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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
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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
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
III. THE CLINICAL DIAGNOSIS (DIAGNOSIS)
Main disease:
Complications of the main disease:
Concomitant diseases:
IV. 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).
V. THE PROGRESS NOTES (CURSUS MORBI)
The third year medical students do not fill this section.
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