Horbachevsky Ternopil State Medical University

Internal Medicine Propedeutics and Phthysiology Department

 

 

 

 

 

 

 

 

METHODICAL INSTRUCTIONS

 

Management of the Patient and Filling in a Training Case History

 (for the 3^rd-year students, medical faculty)

 

 

 

 

 

 

 

 

 

 

 

Ternopil

“Ukrmedknyga”

2006

 

 

 

Compiled by:

 

S.M. Andreichyn, professor, A.V. Yepishyn, professor, P.P.Kusiv, professor,

assistant-professors: T.Yu.Chernets, B.H. Buhay, V.O. Lyhatska,

N.A. Habarova, N.Z. Yaremah,

instructors: N.A.Bilkevych, N. Ya. Vereshchahina, S.L. Malanchuk, M.M. Ruda

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Internal Medicine Propedeutics and Phthysiology Department

 

       

                    The Head of the Department______________________

                                                   The group curator_____________________________

 

 

 

 

 

 

CASE HISTORY

 

                                                                                                                    

 ( name, surname of the patient )

 

 

 

Clinical diagnosis                                                                                                                                                                                                                                     

( Ukrainian-    and English-language diagnosis in full form)

 

The main disease:                              _________________________                

__________________________________________________________________________________________________________________________

Complications of the main disease:                               _______________          __________________________________________________               

Concomitant diseases:                                                                                          ______________________________________________________________________________________________________________________________________

                                                                                                                  

                                                                                        Curator: 3^rd-year student

                                                                                        _____                           ,

                                  medical faculty,

                                  group N_______

 

Beginning of the curation_________________

Ending of the curation__________________

 

 

Ternopil – 2006

 

 

Courses in curation and filling in a Case History is a final step of training at Propedeutics of Internal Diseases’ Department. They are the first attempt of students in elaboration of independent clinical thinking during substantiation of a diagnosis, solving questions concerning methods of examination, treatment  and care of patients, prophylaxis of diseases and prognosis. During courses students use in practice obtained skills and ability to examine a patient and to diagnose a disease. Students formulate obtained results of  examination  and patient’s observation as a Training Case History.

A Case History  is the main medical document, wich should be filled for every  patient in a hospital. This document has both juridical and financial matter. That is why it should be read easily by any physician. Clinical manifestation of the disease, its course must be presented completely, the diagnosis and prescribed treatment should be well proved.

Causes of the diseases are studied on the ground of data of a Case History, as well as disability and forensic  medical examinations are made, recommendations about treatment are given for patients after discharging from the hospital, prophylactic measures are taken. A Case History is the document about a patient first of all, but it also reflects a doctor  as a person, his professional  level and erudition. That is why great importance is attached to training in writing the Case History in educational process. Data of patient’s clinical record are used in scientific research, it reflects the quality of treatment in a hospital, the achievments of medical science and practice.

The famous therapeutists – Yu. Drogobych, V.P.Obraztsov, F.G.Janovskiy, M.D.Strazhesko, B.S.Shcliar, V.H.Vasylenko payed great attention to methods of examination of a patient and filling in a case history. Taking patient’s anamnesis is a  responsible action in doctor’s work. A doctor records in it all data of his observations and treatment as the result of his selfless work near the patient’s bed.

In the case history all recived findings about the patient are recorded consequently. The first steps are the  patient’s  inquiry, general inspection, inspection of separate parts of patient’s body, palpation,  percussion and auscultation. All gathered information should be analyzed and recorded. Further the doctor substantiates a preliminary diagnosis and prescribed the necessary set of laboratory and instrumental methods of examination, consultations of advisers and a plan of treatment.

Then a doctor substantiates a clinical diagnosis on the ground of the results of  supplementary methods of examinations (laboratory and instrumental) and conclusions of advisers, as well as  data of previous patient’s examinations recorded in other medical documentation (ambulatory card, records of previous hospitalizations). Clinical diagnosis should be made not later the third day of hospitalization, a doctor writes it on the title page of the case hystory together with  the date of   substantation.

Finally all the  data about the course of the disease, the results of the following examinations till patient’s discharge from the hospital should be set down completely and in detail in the Case History.

Keeping to the sequence of patient’s examination prevents any  mistakes in diagnostics and substantiation of the diagnosis. Patient’s clinical record  should reflect all data about the patient, be clear and concise.

During the curation, the following tasks should be solved by a student:

1.     To gather patient’s complaints and data of anamnesis correctly, to perform physical examination of a patient  and to make interpretation of revealed data. To pick up signs that reflect the presence of certain disease. To record all data in the Case History. 

2.     To determine independently the necessary set of  laboratory and instrumental methods of examinations.To be able to make interpretation of their results.

3.     To consolidate revealed symptoms into  syndromes and substantiate the preliminary  diagnosis.

4.     To substantiate final  diagnosis on the ground of preliminary  diagnosis, data of observation about a patient (data of diaries) and the results of laboratory and instrumental examinations.

5.     To prescribe treatment for the patient and prophylactic measures of the disease. To give the recomendation concerning the following treatment and examinations.

6.     To use principles of deontology in intercourses with patients.

Keeping to principles of deontology is very important  in process of patient’s examination and taking his anamnesis. The atmosphere of friendship and respect should be created by a doctor during intercourses with a patient. Formal attitude to examination, careless words received by a patient can impede patient’s inquiry and even cause iatrogenic disease. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Questioning a patient (Interrogatio)

1.1. General information about a patient (Praefatio)

Name, surname

Sex

Age

Permanent address

Occupation

Place of employment

The name of referral institution

Date of admission to the hospital

Date of discharge from  the hospital

 

1.2. Patient’s complaints (Molestia aeqroti, Querellae aeqroti)

The main complaints are the main patient’s problems which he is suffered for. Every complaint should be defined with determination of its location, quality, quantity, severity, timing (onset, duration, frequency), the setting in which they occur, factors that have aggravated or relieved them, associated manifestations, any changes of these characteristics in dynamics, appearance of new symptoms.

Full description of complaints should be noted once for do not appaering need of searching different detalis in other parts of the Case History. A curator describes complaints of every system and details them concerning  main suffering system(s).

Then a curator describes in detalis the secondary complaints. To define them is possible only when a doctor asks patients additional questions because these complaints are not so severe.

A curator should present  characteristics of complaints at the day of curing (description of patient’s complaints – see in Appendix 1).

 

1.3. Review of systems (Status praesens subjectivus)

The interviewing should be started from the system which the patient is suffered for most of all. The signs defined in the chapter “Patient’s complaints” should not be repeated.

The review should be started from the system  which disturbances predominates in the clinical manifestation of the disease. If the main affected system is difficult to reveal the questioning  is carried out according to the folloving scheme:

Cardio-vascular system

Does the patient feel pain  in the heart region? If yes, you should define the following characteristics:

            –location (behind the sternum, above the apex, over the whole heart area);

            –when does it develop (on physical exertion, emotional overstrain, at rest);

                   –its irradiation (to the left arm, neck, left part of the neck, low jaw, intercapular space, left shoulder-blade);

            -characteristics of pain (acute, dull, constricting, stabbing, burning, pressing, boring, arching, or  a sense of heaviness);

–intensity (slight, of moderate intensity, strong, severe);

            –timing (persistent, periodical), if periodical – the frequency of its appearance  a day;

            –duration (during some minutes, hours, days);    

            -associated manifestations ;

            -provoking factors (physical or emotional overstrain);

            –factors that relieve or remove  pain;

-patient’s behavior during pain attack,body position that relieves pain.

 

Palpitation. If yes, what are its:

            –frequency (constant, paroxismal);

            -if periodical – duration of an attack, in what time and under what conditions does the attack develop: at physical overload, emotional overstrain, at rest, due to change in posture, without any  reason;

-when does it disappear?

            Is it followed by heart intermissions (a sense of  heart arrest,  heart disposition)? If yes-     what is the reason of these unpleasant feelings on the patient’s own opinion?

     Frequency of attacks a day, their duration, factors that relieve or remove the symptom.

 

Feeling of pulsations in different parts of patient’s body: its

-location, frequency, duration;

-relation to palpitation, heart intermissions, pain;

-provoking factors;

–factors that relieve or remove  symptom.

 

Does the patient complain of dyspnea? If yes, what is

            -the setting of its development (on exertion, during conversation, emotional overstrain, at rest)?

            -Its type (expiratory,  inspiratory or mixed);

            -is it attack-like or constant?

            -Is it more intensive in recumbent or upright position of the patient?

-Relation of dyspnea to body position (upright, recumbent), physical loading.

   

Suffocation: if present, define its

            –time of appearance (in day-time, at night);

            -frequency of attacks;

            -duration;

            -factors, that relieve the symptom;

            -what time and under what conditions does it develop (on exertion, emotional exertion, at night)?

 

Cough: time and condition of its appearance (in the morning, in the evening, at night);

            –timing (is it permanent or periodical), in the last case – duration and frequency of attacks;

            -loudness and intensity of cough (inssiculation, slight, of moderate intensity, loud);

            –character of cough (dry or with expectoration of sputum (moist);

            -under the what conditions does cough develop or become more severe, its relations to respiration, physical loading, singing, conversation etc.);

-factors that relieve or remove cough.

 

If cough is moist, define amount of sputum discharged per day and in one split;

            –peculiarities of discharging (is it heavy or easy, at what day time and in what body position sputum may be best discharged);

            -colour of sputum (greish, reddish);

            -smell of sputum;

            -are there any admixtures of blood in sputum, if yes, what is the degree of bleeding (blood streaks in sputum, sputum mixed with blood, pure blood in several splits, pronounced bleeding). Colour of  sputum should be clarified (light-red, dark), frequency of bleedings, duration, provoking factors, under the what conditions does bleeding become less intense  or disappear.

 

Edema: if present, what is its location?

            –time of appearance (in the morning, in the evening, all time);

            -under the what conditiond does in develip or become more pronounced (physical loading etc.)?

            –Factors, that relieve the symptom (due to usage of diuretics or on its own).

            -Relation of edema to water and salt intake.

Claudicatio intermittens: the time of appearance, relieving factors.

The signs of spasm of perypheral arteries: pain in the limbs, feeling of “freezing”, “numbness” of fingers, feeling of “dead” finger, headache, flickering before eyes.

 

Respiratory system

Does the patient breathe through the nostrils freely  or have any  difficulty in breathing ?

Dryness in the throat or behind the sternum (indicate, if present).

Does he (she) feel pain  in the chest, if yes, desribe, please, its location (with indication of topographic zones and lines);

-irradiation (toward which zone);

            –characteristic (acute, dull, stabbing, arching, pressing, boring, stretching, gnawing);

            –intensity (slight, of moderate intensity, strong, severe);

            –timing (constant, paroxismal)? In the last case – time of appearance;

            –provoking factors, especially the relation of pain to breathing movements, coughing, changes of body position;

            -factors that relieve or remove pain.

 

If patient complains of cough, you should determine its

            -time and condition of appearance (in the morning, in the evening, at night);

            -timing (is it persistent or fitlike), in the last case – duration and frequency of attacks;

            -loudness and tembre of cough (weak, of moderate loudness, loud, barking, loudless);

            -hacking cough (inssiculation);

            –character of cough (dry or with expectoration of sputum (moist).

 

If cough is moist, define: volume of sputum discharged per day and in one split;

            –peculiarities of discharging (is it heavy or easy, at what day time and in what body position is sputum discharged);

            -colour of sputum (greyish, yellowish, greenish, reddish);

            -does it smell of putridity?

            -Are there any admixtures of blood in sputum, if yes, what is the degree of bleeding (blood streaks in sputum, sputum mixed with blood, pure blood in several splits, pronounced bleeding);

            -colour of blood in sputum (light-red, dark, with raspberry hue, rusty).

 

Dyspnea: if present, define  following:

            -setting of its appearance (at rest or on exertion, degree of loading which conducts dyspnea);

            -is it permanent or periodical, in the last case – duration of attacks;

            -type of dyspnea (expiratory,  inspiratory or mixed);

            –provoking factors (smells, emotional strain, overcooling, physical exertion).

 

Suffocation; if present, define the following points:

            -aura: have been the patient ever noticed any previous symptomes like itching, dyspnea, nasal catarrh, sneezing or other before the attack?

            -When does the attack  occur?

            -Patient’s behavior and posture during the attack?

            –Duration, frequency, intensity  of attacks;

            -relieving factors (if the patient feels better after usage of medicines –  define the form of  usage: inhalations or injections).

 

Digestive system

What is patient’s appetite (good, moderate, increased, lack of appetite,  supressed, deranged, distaste for some kind of food (indicate it), fear of food intake).

Saturation: moderate, quick, permanent, constant feeling of hunger.

Mastication: deranged or preserved, pain at mastication (yes, no).

Does the patient complain of thirst? If yes, indicate its timing (constant or intermittent), when does it occure, relieving factors. The volume of water drunk per day.

 Salivation: its periodicity (permament or periodical), duration, when does it occure, relation to food intake, relieving factors.

Dryness in the mouth, pain and burning sensation in the tongue (yes, no).

Taste in the mouth:   normal, sour, bitter, metallic, sweet, deranged, perverted.

Swallowing and passage of food portion through the esophagus (painful, impossible or  difficult (does the difficulty depend on the sort of food – solid, liquid)?

 

Does the patient complain of pain in abdominal region? If yes, define its

            -location;

            -under which conditions does it appear?

            -Relation to the time of food intake (immediatelly after eating, in some minutes, 20-30 min, 40-50 min, in some hours,  “fasting” and “night” pain);

            -to the sort of food (fat, fried, spicy, milk, coarse, sweet) and its amount;

-characteristics of pain: acute, knife-like, dull, burning, boring, girdle, feeling of heaviness in the certain abdominal zone);

            -its intensity (slight, of moderate intensity, strong, severe);

            -irradiation;

            -time relationship (permament, periodical, undulate, seasonal);

            -duration of attacks (during some minutes, hours, days);

            -under what conditions does pain develop or become more intensive?

            –Relieving factors (vomiting, food intake, medications, intake of soda, applying of heat or  cold). In which body position does pain decrease?

            -Associated manifestations (changes of skin colour, urine, feces etc.).

 

Nausea: if present, detail the following:

            -does it preceed vomiting or not?

            -Is there any relation of nausea occurence to food intake (yes, no) and the sort of food (if yes, indicate the sort of food)?

 

If the patient complains of vomiting it is necessary to define the following:

            -time of its appearance (on the empty stomach, relation to  food intake: immediately after or late). Frequency of occurence, relation to pain;

            -provoking factors; relation to food intake, to the sort of food, relieving factors, does vomiting relieve patient’s condition?

            -Volume and character of emesis (with digested or indigested food, as a coffee ground, with admixtures of fresh blood, bile, mucus, foamy);

            -smell of the vomit if any (ammonia, bitter oil, acid, putrid, fecal, without any smell);

            -does vomiting relieve patient’s condition?

 

Regurgitation: if the patient suffers for, define the following:

            -time of its appearance (immediately after meals, some time after meals, after change of body position, on straining effort etc.);

            -character of regurgitation (gaseous, food, bitter or acid belching, musty smelling);

            -its duration, intensity, relieving factors.

 

In the case of heartburn define the frequency of its attacks,  

            -relation to food intake and the sort of food (immediately afer meals, after change of a position of the body);

            -relieving factors (taking baking soda, water, any drugs etc.).

 

Meteorisms: (present or absent);

            -does the patient feel abdominal murmur, fluctuation? If yes,  indicate  their location, under what conditions they develop or become more intensive, relation to food intake (indicate the sort of food) and to pain. Relieving factors;

            -passage of gasses through the intestine: free, difficult or impossible. Their smell (sharp, putrefied, acid). Relation to food intake, the kind of food and defecation.

 

Stool: define the following:

            –frequency of  defecation (frequent, regular, irregular, constipation, after enema);

            -a feeling of incomplete emptying of the bowels after defecation;

            –volume and consistence of stool (formed, fragmentation, semiliquid, ribbon shaped, watery, rie-water);

            -сolour (brown, light, tarry)  and smell of feces;

            –admixtures if any (mucus, blood, pus, helminths, indigested food, foreign bodies);

            -in the case of blood discharging –does it occur during or after defecation; are feces mixed with blood or blood is present on the surface of feces;

            -tenesmus if any.

 

  Itching, anal pains if any: timing, duration, intensity, relation to defecation.

 

Urinary system

Pain in the lumbar region: its  character (dull, aching, acute, colicky);

            -is it permanent or attack-like?

            -Its irradiation, duration;

            –provoking and relieving factors.

 

Urination: define the following:

            -is urinatioormal or painful?

            -Frequency of urinations per day (general and separately during day- and  night-time);

            –the volume of water taken per day and discharged urina per day; correlation between daily and night diureses;

            -colour of urine (straw-yellow, “meat wastes”, “beer”);

            -smell  of urine;

            -urine sediment (present or absent, colour of sediments).

            Urinary incontinence if any: is it permanent or periodical, in the last case- its provoking factors (laughing,  coughing, drinking water etc.).

 

Endocrine system

Ask patient about the following:

Impairment from normal body growth and (or) fortmation of body build.

Any changes of body weight during last years, months (obesity, weight gain or loss, cachexia).

Ask about presence of the following signs: permanent thirst, hunger, dryness in the mouth, frequent urination, profuse urination, skin itching, white discharge, irritability, teafulness, palpitation, tremor of hands, inhibition.

Impairment of initial and secondary sexual signs.

Has the  patient ever noticed any changes of skin (profuse swetting or dryness, red skars, purulent rash of thre skin, “tanny” skin)?

Hair growth pattern:  pathological, excessive, baldness (indicate if any).

Female should be asked about first menstrual period, the duration and regularity of mensrual period, bleeding between periods or during menopause, menstrual cycle disorders, subjective senses associated with menopause (headache, depression, hot flashes). Absence of menses, sterility if any. Evaluation of libido.

 

Musculo-skeletal apparatus

 Pain in joints, bones, muskces: yes, no. If yes, define the following:

            -location; “wandering” pain if any;

            -timing, duration of pain, its intensity;

            -under what conditions does it develop or  aggravate: motion, depending on meterological factors etc.;

            -relieving factors;

            -pain in the backbone at motions (in which zones)?

            -Have the patient ever beeoticed puffiness of joints or changes of their configuration, any deformations? Changes of skin above joints (reddness, glitter, tension, local rising of skin temperature (indicate the afflicted joint)?

            –Is the patient satisfyed with volume of movements in upper, lower limbs?

            -Joint and vertebral columne stiffness (location, duration, under what conditions does it develop  or aggravate, when does it disappear).

 

Nervous system and sensory organs

Does the patient feel headache? If yes, define the character, location, intensity, timing, duration of headache. What factors do relieve or remove  it?

Dizziness: when does it occure, its duration, timing, frequency, intensity.

Sleep: its deepness, duration, character of dreams (normal, deep, insomnia). Does the patient sleep well? Any unususal, expressive dreams.

Work capacity: preserved or  reduced.

Mood: its changes, excessive erritability, tearfulness, apathy, peculiarities of behavior and  speech.

Convulsions, muscular tremor, dizziness, loosing of consciousness (indicate if present). Feeling of weakness in limbs. Deranged sensitivity (parestesias and the like), disorders of gait.

Disorders of sense organs: changes of vision, hearing, smell, taste, desire to eat inedible substances. Noise in the ears if any.

 

Blood system

Pain in bones (indicate its location),  in the right or left hypochondrium: when does it occur, its character, time relationship, duration, intensity, provoking and relieving factors.

Bleeding, hemorrhagic rash on the skin and mucous membranes (their location, character, frequency of occurence, duration). Provoking and relieving factors.

Enlargement of perypheric lymph nodes if any: (their location, consistency, painfulness).

Condition of skin and mucous membranes (itching, pain, change of colour, necrotization). Enlargement of the abdomen in the projection of liver and spleen.

 

General complaints (molestia communis): rise of body temperature (indicate the time and limits of its fluctuation during a day, relieving factors); character of fever and its duration. Chills and their frequency. Sweating: its intensity and time of occurence (night sweating). General indisposition, weakness, fatigue, decreasing of work capacity, other complaints.

 

1.4. History of present illness (Anamnesis morbi)

When and  under the what conditions did the first signs of the disease appeare?

What was the beginning (onset) of the disease (acute, gradual) 

What were the first signs of the disease?

What is the main cause of the disease on the patient’s own opinion? What preceded the disease (overcooling, infection, stress, physical examination or other factors)?

Did the first symptoms change in dynamics? Did new symptoms occur from the beginning of the disease till the moment of admission? (rising, aggravation, releising or removing of new symptoms should be described in chronologic sequence).

Did the patient receive any treatment before the admission to the hospital? If yes, what was it (self-treatment, ambulatory or long-standing hospital treatment)? What kind of medicines or another therapeutical agents did the patient receive?

What was the result of previous treatment (did the patient feel him better, worse or without any  changes)?

Have the patient been ever examined before present admission to the hospital? If yes, what are the results of examination?

In the case of chronic disease following should be detalized: the first attack of the disease (its detail describtion – onset, duration, severity etc), course (frequency, duration of exacerbations, results of their treatment, patient’s self-being after treatment and during remissions),  diagnosis, that was made at previous examinations. The last exacerbation should be described literally. Data about course of the disease during present treatment in the hospital should be recorded too (till the moment of the beginning of curation).

Patient’s work-status (medical insurance) before the hospitalization is than clarified as well as  reasons of hospitalization. Dynamics of symptoms after present admitting till the moment of examination is given.

 

1.5. Patient’s life history (Anamnesis vitae)

The main data about patient’s life should be presented in a short form.

Physical and phsychomotor development of the patient in childhood. Progress in studing process at school: what were the skills in theoretical subjects and physical training (excellent, good, bad), the interest for education and contact with school friends, hobby).

The beginning of work activity and following professional way (which professions was the patient dealt with and how long, the kind of activity (physical, mental), labor conditions, probably harmful professional factors). Present labor conditions: strong noise, vibrations, high ambient temperature, draftes, moistness, character of illumination, cold (work in the open), some chemical and radiation agents.

The mode of work activity: duration of work, breaks, holidays, leave. Are there any tensions at work? If any professional disease is suspicted professional anamnesis should be taken more detaily (see appendix 2).

Material and housing conditions in different periods of patient’s life and nowadays: what is the area of house (flat), which floor does the flat occupy, character of heating, moistness, draftes. Composition of family, family budget, any tensions in the family. How does the patient   spend his leisure time: is it enough time for sleep, rest, walks in the open. Gardening, sport (what kind of sports and exercises does he go in for).

Nutritional mode: regular or irregular feeding, frequency of meals, does the patient eat in the housing conditions or out of home. The character of meals, nutritional habits,  dry meals.

Harmful habits: smoking – if yes, indicate, in which age did the patient start to smoke, the quantity of  sigarettes smoked per day, smoking on empty stomach and at night;

–                        alkohol consumption – if yes, ask about the following: in which age did the patient start to drink alkohol, how often and how much does he drink, the sort of drink, how does the patient tolerate alkohol;

–                        coffeiemania – does the patient drink coffee, if yes – how often and in which day time;

–          drug abuse, toxicomania.

Any diseases, traumas, contusions, wounds in the past – if yes, enumerate all of them in chronological sequence with indication of the following: in which patient’s age did the mentioned above conditions take place, their duration, severity, complications; treatment should be indicated as well.

Special attention should be paid to infectious diseases (thyphus, hepatitis etc.) as well as to veneral diseases, AIDS, tuberculosis in the patient and his relatives. AIDS-risk factors: residence in  endemic regions, multiple sexual relations and perversions, repeated hemotransfusions, operations. If  there is suspicion on infectious disease – infectious anamnesis should be taken more detaily (see appendix 3).

 Family anamnesis:

In female patient it should include the following information:

        –when did the first menstruation (menarche) take place, character of menses (regularity, duration, volume of discharged blood). The age of marriage and beginning of sexual life. Number of  pregnancies and  their results: abortions, inevitable abortions (in which reason), miscarried fetus, delivery, premature birth, jaundice of newborns;

        -breach of menstrual function: painful, premature, delayed, protracted, excessive menstruations, bloody discharges between menstruations. Inflammation of female reproductive system organs;

        -if menstruation had disappearted (climax), it should be recorded in which patient’s age did it take place, were (are) there any unpleasant feelings during climax (headache, reddening of the face, irritability etc.).

In male patients in should be indicated the following information: breach of descent of testes (monirchodoism, cryptorchism), inflammatory diseases  of testes, prostate; sexual problems.

Allergological anamnesis:

Allergic reactions (urticaria, Quincke’s edema, anaphylactic shock etc.) to different kind of food, medicines, industrial or domestic allergens, trees’ blooming, feather etc.  Allergic diseases of relatives. Have any transfusions of blood or blood substitutes been ever given, if yes – has the patient showed  any reactions on them?

Genetic anamnesis: Can the patient remind any genetic diseases in his family? What is  the state of health or cause of death of close relatives (if somebody of relatives had died  – indicate in which age it took place). Has (had) somebody of relatives diabetes mellitus, bronchial asthma or another chronic hereditary-predisposed  diseases? Special attention should be paid for diseases with clinical manifestation similiar to these in the patient.

 

2.Objective examination (Status praesens obiectivus)

2.1. .General inspection (inspectio)

The patient’s general condition (satisfactory, moderate, grave, critical).

The state of consciousness (clear, stupor, sopor, coma), irritative disorders (delusions, hallucinations).

Posture (active, passive, forced).

Face expression (quiet, comprehend, excited, indifferent, suffering, exhausted, amimic).

The type of constitution: normosthenic, asthenic, hypersthenic; proportional, disproportional.

Nutritional status (satisfactory, obesity, poorly nourished, cachexia).

Gait (rapid, slow, atactical).

Bearing (right, straight, stooping, “proud”).

Heighth, body weight, body temperatura.

Anthropometric indexes.

Face: symmetrical or asymmetrical; edematous; nasolabial folds and their expression. Face skin colour, rash. Pathological types of face (Hippocratic face, Parkinson’s face, mitral face etc.).

Width of eye–slits: identical or not identical, exophthalmos, enophthalmos.

Pupils: their size (normal, dilated (mydriasis), constricted (miosis), unequal (anisocoria). Strabismus, lacrimation.

Eyelids: ptosis, edema. Colour of eyelids, xanthomas, xanthelasmas.

Sclera:  colour, injection of vessels.

Conjunctiva: colour, rash, skars, injection of vessels, excretions (serous,  purulent).

Nose: size, shape, any deformations, nostrils participation in breathing.

Ears: colour, shape.

Mouth: shape, symmetry, mouth angles, colour of the lips, fissures.

Neck: shape, symmetry, thickening because of enlargement of thyroid gland or lymph nodes. Visable pulsation of carotic arteries, swelling of neck veins.

Skin: colour (pale-pink, pale, yellowish, red, dark red, grey, cyanotic (peripheral or central) (define the places of the best manifestation);

-moistness (preserved, increased, decreased) (with definition of location);

-elasticity (kept, decreased, increased);

-rash (spots, papules, vesicles, tubercle, nodes, ulceration, vitiligo, pigment spots, teleangiectasis). Elements of rash should be described with assessment of their location, size, form, colour, are they rise above the skin);

        -skars, hemorrhages, angioma, excoriations, bedsores, if they are present you must indicate location and spreading.

Hair: male or female growth pattern, excess hair growth (hypertrichosis), fragility, early getting grey, baldness (total or local), luster (preserved, lost).

Nailes: shape, colour, deformations, transverse striation of nail plates, brittleness, thinning, stratification, surface. Nail bed.

Mucous membranes (of lips, mouth, eyelids):

            -colour (light-pinc, pale, cyanotic, yellowish, reddish);

            -rash – its location, character, ulceration;

            –moistness (preserved, decreased);

            -swelling (if present).

Subcutaneous fat tissue: the degree of  development – moderate, thin, excessive (should be determined according to width of skin fold in subscapular region), distribution (equal or not equal, in the last case- the type of distribution) cachexia (indicate if is detected). Lipomas, subcutaneous masses.

Edema: general or local, in the last case – define their location, consistency, degree of expression (slight-puffiness, moderate, marked), skin above edema: cold or warm.

Crepitation (in the case of subcutaneous emphyzema).

Lymph nodes: all groups of lymph nodes should be examined by palpation (occipital, retroauricular, submandibular, tonsillar, retrocervical, supra- and subclavicular, inquinal, axillary, cubital, subpatellar).

 If  lymph nodes are  felt by palpation: indicate group of revealed lymph nodes, their location, quantity (single or plural), diameter, shape (round, oval, irregular), consistency (soft, elastic or solid), painfulness (yes, no), mobility (yes, no), connection with surrounding tissues or skin (yes, no), condition of the skin above the lymph nodes (hyperaemud, cyanotic, pale, not changed, presence of fistula or scars, in the last case- dischargings (yes,no), swelling of surrounding tissues (yes, no).

Muscles: stage and proportionality of development (atrophy, good, hypertrophy);

            –muscular strength and tonus (preserved, decreased – atony, hypotony, increased – hypertony), tremor (if any);

            -induration in muscles (if any);

            -pain at palpation, active or passive movements  (define location);

-symmetry of revealed changes.

Bones: symmetry of bones, size, shape and symmetry of limbs;

            -the shape of skull, correlation of its facial and cerebral parts. Skars, defects of bones. Superciliary arches: degree of expression, symmetry;

            -pathologic curvature of the spine column if any (lordosis, kyphosis, skoliosis, their combination);

            -bone tenderness to palpation, percussion, at movements;

            -deformity of bones, surface  thickening and uneveness;

            –deformations of the chest,  pelvis, limbs;

            -deformations of fingers, distal phalanxes in the shape of “Hyppocratic fingers” (“drum-stike” fingers), nail plates in the shape of “watch glasses”;

            -“X” and “D”-shaped deformation of  the low extremities.

Joints: configuration, deformations, contractures, ankylosis, puffiness of surrounding tissues. Colour of skin above afflicted joints (hyperaemia, hyperpigmentation), its tension. The capacity of active and passive movements (full volume, limited, impossible), maximal angle of abduction. Pain during motion (yes, no). Skin temperature above joints. The diameter of afflicted joint should be defined in comparison with symmetrical joint. Fluctuation at touch, movements.

Trunk: shape, symmetry.

 

2.2. Respiratiry system (systema respiratorium)

Inspection of the chest:

Static (definition of the chest shape and estimation of its relation to constitutional type);

            -symmetry of both parts of the chest;

            –the position of clavicles, scapules, backbone, intercostal spaces). If the chest is asymmetrical, the location of deformation, protrusion or elevation should be indicated;

            -distension of the chest wall veins;

            -pathologic forms of the chest;

            -intercostal spaces (protruded, drowned, not changed).

Dynamic inspection: symmetry of both parts of the chest  movements during respiration. Retardation of one chest part in respiration;

            -do  the accesory  muscles take part in breathing?

            -Respiration through the nostrils: slow, free, difficult, absent;

            -the type of breathing (thoracic, abdominal, combined);

            -respiratiory rate with evaluation of its frequency (frequent – tachypnoe, rare – bradypnoe, of normal frequency – normopnoe);

            -the depth of respiration (shallow, deep, with prolonged expiration, with prolonged inspiration);

            -voice (loud, clear, hoarse, absent). Noisy breathing, wheeze (if any);

            -dyspnea: expiratory, inspiratory, mixed. Pathological types of respiration.

 

Palpation: pain in different parts of the chest, along ribs and intercostal spaces (indicate location);

            -elastisity of the chest in both directions;

            -feeling of pleural fremitus;

            -determination of vocal fremitus: its symmetry, intensity (increased, weakened, absent), location of revealed changes;

            -breasts: shape, symmetry, consistency, pain on palpation, areoli, nipples.

The comparative lungs percussion: should be executed in symmetrical parts of the chest: supra-  and subclavicular fossae, axillary region, above scapules, interscapular  region, under scapules):

            -the character of percutory sound at symmetrical parts of the chest (clear pulmonary sound, thympanic, dull-to-thympany, bundbox, dull sound). If any changes are revealed they should be recorded topogtaphycally;

            -traube’s space: is thympanic sound preserved or not.

Topographic percussion of lungs:

Determination of height of the lungs apexes anteriorly $ posteriorly,

Determination of the width of Krenig’s areas rightwards and leftwards.

Determination of the lower lungs borders (leftwards and rightwards) (results should be recorded in table 1).

Table 1

The results of topographic percussion of the patient’s lower lung borders

Topographic line	The right lung	The left lung
Parasternal
Midclavicular
Anterior axillary
Midaxillary
Posterior axillary
Scapular
Paravertebral

  Active lung excursion (right and left) should be recordered in  the table 2

Table2

Active lung excursion of examined patient

Topographic line	The right lung	The left lung
Midclavicular
Midaxillary
Scapular

 

Auscultation of the lungs:

Comparative auscultation should be carried out on the symmetrical points: supra-  and subclavicular fossae, axillary region, above scapules, interscapular  region, under scapules):

            -the character of respiratory sounds: vesicular breathing and its types (weakened, increased, pueril, harsh, stridulous, with prolonged expiration), bronchial breathing (its appearance in atypical places, amphoric and mixed breathing); weakening or absence of respiratory sounds. It is necessary to indicate location of revealed changes.

            -adventitious respiratory murmurs;

            -rales: location. Their identification;

            -dry rales: timbre (high- pitched (sibilant) or low-pitched (sonorous);

                   -moist rales (fine-, medium, coarse bubbling rales), their loudness (consonanting, non-consonanting), the places of hearing;

            -crepitation, pleural friction (if any);

            -bronchofony (absent, weakened, increased) Symmetry of changes.

In all cases it is necessary to indicate location of changes obtained by percussion and auscultation.

 

2.3. Cardio-vascular system (systema cardiovascularia)

Pulse  on radial artery: symmetry (synchronous or asynchronous), frequency (accelerated, slowed, the pulse rate),  rhythm (rhythmic, arhythmic), tension (of moderate tension, dull, soft), feeling (full, empty), size (high, small, thready), character (quick, slow), pulse deficiency (indicate the number of missing waves per min).

Presence of pulse on carotic, temporal, subclavial, femoral arteries, a.poplitea, a.dorsalis pedis, abdominal part of aorta, jugular veins.Quincke’s (capillary) pulse.

Inspection and palpation of area of heart and big vessels:

            -heart hump;

            -apex beat (location, area, height, strength, resistance, is it  positive or negative);

            -heart beat (if present);

            -pulsations in the region of heart and big vessels (carotic arteries, jugular veins), in epigastrium. Pulsation and winding  of temporal, subclavial, brachial arteries. Musse’s symptom.

            -pulsation of the liver;

            -vibration murmur (thrill or cat’s purr): its relation to the  phase of heart cycle (systolic, diastolic), location. Positive venous pulsation. Presence of varicose widening veins on the legs.

Percussion (percussio cordis): define heart limits (right, left, upper borders) and compare the revealed data with indicies of a healthy individual:

Table 3

The borders of relative heart dullness in examined patient

The border of heart dullness	Right	Left	Upper
Revealed indicies
Normal indicies

 

The diameter of the relative heart dullness:     

–         Borders and width of the vascular bundlebranch:

The borders of absolute heart dullness (should be presented in table 4):

–         Table 4

The borders of absolute heart dullness in examined patient

The border of heart dullness	Right	Left	Upper
Revealed indicies
Normal indicies

 

Auscultation of the heart (auscultatio cоrdis):

            Heart rhythm (regular, irregular).

Heart rate:

            Heart sounds: their loudness at all points of auscultation;

            -accentuation of the II sound (at the aorta, pulmonary trunk);

            -splitting or doubling of sounds, additional sounds (gallop rhythm, “quial” rhythm “pendulum” rhythm if any).

            Murmurs: their relation to the phases of heart cycle (systolic, diastolic: proto-, mezodiastolic, presystolic);

            -character (mild, blowing, grazing, coarse etc.);

            -intensity: (loud, soft);

            -timbre (high-pitched or low-pitched);

            -duration (long, short, crescendo, decrescendo);

            -the places of the best hearing of murmurs, their transmission;

            -any changes of murmurs’ characteristics depending on the phases of respiration, change of patient’s position, after physical loading.

            Pericardial friction, pleuropericardial murmur if any: their location.

Auscultation of vessels (carotic, subclavicular, femoral arteries, jugular veins). Presence of sounds, murmurs.

Taking of blood pressure (on brachial  artery): systolic, diastolic, pulse pressure. Middle-dynamic blood pressure.

Orthostatic test (positive, negative).

 

2.4. Digestive system (Apparatus digestorii)

Inspection of the oral cavity:

Tongue: shape, size, colour, moistness, condition of lingular papillas, coating, ulci, fissures, crusts, teeth prints, skars, motion of the tongue.

Mucous membrane of the oral cavity (internal surface of cheeks, palate, gums, tongue, pharynx, tonsills, posterior wall of the throat): colour, edema, moisty, rash, hemorrhage,  skars, pigmentations, ulci, Filatov’s spots  etc.

Gums: colour, bleeding, ulcers, excretion of pus, loose or mount gums.

Soft $ hard palate: colour, covering, hemorrhagic rash, ulci.

Tonsils: shape, size (enlarged or not changed), swelling of mucous membrane, colour, presence of coating, ulci, pus “corks”.

Smell of ammonia, acetone, ”heptic”, with putrefied air etc. from the mouth.

Teeth: shape, shine, caries, prostheses, teeth formula (should be presented in table 5)

Table 5

Teeth formula of the examined patient

Indicate condition of each tooth marking them with letters:

i – intact, c – caries, d- destroyed, a – absent, t – treated, p- prostesis.

 

Inspection of the abdomen (in upright and recumbent patient’s position):

            -configuration of the abdomen: regular or irregular; regullary protruded, regullary retracted. Abdominal distension, flatulence, retractions (symmetrical or local). Hernia (with recording of location);

            -patologic shapes of abdomen: “frog-belly” abdomen;

            -distension of superficial veins;

            -visible peristalsis;

            -status of umbilicus;

            -skin hyperpigmentation,  skars, rash;

            -circumference of the abdomen on the lever of umbilicus;

            -does  abdominal wall take part in respiration?  Respiratory movements: active, regular, irregular, absent.

 

Superficial palpation (рalpatio abdominis superficialis):

            -resistance of abdominal wall: soft, resistent, muscular tension – indicate location, magnitude.

            -pain in the  zones of hyperesthesia.

            -Blumberg’s symptom (negative,  positive – in the certain zone of the abdomen  (which of them) of over the whole  abdomen).

            -divergence of rectus abdominis muscles.

            -weak points of the abdominal wall (umbilical, inguinal, femoral rings) – at rest, during respiration and making some efforts.

            -Subcutaneous masses, tumors.

 

Deep sliding palpation (topographic) by Obraztsov and Strazhesko. Palpation of intestine: sigmoid colon, cecum, appendix, final part of ileum, colon ascending, descending and transverse colon should be examined consequently with evaluation of  the following characteristics:

location (in which abdominal zone), shape, diameter (in cm), of each segment as well as length of palpation, surface (smooth, rough), consistence (mild, solid, elastic), painfulness, mobility (movable or not), sounds. Present your findings in  table 6:

Table 6

Data of deep palpation in examined patient

Parts of intestine	Properties
Sigmoid colon
Cecum
Colon ascending
Colon descending
Colon transverse

 

Description of data obtained on palpation – see Appendix 5.

Stomach: determination of the lower border;

            -palpation of the great curvature,  pylorus. Painful points;

            -percussion of the abdomen: character of the percutory sound in symmetrical parts of the  abdomen. The degree of thympanic sound, its change on dull-to-thympany or dull should be detected. The origin of these changes should be determined (fluid, feces, tumors), their location, relation to change of body position have to be recorded;

            -splashing sound over the stomach.

Determination of free fluid in abdominal cavity, its level.

Liver: visible enlargement, its pulsation. Mendel’s, Orthner’s symptom;

-palpation of the liver: margin (acute, round, soft, solid, irregular), in the case of liver enlargement – is it smooth, lobular, tuberous), painfullness;

            -percutory determination of upper and lower limits of liver dullness along right midclavicular line (the distance between liver lower border and the right costal arch in cm);

            -determination of liver limits by Kurlov in cm (present the  results in table 7):

 

Table 7

Liver limits by Kurlov in the examined patient

I	II	III
Right midclavicular line	Medial line	Left costal arch

 

            -location of the liver lover border by Obraztsov and Strazhesko in cm: (record in the table  8):

Table 8

Location of the liver lower border in the examined patient

Right anterior axillary line	Right midclavicular line	Right parasternal line	Medial line	Left parasternal line

 

Gallbladder: palpation. Define the shape, size, mobility, consistence (soft, solid, tuberous) of the gallbladder, painfulness.

Tapping above the gallbladder  region: special symptoms (Courvoisier’s, Mayo-Robson’s, Dezharden’s, Ortner’s, Mendel’s, Ker’s, Murphy’s, Mussey-Georgievsky’s sighns)

Pancreas: is it possible to reveale it by palpation? If yes, define the presence of  pain in zones  of projection.

        Spleen: if it can be revealed  by palpation, define the peculiarities of its margin: (round, acute),  how much does it projected under the costal arch, presence of spleen incisure,  painfulness, consistence (soft, solid), surface (smooth, tuberous), mobility of the spleen on palpation;

          -data of percussion of the spleen: indicate longitudinal and transversal sizes of the spleen.

        Auscultation of an abdomen. Peristalsis of intestine: preserved, weakened, absent, increased, presence of splashing sound).

Peritoneal friction (diffuse or local; in the last case – its location).

 

        2.5. Urinary system (systema uropoeticum)

Inspection of the lumbar region: smoothed contours (swelling). Protrusions, symmetry of revealed changes. Skin hyperemia. Protrusion of abdominal wall over pubic bone by overfeeling of the bladder.

Palpation of kidney ( in upright and recumbent patient’s position). If a kidney is revealed by palpation –define its shape, surface, consistency, painfulness, mobility, degree of the nephroptosis (palpated kidney, mobile one, “migrating” kidney). Painful points.

        Pasternatsky’s symptom (positive rightwards, leftwards, at both sides, negative).

Palpation $ percusson of the bladder (size, shape, surface, consistency, painfulness, mobility, the level of the upper margin of the bladder).

Auscultation: possible peritoneal murmur, murmur under renal arteries.

 

2.6.Endocrine system (systema endocrinica)

Inspection and palpation of thyroid gland: location, degree of enlargement.

Palpation of the right and left lobes of the isthmus of the thyroid gland: size, surface, consistency, mobility, painfulness. Symptom of swallowing. Ocular signs. Presence of secondary sexual charactistics.

Ausculation: presence of vascularmurmurs over the thyroid gland.

Women should be asked about disorders of menstrual function or absence of menses, infertility.

Evaluation of libido.

 

2.7.Nervous system and sense organs

Mental development (preserved, decreased).

Memory of present and past  events.

Orientation in time, space, own person.

Contact: easy, difficult, impossible.

Patient’s behaviour during examination (adequate, spontaneous, psychomotor excitation).

Dream: good, insomnia, somnolence, deranged sleep’s formula.

Coordination of movements: Romberg’s symptom (inspection of equillibrium) – positive or negative.

Width of eye-slits (identical or nonidentical).

Sizes of pupils (normal, mydriasis, miosis).

Reaction of pupils on light (direct, consensual).

Taste, vision, hearing, smell.

Character of dermographysm (white or red, thickness of the line, duration of its presence, painfulness, swelling of skin).

 

3.Preliminary diagnosis with determination of the main syndromes (diaghosis praeliminaris)

Preliminary diagnosis is elaborated on the basis of data  obtained by inquiry and objective examination of the patient. For this purpose a curator should pick up and compose (in according with their similiarity) the most important patient’s complaints that testify about disorders of concrete organs and systems. Data of patient’s anamnesis which substantiate peculiarities and character of the diasease  (acute, chronic etc.) should be revealed as well; a curator should determine  which findings of physical examination prove the results of inquiry.

A curator enumerates  all main and secondary complaints obtained at the day of curing with their detalization as well as data of anamnesis and physical examination that testify about  certain pathology in the patient (see appendix 6). For substantiation of the diagnosis you should use only the most typical for this disease manifestations.

Diagnosis of the disease  is elaborated in a short form using modern classifications of internal diseases.

 

4. Laboratory $ instrumental methods of examination

For a good management of a patient the plan of his (her) futher examination should be elaborated including the set of laboratory and instrumental methods of examination as well as consultations of suitable specialists necessary to detail and confirm the diagnosis (se appendix 7). Only those examinations which are necessary for the certain case should be prescribed.

After revision of the results of prescribed examinations compare them with data of physical examination. On this basis supplementary syndromes should be outlined which complete existing sytndromes. For recording the results use the table 9.

Table 9

The results of laboratory examinations of the patient

Form of examination	The results of examination

 

5. Diary (decursus morbi)

Diary is the short  but complete account of all changes in the course of the disease with compulsory charecteristic of  dynamics by last twenty four hours.

While curing the patient a curator should examine him (her) periodically and record revealed changes in patient’s conditions as a short repots in  the case hystory (see Appendix 8). The report includes  the date of examination, changes in patient’s complaints  within the recent 24 hours, objective picture of the disease with reflection of dynamics of changes in  morbid organs. Data of patient’s inquiry, estimation of his general condition, consciousness, posture, data of general examination, examination of pulse, blood pressure, body temperature, heart rate, previous sleep, appetite, diuresis, defecation should be presented as well as data of examination of respiratory, cardiovascular, digestive, urinary  and nervous systems. Any changes of earlier revealed sings, drugs side-effects are to be indicated as well. Any changes in treatment, prescriptions or examinations, means of care of the patient should be substantiated. If a doctor prescribes some diagnostic manipulations he should indicate the condition of patient’s prepearedness. Information about executed sanitary cleansing should be presented in the report as well. Data of supplementary examinations are presented if it is necessary.

In the diary clinical diagnosis is substantiated clearly. Finally, the diary contents description of  the patient’s treatment at the moment of curing.

 

6.Final diagnosis (diagnosis terminalis).

The final diagnosis should be substantiated by analysis and synthesis  of all aspects of patient’s examination and their changes in dynamics of patient’s treatment. In the Training Case History all data of patient’s inquiry, physical, laboratory and instrumental investigations which prove the appearance of the  certain disease in the examined patient should be presented. Description of the dynamics of these symptoms during treatment should be done as well. Outlined earlier syndromes sholud be  set up in detail using data of laboratory  and instrumental examinations with their evaluation (see Appendix 9). The main syndromes should be composed from symptoms and their substantiation should be carried out.

Syndromes are composed into the clinical diagnosis. In according with classification the form of the disease (acute, chronic), its severity, functional diagnosis and complications should be indicated. The clinical diagnosis should be presented in English and Latin languages in the following form: 

1.     The main disease:

2.     Complications of the main disease:

3.     Concomitant diseases:

 

7.The principles of patient’s therapy and prophylaxis

The necessary measures of care and treatment prescribe for the patient are given  in the following form:

1.Patient’s shedule of activity.

2.Diet.№.____.

3.Medicamentous treatment:

а) ethiological;

б) pathogenetic;

в) symptomatic.

4.Physiotherapeutic treatmen.

5.Sanatory-resort treatment.

6.Primary and secondary prophylaxis.

 

        8.Epycrisis (Epicrisis)

This is  a short account of the Case History which the  following information about the patient (example – see appendix 10):

¨     name, surname, sex, age, permanent address, data of admission to the hospital, data of dischaging from  the hospital, diagnosis at admission;

¨     patient’s complaints and data of his anamnesis at the moment of admission;

¨     data of physical examination at the moment of hospitalization;

¨     the results of laboratory and instrumental methods of examinations and conclusions of medical advisers;

¨     peculiarities of the course of the disease during  treatment in the hospital;

¨     patient’s condition at the moment of discharging;

¨     final diagnosis;

¨     methods of treatment and evaluation of the efficiency  of therapy;

¨     evaluation of patient’s working ability;

¨     recommendations for the patient about treatment continuation (with indication of preparations, their dosage, duration of treatment), diet, regimen, labour activity, dispensary observation for living place, control examinations, sanatory-resort treatment, physical activity, placement (if its necessary), etc.

 

9. Prognosis

Prognosis should be outlined for:

¨     patient’s life (favorable, unfavorable);

¨     recovering, future course of the disease, patient’s working ability, possibility for restoration of deranged functions of organs and systems, general prognosis (good, favorable, doubtful, unfavorable, bad).

 

Literature

 

 

Curator’s signature

Appendix 1.  How to   describe patients complaints

In case, if you have been visited by a patient with chronic pyelonephritis, its possble, that the result of the examination would be the following:

The patient R. complains of a constant dull pain in the lumbar region (nonradiating); it remits after taking Baralginum, No-spa and it increases after taking spicy or salty food; constant rise of body temperature up to 37,8⁰C, chill, frequent urination (up to 10 times a day). Besides, the patient complains of general weakness, insomnia, depression of working ability.

 

Appendix 2. Scheme of Professional History.

After a short, chronological account of  all the professions the patient was dealt with in the past as well as the character of professional activity, you should describe in detail the working conditions, and those periods of work, that could cause the professional disease. You should find out, if the colleagues had the similar illnesses. Also its important to find out whether the holiday and return to work, as well as changes of working condition and the influence of transference of the patient from one department of the plant to another  on the illness. Pay your attention to the moments, characterizing the working hazards:

–          Characteristics of present patient’s work: describe  in details the working process in which the patient takes (took) part;

–          Working hazards: noise, vibration, dust in the air, high and low temperatures, different radiation (infra-red waves, magnetic waves of a high frequency), forced postures, hazard situations, and non- specific factors: lighting, draughts, physical loading, monotony of working process etc.;

–          Character of collective and individual measures of protection provided at the plant (ventilation, hermetization, technological processes, scanning, usage of vibroprotectors, gas-masks, scaphanders, special clothes, antiphones, respirators, etc.);

–          Holiday, its timeliness and duration;

–          Provision with dietetic and special food, recreation at after-work sanatorium;

–          Duration of a working day, lunch-time, places for taking food, overtimes, work regime;

Its necessary to describe the quality, regularity and the full number of medical inspections at the plant, where the patient works.

The professional history, gathered by a curator, according to the patient’s words, should be supplemented with a full sanitary–hygienic characteristic of the working place, made by the doctor, servicing this plant. It also must be signed at the regional sanitary-epidemic station.

While writing the occupational history it is necessary to point out the time, which passed from the beginning of the work in industrial hazards till the first symptoms of the disease, how  the disease was determined – during the medical examination provided at the plant, or patient came to the doctor of his (her) own accord. Acute industrial poisonings, traumas, mutilations and complications, connected with them, allergic reactions to industrial poisons also should be pointed.

The professional history must also be supplemented with the copy of the patient’s service record signed at the personell department.

 

 

Appendix 3. Scheme of Epidemiological Anamnesis

Have you been in contact with a sick infected person (in the family, at school or other group, during a trip, among relatives or colleagues)?

Have you been in contact (at least for a while) with a feverish patient?

Have you been in contact with ill animals or their corpses?

Have you been bitten by insects, mosquitoes, louses, mites?

Presence of parasites and rodents at home

Are there any possibilities to be infected at work, because of the character of profession, use of water, food, clothes, shoes etc?

Have you gone for a trip recently and for how long period of time?

Were you visited by anybody last month? If it is so, where did he come from? Have you been in contact with people which came from abroad?

 Did you keep all the rules of personal hygiene (concerning baths, change of underware etc.)?

What kind of vaccinations were made and when? How many times?

 

Appendix 4. Scheme of Allergological Anamnesis

The patient complains of itching of the skin and mucous membranes, pain, the skin rash, quick swelling on different parts of the body, nasal itching, sneezing, difficulties in deep breathing through the nose, stuffiness in the nose (breathing through nostrils is impossible), palpitation, feeling of discomfort in epigastrium, quick abdominal distension, nausea, vomiting, diarrhea, constipation related to intake of  particular kind of food.

The following agents have influence on the illness course  and its exacerbation:

-Environmental factors: seasons of the year, time of the day, meteorological factors, moisture, cold, overheating in the Sun, bathing;

-Physical exertion, negative emotions, nervous strain, professional hazards (name them), certain places at home or at work etc;

-Different food – meat, fish, mushrooms, eggs, milk, butter, berries, fruits, vegetables, bread and farinaceous foods, nuts, chocolate, beer, vine;

 -Different smells: flowers, pollen of grass and trees, hay;

 -Contact with cotton, hair, wool, featers, home dust, furniture, carpets, books, clothes, bedclothes, and feed for aquarium fish;

-Pregnancy, menses, breast-feeding.

                A patient can react on:

    –  Medicines, vaccines, sera (indicate it if any), (the patient can have reaction in the form of postinjectional infiltration);

–          Contact with chemical substances (name them), cosmetic substances, insecticides;

–          Bee’s, flue’s, bedbug’s bites, etc;

–          Usage of antihistamine and desensebilizating remedies, glucocorticoids can give positive effect.

History of allergological disease (if it is concomitant to the main disease), the time when the first signs of the illness appeared.

Past allergological diseases of the patient and his relatives: bronchial asthma, dermatitis, serum diseases, subglottic laryngitis, exudative diathesis, false croup.

        Such focuses of infection as: caries, chronic tonsillitis, cholecystitis, and chronic female diseases.

 

Appendix 5. Data obtained on palpation of sigmoid colon should be recorded as follows:

Sigmoid colon is palpable in the left iliac region as s smooth   firm cylinder  over     the    length of

20 cm,  with diameter of 2-2,5 cm,  movable, painless, does not produce rumbling sounds.

 

           Appendix 6.  The example of substantiation of the preliminary diagnosis

The patient complains of a constant dull pain in the lumbar region (nonradiating); it remits after taking Baralginum, No-spa and it increases after taking spicy or salty food; constant rise of body temperature up to 37,8 ⁰C, chill, frequent urination (up to 10 times a day). Besides, the patient complains of general weakness, insomnia, depression of working ability.

– Data of history of the disease: the patient has beeoticed the signs of present illness within the recent 5 years. The first time she felt rising of body temperature, chill, rising of frequency of urination, dull pain in the lumbar region at the left side, headache, pain in the muscles, joints. She was treated iephrological department of the Ternopil Regional Hospital for acute pyelonephritis. The patient doesn’t remember the results of the examinations and the medicines she took. After the treatment she felt herself well, but sometimes was disturbed by the pain in lumbar region. Annually she was treated for acute chronic pyelonephritis in the out-patient department, but she doesn’t remember the medicines she took. Six months ago the patient pointed  rising of body temperature, pain in the lumbar region and was treated for exacerbation of chronic pyelonephritis again. After the treatment she felt herself better. The last exacerbation occurred two days ago. After acute respiratory infection she developed fever up to 38 ⁰C, the pain in lumbar region, frequent urination. She treated herself independently (took decoction of bearberry and parsley), but there was no improvement. After the examination by a local therapeutist the patient was referred to the hospital with the diagnosis: exacerbation of  chronic pyelonephritis;

–          Data of life history: professional activity is connected with overcooling;

–          Results of objective inspection: skin and visible mucous membranes are pale; of decreased moisture, slight  edema under the eyes is observed. Pasternatsky’s symptom is negative at both sides.

According with all mentioned above  data, the preliminary diagnosis should be as follows:

Primary bilateral pyelonephritis, the phase of exacerbation.

 

Appendix 7

 The set of main and supplementary examinations should be performed on admitting to the hospital

            The set of examinations should be obviously executed for each patient irrespective of the disease:

1)      Complete blood analysis (with determination of leukocytes formula);

2)      Determination of  glucose concentration in the blood;

3)      Wassermann test;

4)      Urine analysis;

5)       Analysis of feces for worm ova;

6)      Photoroentgenography (if there are no data for the last 2 years);

7)      Electrocardiography;

8)      Tonometry;

9)      Gynecologist’s consultation of (for women);

10)  Urologist’s consultation (for men over 40 years old);

11)  Ophthalmologist’s consultation (for patients over 50 years old);

12)  Thermometry.

 

The most wide-spread examinations for the patients with dysfunction of different systems

Respiratory System

1) Tests for estimation of immune system activity:determination of  concentrartion of Ig A, Ig M, Ig G in blood, T-  and B–lymphocytes count, examination of their functional and proliferative activity, factors of non-specific protection.

2) Sputum examination.

3) Examination of sputum for  tumor cells, mycobacteria of tuberculosis and their resistance to antibiotics.

4) Analysis of pleural punctate;

5) Examination of  external respiratory function (spirography, pneumotachometry);

6) Roentgenological methods of examination (roentgenoscopy, tomography, bronchoscopy, bronchography)

7) Computer tomography.

8) Magnetic-nuclear resonance tomography.

9) Angiopneumography.

10) Radioisotopic methods of examination

11) Ultrasound diagnostics.

 

Blood Circulatory System

1.      Biochemical blood examination (proteins, enzymes, lipids, data of nitrogen metabolism, blood electrolytes, determination of blood coagulation).

2.      Electrocardiography.

3.      Veloergometry

4.      Phonocardiograpy

5.      Ultrasound heart examination

6.      Tonometry.

7.      Sphygmography.

8.      Reovasography.

9.      Roentgenological examination (roentgenography, electrokymograpy, angiocardiography, coronarography).

 

Digestive System

1.      Biochemical blood analysis: determination of bilirubin, urobilin, cholesterol content, transaminases activity, fibrinogen, protrombin, alkaline phosphatase, protein and proteins’ fractions, glucose, C-reactive protein, amylase.

2.      Determination of serum markers  of hepatitis B and C.

3.      Determination of IgA, IgM, IgG content in blood,  immune complexes  etc.

4.      Analysis of urine for determination of  amylase activity and presence of bile pigments.

5.      PH-metry.

6.      Analysis of duodenal content.

7.      Coproragram.

8.      Analysis of feces for occult blood.

9.      Roentgenoscopy of digestive tract.

10.  Esophagogastroduodenoscopy (EGDS)

11.  Rectoromanoscopy (RMS).

12.  Irrigoscopy(IC).

13.  Colonoscopy (CC).

14.  Cholecystography, cholangiography

15.  Ultrasonodiagnostics of the liver, pancreas and gallbladder.

16.  Laparoscopic puncture biopsy of the liver (morphological verification of chronic hepatitis).

17.  Computer tomography.

18.  Sctyntiography of the liver.

 

Urogenital System

1.      Urinanalysis.

2.      Nechyporenko’s test.

3.      Zymnytsky’s test.

4.      Urine analysis for flora and resistance to antibiotics.

5.      Biochemical blood test (products of nitrogen metabolism, proteins and lipids spectra).

6.      Retrograde pyelography.

7.      Ultrasound examination of kidneys, urine bladder and prostate gland.

8.      Plain and exretory roentgenography of kidneys and urethra.

9.      Contrast selective roentgenography of kidneys.

10.  Radioisotope scanning of kidneys.

11.  Computer tomography.

12.   Cystoscopy. 

           

Blood System

1. General blood analysis, leukocytes formula, count  of reticulocytes and thrombocytes.

2. Determination of osmotic resistance of erythrocytes.

3. Determination of hematocryt.

4. Examination of blood coagulation (duration of hemorrhage, time of coagulation, cloth retraction, prothrombine and heparin index etc.). Coagulogram, thromboelastogram.

5. Concentration of calcium in blood and urine.

6. Ultrasound scanning of blood-forming organs (liver and spleen).

7. Sternal puncture.

8. Lymphatic node puncture.

9. Lymphatic node biopsy.

10. Roentgenography of bones.

11.  Roengenoscopy of retrosternal, retrocardial spaces.

12.  Densytometry. 

 

Endocrine System

1. Biochemical blood analyses for glucose, calcium, phosphates, cholesterol, hormones of thyroid gland concentration.

2. Glycemic profile.

3. Examination of urine for sugar content.

4. Examination of urine for 17-ketosteroids concentration.

5. Evaluation of basal metabolism.

6. Ultrasound examination of thyroid gland, suprarenal glands and ovaries etc.

7. Radioisotope scanning of thyroid gland.

8. Plain roetgenography of a skull, a skeleton, roentgenography of a Turkish saddle.

9. Computer tomography. 

 

Nervous System

1. Roentgenography of the skull.

2. Electroencephalography.

3. Surdogram, audiogram, inspection of visual fields, visual acuity.

 

Osteal-Articular System

1. Determination of rheumatoid factor in blood.

2. Rheumo-test (estimation of inflammatory process activity)

3. Determination of LE-cells.

4. Immunologic examinations.

5. Determination of crioglobulines.

6. Arthroscopy.

7. Biopsy of skin, synovial capsule of a joint, rheumatoid nodules.

8. Roentgenography of skin and joints.

9. Radioisotope methods of examination.

10.  Thermovision.

11.  Densytometry.

 

 

Appendix 8. Example of filling in the daries.

4.04.03.

Data of Interview and Physical Examination

Treatment

The patient still complains of the constant dull pain the  lumbar region (nonradiating), that reduces after taking spasmolitics and analgesics; frequent urinqtion (till 10 times per day), general weakness, insomnia, depression of working ability.      Objectively: patient’s general condition is of moderate severity, consciousness is clear, position in bed is active, skin and visible mucous membranes are pale and clear, slight moistness is present. Mucous membranes of the pharynx aren’t hyperemic, palate and palatine tonsils are normal. Lymphatic nodes aren’t enlarged.      Pulse: rate is 78 per minute, rhythmical, of middle tension, full. Blood pressure: 120 and 80 mm Hg. Heart borders aren’t displaced, heart sounds on auscultation are  loud, heart activity is  rhythmic.      Lungs: pulmonary sound is revealed on percussion, vesicular breathing is heard on auscultation. The tongue is moist, uncoated. Abdomen is soft, painless on palpation. The segments of the intestine and the stomach are normal on palpation. Lower liver border is at the level of right costal arch, it is elastic, acute, painless on palpation. Kidneys, pancreas, spleen aren’t palpated. Pasternatsky’s symptom is positive bilaterally. Stool is of normal frequency (once a day) and formed. Urination is up to 10 times a day, painless.

1.                  Regim – semi-strict. 2.                  Diet number 7. 3.                  Rp: Tab. Nitroxilini 0,05 N40. D.S. 2 tablets 4 times a day. 4.Rp.: Sol. Baralgini 5 ml D.t.d.N. 5 in ampull. S. 5 ml. intramusculary. 5. Rp.: Decocti fol. Uvae Ursi 10,0:180 ml. D.S. 1 tablespoon 5-6 times a day. 6. Rp.: Tab. Duoviti N40. D.S. Take 1 blue and 1 red tab. in the morning. 7. Rp.: Enterosgeli 400,0 D.S. 1 tablespoon should be dissolved in 30 ml of water; take inside 3 times a day between taking meals.

The signature of the Curator:

 

12.04.03.

Data of Interview and Physical Examination

Treatment

The patient feels herself better, urination is normal. She isn’t troubled by the lumbar pain, but she feels tension in the lumbar region and general weakness. She slept well at night. Objectively: general condition is satisfactory, consciousness is clear, position in bed is active. Skin and visible mucosa are pale, clear, of normal moisture. Pulse: 74 per minute, rhythmic, of middle tense, full.           Blood pressure: 120 and 80 mm Hg.           Heart borders aren’t displaced, heart sounds are  loud on auscultation, heart activity is  rhythmic. Lungs: pulmonary sound is revealed on percussion, vesicular breathing is heard on auscultation. The tongue is moist, uncoated. Abdomen is soft, painless during palpation. The segments of the intestine and the stomach are normal on palpation. Lower liver border is at the level of right costal arch, it is elastic, acute, painless on palpation. Kidneys, pancreas, spleen aren’t palpated. Pasternatsky’s symptom is slightly positive at both sides. Stool is of normal frequency (once a day) and formed. Dysuria is not observed. Data of urine analysis (10.04.03) and Nechyporenko’s test are normal.  The patient was prescribed to repeat Nechyporenko’s test and urinanalysis. As the pain in lumbar region was reduced the intake of Baralginum was stopped. The treatment is continued. Physiotherapeutic procedures should be added to the main treatment.

4.                  1. Regim – semi-strict. 2.Diet number 7. 3.Rp: Tab. Nitroxilini 0,05 N 40. D.S. 2 tablets 4 times a day 5.              Rp.: Tab Trentali 0,1 N40. D.S.1 tab. x 3 times a day. 5. Rp.: Decocti fol. Uvae Ursi 10,0:180 ml. D.S. 1 tablespoon 5-6 times a day. 6. Rp.: Tab. Duoviti N40. D.S. Take 1 blue and 1 red tab. in the morning. 7. Rp.: Enterosgeli 400,0 D.S. 1 tablespoon should be dissolved in 30 ml of water; take inside 3 times a day between taking meal. 8. Centimetre electromagnetic waves  on the kidneys’ region N6.

The signature of the Curator:

 

Appendix 9. Substantiation of the Final Diagnosis.

The patient complains of a constant dull pain in the lumbar region (nonradiating); it remits after taking Baralginum, No-spa and it increases after taking spicy or salty food; constant rise of body temperature up to 37,8 ⁰C, chill, frequent urination (up to 10 times a day). Besides, the patient complains of general weakness, insomnia, depression of working ability.

– Data of history of the disease: the patient has beeoticed the signs of present illness within the recent 5 years. The first time she felt rising of body temperature, chill, rising of frequency of urination, dull pain in the lumbar region at the left side, headache, pain in the muscles, joints. She was treated iephrological department of the Ternopil Regional Hospital for acute pyelonephritis. The patient doesn’t remember the results of the examinations and the medicines she took. After the treatment she felt herself well, but sometimes was disturbed by the pain in lumbar region. Annually she was treated for acute chronic pyelonephritis in the out-patient department, but she doesn’t remember the medicines she took. Six months ago the patient pointed  rising of body temperature, pain in the lumbar region and was treated for exacerbation of chronic pyelonephritis again. After the treatment she felt herself better. The last exacerbation occurred two days ago. After acute respiratory infection she developed fever up to 38 ⁰C, the pain in lumbar region, frequent urination. She treated herself independently (took decoction of bearberry and parsley), but there was no improvement. After the examination by a local therapeutist the patient was referred to the hospital with the diagnosis: exacerbation of  chronic pyelonephritis;

–          Data of life history: professional activity is connected with overcooling;

–          Results of objective inspection: skin and visible mucous membranes are pale; of decreased moisture, slight  edema under the eyes is observed. Pasternatsky’s symptom is negative at both sides.

According with all mentioned above  data, the preliminary diagnosis should be as follows:

Primary bilateral pyelonephritis, the phase of exacerbation.

–          Data of additional methods of examination: general blood analysis (2.04.03.): hypochromic anemia, neutrophyl leukocytosis, deviation of the differential count to the left, elevation of the erythrocytes sedimentation rate;

–          Biochemical blood analysis (2.04.03.) creatinine – 0,22 mlmol/l, urea – 9,3 mlmol/l (increasing of concentration of creatinine and urea).

–          Urine analysis (2.04.03.): amount of urine – 80 ml, color is light-yellow, specific gravity – 1010, reaction – slightly alkaline; protein – 0.09 gr/l, great number of scaly epithelium; leukocytes – 20-22 in  a visual field; erythrocytes: 4-6 in  a visual field, hyaline casts: 4-6 in  a visual field, mucus – low amount, great number of bacteria (hypostenuria, proteinuria, erythrocyturia, leukocyturia, cylindruria, bacteriouria).

–           Nechyporenko’s urine test (4.04.03.): Er: 2x10⁶/l, leuk: 8x10⁶/l, hyaline casts: 3x10⁶/l. (prevalence of leukocytes).

–          Zymnytsky’s test (4.04.03.): polyuria, hypoisosthenuria, nicturia.

–          Bacteriological examination of urine (4.04.03.): E.coli: 2x10⁵/ml – bacteriuria;

–          Renal clearence according to endogenous creatinine: glomerular filtration: 55 ml/min (decreasing of glomerular filtration).

–          Ultrasonography of the kidneys: dilatation, deformation, indurations of walls of kidney complex; non-homogenous acoustic density of kidney parenchyma, unequality of kidney shadow (morphological changes typical for chronic inflammatiory process).

–          Excretory urography (4.040.03.): decreasing of concentration ability of kidneys and slowing up of urographine’s excretion, dysfunction of calyces’ and urinary passages’ tonus. Dilatation of calyces with deformation of fornixes (morphological changes typical for chronic inflammatory process).

–          According to all mentioned above symptoms the following syndromes can be outlined: pain syndrome, intoxication syndrome, urinary syndrome,  syndrome of chronic renal failure and anemic syndrome (you should present pathogenetic substantiation of outlined syndromes in your Case History).

     According to all obtained data, the final diagnosis is the following:

The main disease: primary chronic bilateral pyelonephritis in the phase of exacerbation;

Complications of the main disease: chronic renal failure of the  1 stage.

 Concurrent diseases: hypochromic anemia of a mild course.

 

 

 

Appendix 10. Filling in of the Epicrisis

   The patient Revda Oksana Igorivna has been treated in Therapeutic Department of Ternopil City Hospital N3 since 1.04.03 till 14.04.03. with the diagnosis: ”Primary chronic bilateral pyelonephritis in the phase of exacerbation. Chronic renal failure of the  1 stage. Hypochromic anemia of a mild course.”

On admittamce the patient complained of a constant dull pain in the lumbar region (nonradiating); it remits after taking Baralginum, No-spa and it increases after taking spicy or salty food; constant rise of body temperature up to 37,8 ⁰C, chill, frequent urination (up to 10 times a day). Besides, the patient complained of general weakness, insomnia, depression of working ability.

– Data of history of the disease: the patient has beeoticed the signs of present illness within the recent 5 years. The first time she felt rising of body temperature, chill, rising of frequency of urination, dull pain in the lumbar region at the left side, headache, pain in the muscles, joints. She was treated iephrological department of the Ternopil Regional Hospital for acute pyelonephritis. The patient doesn’t remember the results of the examinations and the medicines she took. After the treatment she felt herself well, but sometimes was disturbed by the pain in lumbar region. Annually she was treated for acute chronic pyelonephritis in the out-patient department, but she doesn’t remember the medicines she took. Six months ago the patient pointed  rising of body temperature, pain in the lumbar region and was treated for exacerbation of chronic pyelonephritis again. After the treatment she felt herself better. The last exacerbation occurred two days ago. After acute respiratory infection she developed fever up to 38 ⁰C, the pain in lumbar region, frequent urination. She treated herself independently (took decoction of bearberry and parsley), but there was no improvement. After the examination by a local therapeutist the patient was referred to the hospital with the diagnosis: exacerbation of  chronic pyelonephritis;

–          Data of life history: professional activity is connected with overcooling;

–          Results of objective inspection: skin and visible mucous membranes are pale; of decreased moisture, slight  edema under the eyes is observed. Pasternatsky’s symptom is negative at both sides.

According with all mentioned above  data, the preliminary diagnosis should be as follows:

Primary bilateral pyelonephritis, the phase of exacerbation.

–          Data of additional methods of examination: general blood analysis (2.04.03.): hypochromic anemia, neutrophyl leukocytosis, deviation of the differential count to the left, elevation of the erythrocytes sedimentation rate;

–          Biochemical blood analysis (2.04.03.) creatinine – 0,22 mlmol/l, urea – 9,3 mlmol/l.

–          Urine analysis (2.04.03.): amount of urine – 80 ml, color is light-yellow, specific gravity – 1010, reaction – slightly alkaline; protein – 0.09 g/l, great number of scaly epithelium; leukocytes – 20-22 in  a visual field; erythrocytes: 4-6 in  a visual field, hyaline casts: 4-6 in  a visual field, mucus – low amount, great number of bacteria.

–           Nechyporenko’s urine test (4.04.03.): Er: 2*10⁶/l, leuk: 8*10⁶/l, hyaline casts: 3*10⁶/l.

–           Zymnytsky’s test (4.04.03.):

Time	Volume	Density
6-900	200.0	1010
9-1200	300.0	1008
12-1500	230.0	1009
15-1800	170.0	1010
18-2100	350.0	1009
21-2400	360.0	1010
24-300	270.0	1010
3-600	420.0	1009

                     

–          Bacteriological examination of urine (4.04.03.): E.coli: 2*10⁵/ml;

–          Renal clearence according to endogenous creatinine: glomerular filtration: 55 ml/min.

–          Ultrasonography of the kidneys: dilatation, deformation, indurations of walls of kidney complex; non-homogenous acoustic density of kidney parenchyma, unequality of kidney shadow.

–          Excretory urography (4.040.03.): decreasing of concentration ability of kidneys and slowing up of urographine’s excretion, dysfunction of calyces’ and urinary passages’ tonus. Dilatation of calyces with deformation of fornixes.

                Treatment: Nitroxolin 00.5gr. 2 tab. 4 times per day, Trental 0.1gr. 2 tab. 3 times per day, Decoction from leaves of Uvae Ursi 1 tablespoon 5-6 times per day, Duovit 2 tab. in the morning, Enterosgel 1 tablespoon, dissolved in 30 ml of water, 3 times per day, between taking the meals centimetre electromagnetic waves on the lumbar region N6.

                After the treatment the patient felt herself much better. In the satisfactory condition she was discharged from the hospital.

       Recommendations: Diet N7, reduction of salt intake, a limited amout of fluid – about 1-1,5 liters per day, moderate limitation of protein consumption in food. To avoid physical loadings  and overcooling. Medical treatment: Trental 0.1gr. 2 tab. 3 times per day, Duovit 2 tab. in the morning,  Decoction from leaves of Uvae Ursi 1 tablespoon 5-6 times per day, Renal Tea 0.5 glass 3 times per day during 30 days. Dispansery observation of a local therapeutist and nephrologist. Control analysis of blood and urine.

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