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Laboratory examinationThe 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 __________________________________________________________________
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. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Preliminary diagnosis ________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________ Laboratory examination Blood analysis
Urine analysis
Blood investigations for Wassermann test _____________________________________ Blood investigations for sugar_______________________________________________ Feces investigation for ovum of helminthes ____________________________________ Others investigations ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date: 2015-12-11; view: 1245
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