Laboratory examination

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_____________________________________________

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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) __________________________________________________________________

_______________________________________________________________________

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 _______________________________________________

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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 ___________________________________________________

_______________________________________________________________________

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.

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Preliminary diagnosis ________________________________________________

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Laboratory examination

Blood analysis

Urine analysis

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: 1502