A. General condition and neural system characteristic

Every diagnosis should be classified by ICD-10,

In cases with cancers – by TNM classification also.

Student (Curator)

Faculty

Course Group

Teacher

Date of submitting

Mark

Passport part

1. Patient’s name, surname

2. Patient’s age in years

3. Date of birth

4. Gender

5. Occupation

6. Date of admission to the hospital

Complains

Complains at the moment of admission. Separate main complain from secondary complains and describe in details their character from the main complain to the secondary complain.

1.1. The main complains are the leading conditions that brought the patient to the hospital.

2.1. The secondary complains are not typical to the main disease.

3.1. General complains are the complains that are not specific to any disease like headache, weakness, tiredness, depression.

Anamnesis of the disease (Anamnesis Morbi)

Development of the disease expanded in chronological order since the moment of the onset of the disease to the moment of examination, the reason of disease, exso- and endogenic, information about medical care, dynamic of symptoms, results of paraclinical investigation, treatment, its effectiveness, side effects of antibiotics and chemical preparations. The disease should be described in details from the very onset (when exactly he felt sick, date and time if possible), what was the cause of the disease, list of first symptoms, the patient’s reaction (did he consult a doctor, or self curing procedures).

Describe the indication for admission into the hospital, the reasons for aggravation of the patient’s state, the aim of admission into the hospital.

Anamnesis vitae

1. Biographical data (Date of birth, childhood life, living conditions, occupational conditions).

2. Previous medical history. Infection and somatic diseases in past, information has to be done in chronological order. It is necessary to mark the character of the disease, peculiarity of the clinical characteristic, to pay attention to diseases of the allergic cause, to the nutrition and medicine intolerance. Previous surgeries and traumas.

3. Information about contacts with infectious patients during last 3 weeks before admission, with tuberculosis patient and other infections (occasional, family, flat contact)

4. Information about prophylactic vaccination, reactions on vaccination.

5. Family anamnesis

5. Present state:

A. General condition and neural system characteristic.

General state of the patient is (satisfactory, moderate severity, grave, extremely grave). Patient’s position is (active, forced patient’s attitude position, passive patient’s position). State of consciousness. Mental state, estimate of intelligence, memory, speech. Abnormalities of gait, posture, coordination.State of sensitiveorgans: vision, hearing, skin sensitivity, olfactory, taste characteristic.

Поиск по сайту: