somatic illnesses __________________________

________________________________________________________________________________________________________________________________________________ genetical illnesses _________________________________________________________

allergic reactions __________________________________________________________

Summery: ______________________________________________________________

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Objective examination of the patient

The patient’s general condition is extremely grave, grave, moderately grave, satisfactory, good (the necessary underline).

The state of consciousness is clear, sopor, stupor, coma (the necessary underline).

The mental state is (not) adequate or not adequate (the necessary underline).

Position is active, passive, forced (attitude) (the necessary underline).

The patient is asthenic, hyposthenic, hypersthenic constitution (the necessary underline). The patient is of regular, irregular body build (the necessary underline) _________________

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Anthropometrical measurements

Evaluating of physical development according percentile tabl s

Criterion	percentile	Conclusion
Weight, kg
Head circumference, cm
Body-mass Index, BMI

Summery: _____________________________________________________________

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The Skin and mucous membranes

Colour of a skin ________________________________________________________

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lip-nose triangle ___________________________________, cyanoses _____________

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Rashes (colour, characteristic lesions, localization, size, presence of warmth, itching, type of distribution) _____________________________________________________________

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Surface of a skin is (smooth, velvety, rough, dry, moist)__________________________________. The elasticity of the skin is ________________________________________________.

Temperature of a skin ___________________________________________________.

The dermographism is ___________________________________________________

Sensitivity of the skin: temperature ___________, pain ______________, tactile _____,

vibration ___________.

Nails: (shape, colour, thickness, quality) _____________________________________, ______________________________________________________________________.

Hair: (color texture, quality, distribution, and elasticity) _________________________

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Mucous membranes of a mouth (colour, moisture, presents of lesions) ______________

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Gums: ( colour, presents of lesions, ability to bleeding ) __________________________

Conjunctiva and sclera of eyes ______________________________________________

_______________________________________________________________________ The subcutaneous fat is distributed _________________________________________. The skinfold thickness is _____ cm on abdomen,.

The oedema ___________________________________________________________

The skin turgor is kept, decreased, flabby (the necessary underline).

Дата добавления: 2015-11-14