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MEDICAL CARD
name, surname of the patient
_______________ age of the patient
Clinical diagnosis: basic diagnosis __________________________________________ __________________________________________ Complication __________________________________________ __________________________________________ Concomitant disease __________________________________________ __________________________________________ __________________________________________
Sumy GENERAL INFORMATION ABOUT PATIENT Name _________________________________________________________________ Surname _______________________________________________________________ Date of birth ____________________________, age ___________________________ Home address __________________________________________________________ Preschool or school institution _____________________________________________ Date of admission to the hospital ___________________________________________ Institution which has directed patient to the hospital ____________________________ Pre-admission diagnosis __________________________________________________ ______________________________________________________________________ Patient’s department _____________________________________________________ I. COMPLAINTS Main: ________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Additional: ____________________________________________________________ ___________________________________________________________________________________________________ ______________________________________________________________________
II. ANAMNESIS OF THE DISEASE The onset of disease acute, subacute, gradually (the necessary underline). The duration of the diseases is ______________. What preceded the disease (cooling, defects of nutrition, viruses infection, the contact with ill person, etc) ___________________________________ ___________________________________________________________________________________________________ ______________________________________________________________________ The development of disease _______________________________________________ ______________________________________________________________________ ______________________________________________________________________ The result of previous additional methods of investigation (if they were presence) _______ ______________________________________________________________________ ______________________________________________________________________ The previous treatment (if it was presence): _____________________________________ ____________________________________________________________________________________________________________________________________________ The effect of previous treatment ____________________________________________ ______________________________________________________________________ The reason of hospitalization _______________________________________________ ______________________________________________________________________ III. ANAMNESIS VITAE For children till 3 years The child from ____ (behind the account) pregnancy, _____ delivery. Age of the mother during the given pregnancy. The pregnancy proceeded (with, without) gestosis in ___ trimester, on a background (without) of the extragenital pathology ___________ ________________________, or inflectional diseases ___________________________ ___________________________________ or somatic illness ____________________ ________________________________________________ in _______ trimester. The mother used such medicines (to specify the trimester) _______________________________ ______________________________________________________________________ Harmful habits at the mother: ______________________________________________, at the father ___________________________________________________________. Conditions of work of the mother during pregnancy ____________________________ Conditions of life of the mother during pregnancy ______________________________ Delivery at timed or premature (the necessary underline), in ___ weeks of gestation. Labor via vaginal way or by caesarean section, with (without) medicamental stimulation _______________________ (the necessary underline). The child was mature or immature, according Apgar’s score _____ points at first min. and ____ points at 5th min. Birth weight was ______ g, length of the body was ___ ñm, head circumference was ___ ñm, chest circumference was ___ cm. The umbilical stump (residual cord) has fallen off in ___ days. After the stump has fallen off, the state of cord base was dry, or was weeping during __________ weeks. The child discharged from maternity department on ____ day (when it was more than 5-6 days, specify the cause of delay) __________________________________________. During the firs year the child was at ___________________ feeding. The reason of artificial feeding was ____________________________________________________. Mother used to such ______________________________________________________ Formulas. The term of introduction of fruit juice __________, fruit puree ______, egg yolk __________, cottage cheese ___________, meat ____________. The first addition food was __________________ at _______ mo. The second addition food was _______ ____________ at _____ mo. The third addition food was _____________ at _____ mo. The dynamics of body weight ______________________________________________ ______________________________________________________________________. Dynamics of body length _________________________________________________ ______________________________________________________________________. Dynamics of head circumference __________________________________________. Dynamics of chest circumference ___________________________________________. The psychomotor development of the child ___________________________________ ____________________________________________________________________________________________________________________________________________. For all children irrespective of age The child had such diseases (before admission) ________________________________ ______________________________________________________________________ ______________________________________________________________________ Housing conditions of the child is satisfactory or not satisfactory (the necessary underline and explain why) __________________________________________________________. Character of nutrition before present disease (character of meal, schedule of feeding) __
Allergological history Presence of allergy symptoms _____________________________________________. The intolerance of products _____________________________________________, that accompanied with ___________________________________________________, The intolerance of medicament (drug) _______________________________________ that accompanied with ___________________________________________________. Prophylactic vaccinations _________________________________________________. ______________________________________________________________________ The nearest relatives have such chronic somatic illnesses ________________________ ____________________________________________________________________________________________________________________________________________, genetically illnesses ____________________________________________________, allergic reactions _______________________________________________________. Epidemiological history The child didn’t contact with patients who suffered with inflectional diseases last 3 weeks. The symptoms of diarrhea were _______________ during last three days. Genetical history The data about siblings is collecting in everyone separately (How many children were at the family? How many children had died? What cause of death? What was physical and mental development? What diseases have had the child? How old were the parents at the moment of birth of the child? Especial attention is deserved with the following practical moments: 1. Age of parents. 3. Nationality of parents. 4. Residence of the family. 5. Parents occupation. 6. Presence of chronic diseases at the relatives (beginning of disease, the clinical features of the diseases). For the relatives, who had died, indicate the cause of death and age of the person. To make the pedigree of the patient, using common symbols:
Summery: ______________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date: 2015-01-02; view: 930
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