CASE HISTORY

Semipalatinsk 2013

SCHEME OF CASE HISTORY

A. INTERVIEWING OF THE PATIENT

I. Identifying Data

1. Surname, name

2. Age, sex

3. Nationality

4. Education

5. Occupation

6. Place of work

7. Residence

8. Date of hospitalization

9. Date of examination (by student)

11. Provisional diagnosis

12. Clinical diagnosis (basic disease, complications and accompanying disease)

II. Present complaints

A). Complaints on first day in hospital (date of hospitalization)

You should ask the patient for these complaints and write only that present with accentuation on:

- Chief (basic) complaints from basic pathological system

- Additional complaints from basic pathological system

- other complaints from another systems

1. Psychological, mental sphere

1. Mood and its changes.

2. Memory (on the present and the last events) attention

3. Sleep (depth, duration, character of dreaming, sleeplessness)

4. Head pain

5. Other complaints from the nervous system

2. Cardiovascular system

1. Dyspnea (constant or periodical, in rest or on exertion, depending on a position in bed, at conservation. Attacks of dyspnea, time circumstances of their occurrence and behavior of patient

2. Palpitation, characters of palpitation (constant or attacks, duration) the reasons of occurrence of palpitation (on exertion, at rest, at change of position of body, at excitement and others)

3. Heart pain - constant or by attacks, localization (retrosternal, at the apex etc), character (burning, pressing, dull and etc.), intensity, radiation, duration, frequency, factors that aggravate or decrease pain)

4. Arrhythmia

5. Edema on legs or other places and time of their occurrence

6. Sensation of pulsation (in what part of body)

3. Respiratory system

1. Сough; character - with a sputum or dry, time of presence (morning, evening, night), constant or periodical, etc.

2. Sputum: quantity; character, color of sputum, with a smell or without a smell, etc

3. Hemoptysis; quantity of the blood, color, frequency, etc.

4. Dyspnea - constant or periodical, in rest or on exertion, depending on a position in bed, at conservation. Attacks of dyspnea, time circumstances of their occurrence and behavior of patient

5. Chest pain – localization, character, relation with breathing, intensity, radiation, duration, frequency, factors that aggravate or decrease pain

4. Digestive system

1. Appetite - good, decreased, increase, etc.

2. Thirsts

3. Taste in the mouth, acidic bitter, metal, and dryness in the mouth

4. Swallowing and passage of nutrition from esophagus: free, difficult (dysphagia)

5. Eructation – by air, acidic, bitter, with a smell of rotten egg, eat up

6. Nausea, dependence on receiving of nutrition and character of nutrition

7. Vomiting; on an empty stomach after receiving of nutrition

8. Abdominal pain: localization and irradiation, altitude to reception of nutrition, hunger pain, night pain. Whether the pain now or after receiving of nutrition decreases. Whether the vomiting of pain facilitates: dependence on character of nutrition, the character of pain, whether occurs after an attack of a pain

9. Abdominal distention

10. Burning sensation, itching

11. Constipation, diarrhea, with what is connected, how many time per day happens, and other characteristics

12. The bleeding from the anus due to hemorrhoids.

5. Urinary system

1. Frequency of an urination, at night.

2. Quantity of urine for one day.

3. Burning sensation, during an urination.

4. Difficulty in urination

5. Color of urine; normal, dark and etc

6. Presence of blood during urination

7. Pain in lumbar area, character (dull, acute, paroxysmal), connection with an urination , irradiation

6. Locomotor system

1. pain in extremities, muscles, joints, character by sick, connection of pain with change of weather.

2. presence of morning stiffness

3. Difficulty at movement and in what joints, volume of movements

4. Pain and difficulty at movement in a backbone

7. Fever

1. Character of a fever and duration of fever

2. Sweats, their intensity and time of occurrence

B). complaints on day of examination by student

- Chief (basic) complaints from basic pathological system

- Additional complaints from basic pathological system

Date: 2015-01-12; view: 861