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I.Basic Parts of Case History

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Fill in the Case History of Mr./Mrs./Ms./Miss N according to the plan given below (use the special boxes (A, B, C) for details) (some gaps can be left without any information):

1) Hospital

Register № _____

Department _____

Doctor _____

Admitted to the hospital on _____

Hospitalization days number _____

Discharged from the hospital on _____

Transferred to _____

Died on _____

A)

2nd February Specialized Sanatorium, Sherwood John Smith, MD Department of Cardiology 2 weeks

B)

Tropical Dermato-Venereology Department Professor Nick Swan 2 weeks 23rd August 25NS

C)

Doctor Anna Cornex Trauma TD6-01/02/2011 Car injury on 1st February The injured unconscious person has been brought from Perlax Street

 

2) Identification of a patient

Name _____

Surname _____

Sex _____

Age _____

Citizenship _____

Place of employment _____

Profession _____

Diagnosis on admission _____

Chief complaints _____

History of present illness _____

Past History _____

Family History ______

A)

Female Tram driver Lobar pneumonia Irish No cases of pneumonia Persistent dry cough, pains in the chest, fever Jane State Tram Company Half a year ago – series of colds 3 weeks of non-stopping cough Stompson

B)

Peru Frequent cases of gum and nose bleeding among family members P.Lumumba University student Acute form of gangrenous stomatitis Ulceration of the mucous membrane of the cheek, profuse salivation Male Tumbu-Hadgeru The disease developed gradually after some hot days of bad hygiene and started from a burning sensation in the mouth

C)

Male Closed skull injury is suspected Not known There is considerable displacement of bone fragments No information The patient has some open fractures Urgent case, no history Approximately 35 years old The patient is severely wounded The patient has multiple soft tissue bruises

 

3) System Review and Physical Examination

Laboratory tests/instrumental invesstigations _____

Clinical diagnosis _____

Complications _____

Surgery notes _____

Surgeon _____

Anaesthetist and anaesthetic used _____

Postoperative treatment _____

Doctor’s recommendations _____

A)

Blood test – high level of leucocytes No liquid found in the pleural cavity No sequalae Clinically confirmed lobar pneumonia Adequate airway should be maintained

B)

To rinse the mouth with a warm solution of sodium bicarbonate Clinically confirmed gangrenous stomatitis There is a facial asymmetry on account of swollen soft tissue Reddened and edematous mucosa Treat the oral cavity with antiseptics

C)


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