Laboratory examination The case history
Of the patient ___________________________________
____________________________________
Clinical diagnosis:
Basic: ___________________________________________
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Concomitant:_____________________________________
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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 _______________________________________________________
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5. Occupation ______________________________________________________________ _______________________________________________________________________ ___________________________________________________________________________________
6. Admitting date ________________________________________________
7. Admitting diagnosis_____________________________________________
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8. Clinical diagnosis ______________________________________________
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Present complaints
(with detail)
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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.
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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) __________________________________________________________________
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The condition of the hair __________________________________________________
Nails characteristics ______________________________________________________
Mucous membranes ______________________________________________________
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Subcutaneous fat _________________________________________________________
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Lymph nodes ___________________________________________________________
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The locomotor and muscular system ________________________________________
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The respiratory system: percussion of the lungs____________________________ _______________________________________________________________________
Auscultation of the lungs: _________________________________________________
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The cardiovascular system: borders of the heart ________________________________
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Auscultation: heart sounds _________________________________________________
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Pulse ________ per min. __________________________________________________
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Blood pressure _____________mm of Hg
The gastrointestinal system:
Mouth and throat Lips___________________________________________________________________ Tongue ________________________________________________________________
Teeth__________________________________________________________________
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Gums__________________________________________________________________
Pharynx________________________________________________________________
Tonsil _________________________________________________________________
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Examination of the abdomen _______________________________________________
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Palpation of the abdomen __________________________________________________
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The liver_______________________________________________________________
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The gallbladder __________________________________________________________
The spleen ______________________________________________________________
The pancreas ___________________________________________________________
Shchetkin-Blumberg symptom ______________________________________________
Stool __________________________________________________________________
Genitourinary system:
Kidneys_______________________________________________________________________________________________________________________________________
Pasternatskii's symptom ___________________________________________________
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Frequent micturition ______________________________________________________
Diuresis ________________________________________________________________
Urination _______________________________________________________________
External genitals ________________________________________________________
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The neural system:
Mental state ____________________________________________________________
Excitability _____________________________________________________________
Sleep __________________________________________________________________
Memory _______________________________________________________________
Tendon reflexes _________________________________________________________
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Pupil reflexes ___________________________________________________________
Pathological reflexes _____________________________________________________
Organs of sense:
Vision ________________________________________________________________
Hearing ________________________________________________________________
Smelling_______________________________________________________________
Taste __________________________________________________________________
Status localis
The lesions of the skin and mucous membranes must be described in succession, according to a definite pattern :
The character of the affected skin (an inflammatory – acute, subacute, chronic or non-inflammatory etc.). The lesions (abundant rash, poor, single eruption, only one focus). Localization (prevalent distribution, less affected areas, places free of the lesions). Symmetrical or asymmetrical rashes. The monomorphic (polymorphic) eruptions.
The description of the foci and lesions: foci (size, configuration, borders, colour, consistency, swollen, atrophy, morphological lesions on the background of the foci and around them).
Primary and secondary morphological lesions: size (in cm. or mm.), shape (flat, conical or semispherical), configuration (round, oval, polygonal, irregular), borders (defined, poorly defined, not defined), colour , surface (smooth, rough, umbilicated surface), consistency (soft, firm, ligneous, firm-elastic, solid) etc., sings. Positional relationship of the lesions (uniform, nonuniform, group, union, isolated from each other).
Diagnostic phenomena (if any then describe).
Mucous membranes (affected or not affected; if affected then describe).
Hairs in affected area.
Nails (affected or not affected; if affected then describe).
Subjective impression.
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Preliminary diagnosis ________________________________________________
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Laboratory examination
Blood analysis
Date
R.B.C.
Hb.
Color index
W.B.C.
Eos.
Bas.
Neutroph.
Mon.
Lymph.
ESR
Urine analysis
Date
Color
Trans.
ph
Specific gravity
Sugar
Protein
Epith.
Erit.
Leuc.
Salts
Microflora
Blood investigations for Wassermann test _____________________________________
Blood investigations for sugar_______________________________________________
Feces investigation for ovum of helminthes ____________________________________
Others investigations
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Date: 2015-12-11 ; view: 1390