|
Читайте также: |
The case history
Of the patient ___________________________________
____________________________________
Clinical diagnosis:
Basic: ___________________________________________
_________________________________________________
Concomitant:_____________________________________
__________________________________________________
Complication:_____________________________________
Starting of curacy work________________ work done by:
End of curacy work: __________________ Student IV year
_________group
_________________________
__________________________
__________________________
1. Surname and first name ________________________________________________
______________________________________________________________
2. Age ___________________
3. Gender_______________
4. Home address _______________________________________________________
______________________________________________________________
5. Occupation ______________________________________________________________ _______________________________________________________________________ ___________________________________________________________________________________
6. Admitting date ________________________________________________
7. Admitting diagnosis_____________________________________________
___________________________________________________________
8. Clinical diagnosis ______________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Present complaints
(with detail)
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Anamnesis Morbi
(The time of the disease onset. The cause of the onset and exacerbations of the disease. The dynamic of the skin disease. Previous examinations, treatments and their results.
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Anamnesis Vitae (Past medical history)
(The heredity, the development in the childhood, the occupational history, the social history, the family history, the obstetric and gynecological history, past diseases.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Viral hepatite______________________Tuberculosis___________________________
Venereal diseases________________________________________________________
Malaria ___________________
Bad/Pernicious habits ____________________________________________________
Allergic history _________________________________________________________
Objective examination
(Status praesens objectivus)
General patient's condition ________________________________________________
Posture of the patient: active, passive, forced ___________________________________
Consciousness __________________________________________________________
Inspection of the healthy skin areas:
Turgor ______________________Color ______________________________________
The character of perspiration________________________________________________
The condition of the sebaceous glands _______________________________________
Dermographism ____________________________The skin sensitivity (pain, temperature, tactile) __________________________________________________________________
_______________________________________________________________________
The condition of the hair __________________________________________________
Nails characteristics ______________________________________________________
Mucous membranes ______________________________________________________
_______________________________________________________________________
Subcutaneous fat _________________________________________________________
_______________________________________________________________________
Lymph nodes ___________________________________________________________
_______________________________________________________________________
The locomotor and muscular system ________________________________________
_______________________________________________________________________
The respiratory system: percussion of the lungs____________________________ _______________________________________________________________________
Auscultation of the lungs: _________________________________________________
______________________________________________________________________
_______________________________________________________________________
The cardiovascular system: borders of the heart ________________________________
______________________________________________________________________
Auscultation: heart sounds _________________________________________________
_______________________________________________________________________
Pulse________ per min. __________________________________________________
_______________________________________________________________________
Blood pressure _____________mm of Hg
The gastrointestinal system:
Mouth and throat Lips___________________________________________________________________ Tongue ________________________________________________________________
Teeth__________________________________________________________________
______________________________________________________________________________________________________________________________________________
Gums__________________________________________________________________
Pharynx________________________________________________________________
Tonsil _________________________________________________________________
_______________________________________________________________________
Examination of the abdomen _______________________________________________
_______________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________
Palpation of the abdomen __________________________________________________
_______________________________________________________________________
The liver_______________________________________________________________
_______________________________________________________________________
The gallbladder __________________________________________________________
The spleen ______________________________________________________________
The pancreas ___________________________________________________________
Shchetkin-Blumberg symptom ______________________________________________
Stool __________________________________________________________________
Genitourinary system:
Kidneys_______________________________________________________________________________________________________________________________________
Pasternatskii's symptom ___________________________________________________
_______________________________________________________________________
Frequent micturition ______________________________________________________
Diuresis ________________________________________________________________
Urination _______________________________________________________________
External genitals ________________________________________________________
______________________________________________________________________
The neural system:
Mental state ____________________________________________________________
Excitability _____________________________________________________________
Sleep __________________________________________________________________
Memory _______________________________________________________________
Tendon reflexes _________________________________________________________
______________________________________________________________________
Pupil reflexes ___________________________________________________________
Pathological reflexes _____________________________________________________
Organs of sense:
Vision ________________________________________________________________
Hearing ________________________________________________________________
Smelling_______________________________________________________________
Taste __________________________________________________________________
Дата добавления: 2015-08-03; просмотров: 85 | Нарушение авторских прав
| <== предыдущая страница | | | следующая страница ==> |
| Set the Strategy, Plan the Attack, and Execute. | | | Status localis |